THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 
 MRS. PRUDENCE W. KOFOID 
 
OBSTETRIC CATECHISM; 
 
 CONTAINING 
 , TWO THOUSAND THREE HUNDRED AND FORTY-SEVEN 
 
 QUESTIONS AND ANSWERS 
 
 OBSTETKICS PROPER. 
 
 BY JOSEPH WARRINGTON; M. D. 
 
 #iie I^UE^rcts aElJ §\it^ Wim\m^\w,%* 
 
 PHILADELPHIA: 
 
 EDMOND BARRINGTON AND GEO. D. HASWELL. 
 
 18 5 3. 
 

 Entered according to Act of Congress, in the year 1853, by 
 BARRING TON & HA SWELL, 
 
 in the Clerk's Office of the District Court of the United States, in 
 and for tlie Eastern District of Pennsylvania. 
 
CONTENTS 
 
 
 Accouchee — Arrangements of the 
 
 chamber and bed of 144 
 
 After pains 1' 
 Alterations in the os and cervix uteri ( 
 
 Amenorrhoea 316 
 
 Varieties of 318 
 Treatment of 
 From physical causes 
 Duties to be performed in 
 Anatomy of the female pelvis 
 Anterior half of 
 
 Posterior half of 20 
 
 Animal life of the fetus dormant 100 
 Axis of the pelvis 
 
 Ballottement, how performed 115 
 
 Bandage — adjustment of 163 
 
 Bed — arrangement of 144 
 
 When to put patient upon it 154 
 
 How to put patient up in 165 
 
 Blood-vessels — of the genitalia 44 
 Body of Fetus— how to manage it 
 
 when extruded before the head 182 
 
 Bowels— torpor of, after delivery 176 
 
 Carus' Curve 29 
 
 Cesarean Section 304 
 
 Objections to it 304 
 
 Time proper for performing it 305 
 
 Management of such cases 305 
 
 Changes in the mode of circulation 
 
 after birth 96 
 Changes in the form of the uterus 66 
 Child — mode of receiving and dis- 
 posing of 159 
 Attention to be given to 167 
 Washing 167 
 Uses of bandage on 169 
 Pressing the 169 
 Presentation of to mother 170 
 Usual condition of, a few days af- 
 ter birth 177 
 State of bovi^els of 178 
 Condition of skin of 178 
 Chlorosis 324 
 Treatment of 32>J 
 Coccyx 15 
 Conception 59 
 Convulsions 234 
 Classification of 234 
 Hysteric, symptoms of 234 
 Apoplectic, symptoms of 235 
 Treatment in cases of 236 
 Cord, tying and dividing the 159 
 Dressing the 168 
 Decadence of the 178 
 What to do with it in pelvic pre- 
 sentations 182 
 Prolapse of 225 
 Too short a 226 
 Corpus Lutuum 55 
 
 Cranium — composition of 
 
 Ovoid form of 
 
 Fontanellesin 
 
 Sutures in 
 
 Vertex of 
 
 Diameters of 
 
 Compressibility of 
 
 Mensuration of 
 
 Too large from any cause 
 Cranial surfaces, form of 
 Cranial bones, how to remove 
 Craniotomy 
 Crotchet, how used 
 Decidual membrane 
 Decidua uteri and decidua reflexa 
 Delivery — clearing patient after 
 
 Treatment of patient immediate- 
 ly after 
 
 Usual changes in the condition 
 of the woman after 
 
 Getting up after 
 
 Premature artificial 
 Dimensions of the fetal skeleton 
 Diameters of the cranium 
 Dysmenorrhoea 
 
 Symptoms of 
 
 Causes of 
 
 Treatment of 
 Embryo 
 
 Accidents to 
 Ergot • 
 
 Sometimes inert 
 
 Not proper in pelvic deformities 
 Fallopian Tubes 
 Fecundation 
 Fetus 
 
 Accidents to in utero 
 
 Animal life dormant in 
 
 Anencephalous, West's case of 
 
 Doublets or triplets 
 
 Double fetus, Thom's case of 
 
 Osseous system of 
 
 Physiol tgical characters of the 
 
 Viability of 
 
 Weight of 
 Fetal Ellipse 
 Fetal Heart and circulation 
 
 Skeleton, dimensions of 
 Females, Physiological and Patholo- 
 gical condition during the repro- 
 ductive life of 
 
 Hygienic rules for 
 Flexion, how to assist 
 Fontanelles 
 
 Functions of the genital organs 
 Genitalia 
 
 Infiammation of the 
 Generation 
 Getting up 
 
 8 
 
 101 
 102 
 103 
 103 
 104 
 104 
 107 
 107 
 226 
 102 
 292 
 283 
 292 
 71 
 74 
 162 
 
 170 
 
 303 
 
 101- 
 
 104 
 
 327 
 
 328 
 
 3'29 
 
 a-o 
 
 238 
 302 
 
 414 
 luO 
 42J 
 227 
 415 
 100 
 
 66 
 176 
 
 Mtimem 
 
CONTENTS. 
 
 Hymen 
 
 Ilydrometra 
 
 Head too large 226 
 
 Causes arresting it above the su- 
 perior strait 230 
 Husband — Duty of Physician and 
 
 Nurse to 171 
 
 Hemorrhage at or shortly after ter- 
 mination of labor 239 
 Management of 240 
 How to prevent it by anticipa- 
 tion 240 
 Concealed 241 
 Labor — Precursory signs of 119 
 Action of uterus in 120 
 Bag of waters in 122 
 Action of accessory powers in 123 
 Different stages of 124 
 Physical inquiry into the fact 
 
 or progress of 150 
 
 Relation of the diflFerent stages 
 
 of 
 
 General classification of 130 
 
 Prognosis of by touch 126 
 
 When to be put to bed for the 
 
 completion of 154 
 
 Average duration of 126 
 
 Conditions incident to the differ- 
 ent stages of 127 
 General classification of 130 
 Presentation and position of the 
 
 child's head in 131 
 
 Classification of presentation in 131 
 Grand varieties of occipital posi- 
 
 tion ii 
 
 131 
 
 Particular positions of cephalic 
 
 exti-emity in , 132 
 
 Flexion in 135 
 
 Rotation in „ 135 
 
 Extension in 136 
 
 Restitution in 137 
 
 Rotation of the shoulders in 138 
 Two main points to be studied 
 
 in the mechanism of 142 
 
 Additional positions of head in 142 
 Convertibility of the positions in 142 
 Movements executed on the 
 
 shoulders in 142 
 
 Duties of physician, nurse and 
 
 patient in second stages of 154 
 What to do when the head has 
 
 passed through the vulva in 157 
 Complicated with prolapsion of 
 
 the bladder, vagina, &c. 230 
 
 Dr. B's case of Hernia of intes- 
 tines into the perinteal cul-de- 
 sac 231 
 Complicated by lesions of func- 
 tion of the nervous, vascular, 
 or muscular system 232 
 Complicated with incapacity for 
 
 spontaneous delivery 248 
 
 Instrumental surgery in 249 
 
 Classification of obstetric instru- 
 ments to be used in 249 
 Forceps in 250 
 Cases for the use of forceps in 253 
 
 Labor — Position of patient for the 
 
 use of forceps in 253 
 
 Mode of application of forceps in 254 
 Ligature on the forceps handles 
 
 in 256 
 
 Principle of action of the for- 
 ceps in 256 
 Forceps in 1st position of the- 
 
 head in 257 
 
 Forceps in 2d position, in 258 
 
 Forceps in posterior position in 258 
 Forceps in transverse positions 
 
 of head in 259 
 
 Forceps in mento-anterior cases 
 
 of face in 261 
 
 Forceps in breech presentation 
 
 in . 261 
 
 Dr. Hodge's Modification of For- 
 ceps to be used in 262 
 Dr. Bond's remarks on Forceps 267 
 Complicated with distortion of 
 
 the pelvis 280 
 
 Mode of measuring distortions 
 
 previous to 285 
 
 Mode of delivery in cases of pel- 
 vic distortion 287 
 Craniotomy for the termination 
 
 of 288 
 
 How to use instruments for crar 
 
 niotomy in 291 
 
 How to aid the collapse of the 
 
 cranium in 291 
 
 Veetis in these cases of 291 
 
 Crotchet in 292 
 
 How to remove the cranial 
 
 bones in 292 
 
 Dr. Hodge's Compressores Cranii 
 
 in 296 
 
 Version by the feet in cases of 
 
 deformity of the pelvis in 302 
 
 Professor Simpson's arguments 
 
 in favor of^— in 302 
 
 Accidents in third stage of 305 
 
 Management of such cases in 305 
 Management of the cord when 
 
 ruptured in 306 
 
 Retention of the placenta in 306 
 Management of the placenta 
 
 when retained in ■ 306 
 
 Coagula between the uterus and 
 
 placenta in 307 
 
 What to do in such ca.ses in 307 
 
 Leucorrhoea 333 
 
 Causes of 334 
 
 Difficulties of diagnosis of 334 
 
 Character of the discharge .335 
 
 Chronic 335 
 
 Treatment of 333 
 
 Vaginal 339 
 
 Chronic 341 
 
 Ligaments, anterior and posterior of 
 
 the uterus 50 
 
 Lochia 175 
 
 Lying-in room— admission of com- 
 pany into 171 
 Medicine and surgery of the 187 
 Menstruation 51 
 
CONTENTS. 
 
 Menstruation— termination of 53 
 Menstrual functions — disorders of 316 
 Absence of 316 
 Varieties of amenorrhoea 318 
 Treatment of do. 319. 
 Milk 175 
 Menorrhagia 331 
 Causes of 332 
 Treatment of 332 
 Nerves of the uterus and its appen- 
 dages 44 
 Obliquity of the uterus 229 
 Os innominatum 16 
 Osseous system of the fetus 100 
 Os uteri, sometimes difficult to find 229 
 Alteration in from pregnancy 60 
 Contraction of on the placenta 308 
 Ovaries 48 
 Ovum, constitution of 75 
 Patient, treatment of after delivery 173 
 Pelvis — Anatomy of the female 13 
 Anterior half of 19 
 Axis of 28 
 Contents of the 30 
 Inclined Planes of 26 
 Posterior half of 20 
 Proper 21 
 Perinaeum 38 
 Applying napkins to 163 
 Physical Exploration — to detect preg- 
 nancy 112 
 Arrangement of patient for it 114 
 Inquiry into the fact or progress 
 
 of labor 150 
 
 Time and manner of making it 153 
 
 Physiological characters of the fetus 97 
 
 Physomelra 379 
 
 Treatment of 380 
 
 Placenta 82 
 
 Management of 161 
 
 How to promote delivery of 161 
 
 How to receive and dispose of it 162 
 
 Tardy delivery of 305 
 
 Retention of 306 
 
 Management of retention of 306 
 
 Retention of from contraction 
 
 of OS uteri 308 
 
 How to act in such cases 308 
 Mianagemont when the cord is 
 
 ruptured 306 
 Coagula between the uterus and 307 
 What to do in such cases 307 
 Retention of from irregular con- 
 traction of the uterus 310 
 Hour-glass contraction ol 311 
 Adhesion of the 312 
 How to treat it 312 
 Consequence of failure to extract 
 the 812 
 Planes inclined 26 
 Presentation and position 131 
 Classification of 131 
 Second class of 179 
 Diagnosis of pelvic 180 
 Different positions of pelvic 180 
 Mechanism of labor in pelvic 181 
 Of anterior fontanelles 193 
 Classification of face 200 
 1* 
 
 Presentation— Cases proper to be 
 
 converted into face 202 
 
 Of side of the head 218 
 
 Of Cephalic extremity 132 
 
 Bringing down the feet in breech 221 
 Deviations, always rectify them 
 Deviated breech 221 
 
 Diagnosis of pelvio 180 
 
 Instrumental delivery in shoul- 
 der 216 
 Pelvic, subdivisions of 184 
 Of the shoulders 211 
 Classification of, in shoulder 211 
 Rules for the band with which 
 
 to correct deviation of 214 
 
 How to rectify them 221 
 
 Fillet in 222 
 
 Blunt hook in 223 
 
 Position of the shoulder 212 
 
 Further inquiries respecting di- 
 agnosis of 217 
 Changes of in the early part of 
 
 labor 218 
 
 Other deviations of 219 
 
 Position of umbilicus 92 
 
 Position and presentation 131 
 
 Grand varieties of 131 
 
 How to convert one into another 190 
 Pregnancy 59 
 
 Alteration of size and position 
 of the pelvic and abdominal 
 viscera caused by 68 
 
 Signs of 108 
 
 Development of uterus caused by 109 
 Physical exploration in 112 
 
 Touch in 113 
 
 Arrangements for physical exa- 
 mination in 114 
 Ballottement in 115 
 Ausciiltation in 116 
 Condition of vagina, urine, &c., in 118 
 Duration of 119 
 Diseases incident to 387 
 Plethora in 388 
 Consequences of plethora in 388 
 Fever from nervous irritation 
 
 during 390 
 
 Best remedy for it in 390 
 
 Mild treatment most proper in 391 
 Exercise during 392 
 
 Venesection in 892 
 
 Catheterism in 393 
 
 Aperients in 394 
 
 How to treat hernia in 395 
 
 Caution about dress in • 395 
 
 Sympathetic treatment Ofirrita- 
 
 tion in 396 
 
 Pruritis vulvae in 396 
 
 Irritation of the bladder, Ac, in 896 
 Care to be taken of the mammae 
 
 in 398 
 
 Hemorrhage from the uterus 
 
 during 400 
 
 Placenta praevia in 400 
 
 How managed 400 
 
 Retroversion of uterus in 402 
 
 Extra uterine 410 
 
 Treatment in extra uterine 413 
 
CONTENTS. 
 
 Puerperal women — usual changes in 
 
 the condition of 
 Quickening 
 Reproduction 
 Rigidity, &c. 
 
 Treatment of 
 Rotation — How to effect 
 Sacrum 
 Speculum 
 Superfetation 
 Sutures of the Cranium 
 Thymus Gland 
 Umbilicus — ^Position of 
 Urethra 
 Urine 
 Uterus 
 
 Alterations in neck and mouth of 
 
 Changes in form of 
 
 Condition of in the second stage 
 of labor 
 
 Obliquity of— cause of deviation 
 
 Obliquity of 
 
 Irregular contraction of 
 
 Treatment of irregular contrac- 
 tion of 
 
 Rigidity of 
 
 Treatment of rigidity of 
 
 Inertia of 
 
 Treatment of inertia of 
 
 Rupture of 
 
 Blundell's instructions in 
 
 Prolapsus and procidentia 
 
 Inversion of 
 
 Degrees of inversion of 
 
 Diagnosis of inversion of 
 
 Treatment of inversion of 
 
 Cause of retention of the pla- 
 centa 
 
 Irritable 
 
 Treatment of irritable 
 
 Displacement of 
 
 Symptoms of displacement of 
 
 True method of diagnosis to ve- 
 rify displacements of 
 
 Treatment of displacements of 
 
 Pessaries in displacements of 
 
 Manner of introducing pessaries 
 in displacements of 
 
 Objections to pessaries in dis- 
 placements of 
 
 Prolapsus of 
 
 Ordinary causes of prolapsus of 
 
 Bandages and compresses in dis- 
 placements of 
 
 Autevcrsion of 
 
 Retroversion of 
 
 Symptoms of retroversion of 
 
 Partial or incomplete retrover- 
 sion of 
 
 Causes of retroversion of 
 
 Treatment of retroversion 
 
 Professor Meigs' instrument in 
 retroversion of 
 
 Uterus — Dr. Henry Bond's instru- 
 ment in retroversion of the 359 
 Retroflexion of the 363 
 
 Tumors in, or springing from 
 
 the 363 
 
 Not always easily diagnosticated 
 
 in the 303 
 
 Treatment of tumors in the 3C4 
 
 Polypus of the 364 
 
 Treatment of polypus of the 366 
 Inflammation of the 367 
 
 Symptoms of inflammation of 
 
 the 367 
 
 Modes of termination of the in- 
 flammation of 368 
 Abscess of 1 he 368 
 Treatment of acute inflamma- 
 tion of 369 
 Ulceration of the 370 
 Best mode of recognition of 371 
 Treatment of ulcers of the 373 
 Malignant ulceration of 373 
 Diagnosis of malignant ulcers of 374 
 Treatment of malignant ulcers 
 
 of the 375 
 
 Cancer of the 376 
 
 Treatmentofcancer of the 377 
 
 Cauliflower excrescence of the 378 
 Treatment of the cauliflower ex- 
 crescence of the 379 
 Vagina 36 
 Vaginitis 340 
 Different stages of 340 
 Gonorrhoeal 340 
 Treatment of 341 
 Pain in back, &c., not always de- 
 pendant upon 342 
 Vectis or lever 188 
 Manner of using it 189 
 Try to use in presentations of 
 
 anterior fontanelle 196 
 
 In cases of craniotomy 291 
 
 Version by Head 192 
 
 Different steps of 192 
 
 By the feet 202 
 
 By the feet in pelvic deformity 302 
 Simpson's argviment 302 
 
 Condition of mother favorable to 203 
 Only while head is within the 
 
 OS uteri 203 
 
 Operation of 203 
 
 I'osition of patient proper for it 204 
 Rule for the use of the particu- 
 lar hand in 204 
 "When to act on the breech only 
 
 in 207 
 
 What to do with the cord in 208 
 
 Spontaneous 213 
 
 Vertex of the cranium 104 
 
 Viability of fetus 91 
 
 Vulva— What to do when the head 
 
 has passed through it 157 
 
 Weight of fetus 92 
 
INTRODUCTORY ADDRESS 
 
 TO MY OWN OBSTETRIC PUPILS, AND TO STUDENTS OP 
 MEDICINE GENERALLY; 
 
 Gentlemen : I dedicate this little work to you. 
 
 Were I in the midst of you, as I present each a copy, I 
 would address you principally in the following words : 
 
 I have designed this little book, as an aid to you in the 
 prosecution of your studies in a very important branch of 
 the science and art of medicine, or as an occasional re- 
 membrancer for you, when you are engaged in the practice 
 of your profession, remote from any experienced living 
 counsellor. 
 
 It is written for you, as a sort of vade raecum, or reviver 
 of your knowledge in this matter, and in this respect as 
 far as it goes, I am sure it will be useful to you ; but re- 
 member, it is not your text book : it is your tes,t book : it is 
 your catechist or inquisitor, not to tell you any thing new, 
 but enable you to determine what you do, or what you do 
 not already know. 
 
 Your knowledge of the great principles on which the 
 important subject of obstetrics is founded, is to be derived 
 from other sources ; from well approved standard works : 
 as those written by Velpeau, by Dewees, by Rigby, by 
 Ramsbotham, by Churchill, by Meigs, Lee, &c. ; and to un- 
 derstand either, or all of them well, you must give faithful 
 attention to the study of the anatomy of the female pelvis, 
 and all those organs which are concerned in the process of 
 conception, gestation, parturition and lactation. These 
 you must study by personal application of your scalpel, 
 under the direction of a skilful anatomical teacher. 
 
 Then follow closely upon the demonstrations of your Ob- 
 stetric Professor through his whole course — examine his 
 various pictorial illustrations, anatomical and physiological 
 
 . (7) 
 
8 INTRODUCTOEY ADDRESS. 
 
 specimens, and give earnest heed to his demonstrations of 
 the mechanism of the various kinds of labor upon the 
 mannikin, — naj, more than this, embrace every possible 
 opportunity to exercise yourselves, either alone with a 
 demonstrator, or in small classes, till you become familiar 
 with every variety of presentation, position, mode of cor- 
 recting those which are deviated — the proper mode of per- 
 forming version — the use of obstetric instruments, &c. 
 This done, my little book will be of service to you, and I 
 shall be gratified, if, when you use it as a catechism of 
 your knowledge in midwifery, you shall have been so well 
 instructed by the method I have just pointed out, that 
 you may detect any error which may exist, either from want 
 of critical knowledge on my own part, or which may have 
 been inadvertently committed, in the haste I have made to 
 supply it to those who have demanded it of me for your 
 sakes, while, as some of you know, I have been closely oc- 
 cupied, not only in the ordinary duties of private practice, 
 but in teaching the science and exercising the art of ob- 
 stetrics in connexion with the Philadelphia Dispensary, 
 Lying-in-Charity, and Nurse Society, since the year 1837, 
 to successive classes of young men, in four courses per an- 
 num, of at least sixty lessons each; have assisted in the 
 training of more than three hundred and seventy advanced 
 students or recent graduates in medicine; stationed them 
 by the bedsides of more than two thousand parturient wo- 
 men ; superintended their conduct there ; relieved them in 
 their embarrassments and aided them in their difficulties ; 
 examined their clinical histories ; superintended the prac- 
 tical education of nearly one hundred nurses; have been 
 engaged with lady visitors of the Institution in deciding 
 the fitness of these candidates to enter upon their respon- 
 sible duties of taking care of parturient and puerperal fe- 
 males under the direction of their physicians, and there- 
 fore, little time has been allowed me for authorship. 
 
 I have not followed the systematic arrangement adopted 
 by any obstetric writer in preparing this little offering, and 
 1 have not calculated it for the meridian of any particular 
 school. 
 
 The grand principles of this science and art are the same 
 every where ; and from the numerous institutions for me- 
 dical teaching, which have sprung up around the parent 
 
INTRODUCTORY ADDRESS. 9 
 
 Btalk throughout the different sections of our wide-spread 
 country, we may hope for a powerful and honorable com- 
 petition for excellence in the mode of illustrating these 
 principles, and the extension of facilities for properly qua- 
 lifying the candidates to enter usefully upon the exercise 
 of one of the most important functions which one human 
 being can exert towards another. 
 
 I have written out the matter now presented to you dur- 
 ing the minutes, for I have not hours of leisure ; and, 
 therefore, lay no claim to great precision in the language I 
 have used. The questions are to be taken, as though they 
 were put to you extemporaneously and familiarly, and the 
 answers are mostly made out as though you were unex- 
 pectedly called upon to give them, and in this I consider 
 consists some good quality in the little essay now put into 
 your hands. 
 
 It will be perceived that I have said much, or rather, al- 
 lowed others to say much respecting the various kinds of 
 forceps which they have purposed for the benefit of the 
 child in cases in which the mother is found incompetent to 
 give it birth in season to secure its continued existence, 
 and have inquired somewhat minutely in reference to the 
 character of instruments which hav^ been contrived to 
 complete the delivery for the mother's sake more especially. 
 I have done this, because, while I continue to believe that 
 instruments of any kind are comparatively rarely needed in 
 cases of well conducted obstetricy, it is exceedingly impor- 
 tant that no man should be allowed to enter upon this de- 
 partment of the profession, in any place whatever without 
 having been first not only shown, hut thoroughly tested in 
 the mode of use of the instruments which unfortunately 
 may be needed for the full accomplishment of all the pain- 
 ful duties which may devolve upon him. 
 
 I have thoughtfully refrained from alluding to the sub- 
 ject of anaesthaesia in obstetric practice, having not much 
 to say from my own experience in its use, and after stat- 
 ing my strong objection to making women, even transiently, 
 drunk, whenever any substitute may be successfully avail- 
 able, I have still preferred not to attempt in the text to 
 prejudice the mind of the student against any preceptorial 
 or professorial biases he may have received. 
 
 I have introduced into this book the sentiments of a few 
 
10 INTRODUCTORY ADDRESS. 
 
 of the .numerous cultivators of obstetric medicine now liv- 
 ing — and I have apparently made you draw some of your 
 responses from a few of the many excellent volumes which 
 have been written on obstetrics. I know full well, young 
 gentlemen, that during the hurried pupilage, which unfor- 
 tunately is the custom of the present age, you cannot have 
 read and reflected upon all that such industrious men could 
 tell you, or have written for you; but should not the al- 
 most unanimous sentiment of the great American medical 
 association influence you and your successors to protract 
 the period of your studentship, I pray that you may, even 
 after having acquired the degree of the Doctorate in the 
 schools of your choice, before you attempt to share largely 
 in those weighty responsibilities which are experienced by 
 some of your older brethren, embrace every possible op- 
 portunity to make yourselves acquainted with the results of 
 their carefully made observations, either by conversation or 
 correspondence with those who are now busy on the stage 
 of professional life, or studying the works of those who 
 have fulfilled their destiny here and have gone hence to 
 receive their retribution, leaving to us a rich legacy in 
 their recorded sentiments and experience. 
 
 Gentlemen — in the course of a quarter of a century de- 
 voted to the practice of medicine, and especially to that of 
 obstetrics, I have many times fuiRy realized the truth of the 
 assertion of the venerable Dr. John W. Francis of New 
 York, uttered more than thirty years ago, and which, on 
 the present occasion, I transmit to you. 
 
 ^' Another circumstance which fortifies the claims of this 
 branch of study, arises from the absolute certainty, that 
 every one engaged in the practice of medicine, is liable to 
 be called upon in obstetrical cases. Although it is per- 
 mitted, that the practice of physic and surgery be exercised 
 by the same individual, it is not unusual for persons to se- 
 lect that particular branch to which their genius or feelings 
 are most partial. But, it is proper for us to bear in mind, 
 that whether emulous of medical or surgical reputation, in 
 the course of our duties, calls in midwifery happen to all. 
 To gentlemen who enter upon the practice of medicine in 
 this country, a knowledge of the obstetric art is indispens- 
 able. Cases of labor occur in every well regulated family, 
 and calls of this nature can neither be parried or delayed. 
 
INTRODUCTORY ADDRESS. 11 
 
 Our wide-spread population is little favorable to that divi- 
 sion of the profession which elsewhere obtains, and what is 
 regulated by common consent, is not to be controlled by 
 individual feeling. 
 
 " To studious and ingenuous youth, our science presents 
 attractions in no wise inferior to any other branch of know- 
 ledge. The whole range of physiology solicits his dili- 
 gence, and will amply reward his toil. Talents of the 
 highest order have lately entered into this field of inves- 
 tigation, and the most sanguine anticipations have been 
 realized. 
 
 " But, it is not the charms of philosophy, nor an honest 
 ambition of fame, which, in this case, are alone to be 
 consulted. Considerations of prudence, and the claims of 
 humanity, alike urge us to the acquisition of this part of 
 the profession. In no situation in which the physician 
 can be placed, does he encounter greater responsibility 
 than in the practice of midwifery. The lives, both of 
 the mother and child, are dependent on his skill, and 
 amid the most trying and perplexing difficulties, his char- 
 acter is committed to the tribunal of censorious and 
 often incompetent judges. Nothing but conscious ability 
 can arm his resolution, or protect his feelings from in- 
 sult. Of that knowledge which lends its aid to art, 
 it is not only requisite that it be possessed, but that it be 
 ready and forthcoming ; and on the practice of mid- 
 wifery above all others, it is incumbent, that his know- 
 ledge be present, and at command. No where is promp- 
 titude and decision more required ; in no instance is the 
 man of science more distinguishable from the mere preten- 
 tender ; in no situation is the conduct of the physician 
 more the object of present attention, or of subsequent 
 criticism. In the Lying-in-chamber no opportunity is 
 afi'orded for qualification or deliberation. The case de- 
 mands immediate assistance, and it is vain to tempo- 
 rise. Vacillation and delay, always dangerous, may here 
 prove fatal. The student's mind must be thoroughly 
 prepared, else the imputation of ignorance will attend his 
 hesitation and confusion. Firmness and decision, founded 
 upon accurate and precise knowledge, will alone secure to 
 him present confidence and future approbation." 
 
 I have addressed you numerous — 2347 — interrogatories ; 
 
12 INTRODUCTORY ADDRESS. 
 
 yet I have omitted many things — but should I discover that 
 you profit well by what I have already done, 1 shall aim, 
 time permitting, to catechise you at some future period 
 upon the whole subject of obstetric medicine, which I con- 
 sider includes not only practical midwifery, but obstetrics 
 proper, and the diseases of puerperal and nursing women, 
 and young children. 
 
 Very respectfully yours, 
 
 JOSEPH WARRINGTON. 
 
 No. 229 Vine Street, Franklin Square, 
 Philadelphia, Jan. 1, 1853. 
 
OBSTETRIC CATECHISM, 
 
 THE FEMALE PELVIS. 
 
 What part of the osseous system of the female, is 
 entitled to the greatest consideration of the practical 
 accoucheur ? That portion called the pelvis. 
 
 Fig. 1. 
 
 Where is the pelvis situated ? At the lower ex- 
 tremity of the trunk, between the last lumbar verte- 
 bra and the upper portion of the ossa femora. 
 
 Of how many bones is the adult pelvis constituted ? 
 Four. 
 
 What are they ? One sacrum, one coccyx, and two 
 ossa innominata. 
 
 Where is the sacrum situated ? Between the last 
 lumbar vertebra above, and the coccyx below, and be- 
 tween the ossa innominata behind. 
 
 2 (13) 
 
14 
 
 ANATOMY OF THE FEMALE PELVIS. 
 
 What is the shape of the sacrum ? Triangular or 
 pyramidal — concave anteriorly and convex posteriorly. 
 
 Fig. 2. 
 
 How many articulating surfaces does it present ? 
 Four. Its base above, for connection with the lumbar 
 vertebra ; its apex below, for the coccyx, and one on 
 the upper half of each side for the posterior portion 
 of the ossa innominata. 
 
 What is found on the anterior surface of the sa- 
 crum ? Four or five quadrangular facettes, with the 
 same nunjber of transverse lines, marking the point 
 of fusion of the originally distinct bones ; at the end 
 of these transverse lines an equal number of foramina, 
 for the passage of the anterior branches of the 
 sacral nerves. 
 
 What muscles are attached to the outer edges of the 
 sacrum, and between these holes ? The pyramidal 
 muscles. 
 
 What is attached to the sharp edges of the inferior 
 half of the sacrum ? The sacro-ischiatic ligaments. 
 
 What is the general appearance of the posterior 
 portion of the sacrum ? Convex, and very rough. 
 
ANATOMY OF THE FEMALE PELVIS. 
 
 15 
 
 What do we find in the median line ? Several spi- 
 nous processes. 
 
 What is to be seen at the upper portion of the pos- 
 terior face ? Articulating surfaces for the last lumbar 
 vertebra. 
 
 What exists at the lower portion ? A triangular 
 notch, in which terminates the spinal canal. 
 
 What is to be seen on each side of the spinous pro- 
 cesses of the sacrum ? Four or more foramina for the 
 transmission of the posterior branches of the sacral 
 nerves. 
 
 What is the object of the rough surfaces near the 
 edges of the posterior face of the sacrum ? To pre- 
 sent points for the strong attachment of sacro-iliac 
 and sacro-ischiatic ligaments. 
 
 What is the object of the broad oblique and some- 
 what rough surface, at the upper lateral portions of 
 this bone ? For articulation with the ilia or inno- 
 minata. 
 
 What is the situation of the coccyx ? At the in- 
 ferior termination of the sacrum,- with which it is ar- 
 ticulated. 
 
 What is its shape ? Triangular. 
 
 What projects upwards, or 
 backwards, from its base ? Two 
 prolongations, resembling horns. 
 
 What is the shape of its apex ? 
 Tuberculated and rounded. 
 
 What is attached to its edges ? 
 The ischio-sacral, or short sacro- 
 ischiatic ligament. 
 
 What muscles are inserted in- 
 to its edges ? The ischio-coccy- 
 geal muscles. 
 
 What muscle is attached to its 
 point ? The external sphincter 
 ani muscle. 
 
 Of how many bones is the coccyx originally com- 
 posed ? Three or four. 
 
 Fig. 3. 
 
16 
 
 ANATOMY OF THE FEMALE PELVIS. 
 
 What kind of articulation exists between the sacrum 
 and coccyx ? Gynglimoid, or hinge-like. 
 
 What is the direction of the motion of the coccyx 
 upon the sacrum ? Antero-posterior. 
 
 What is the extent of movement usually allowed to 
 the apex of the coccyx ? Erom half an inch to an 
 inch. 
 
 Does the presence of the coccyx necessarily inter- 
 fere with the process of labour ? Only when it is 
 partially or completely anchylosed. 
 
 What is the general shape of an os innominatum ? 
 It has a very irregular quadrangular shape, appearing 
 as if strangulated at its middle, and twisted in two op- 
 posite directions. 
 
 Fig. 4. 
 
 How many surfaces has it ? Two, one external and 
 one internal. 
 
 What is the arrangement of its internal surface ? It 
 is divided into two nearly equal portions ; the upper 
 one, extensively excavated, is called the internal iliac 
 fossa. 
 
ANATOMY OF THE FEMALE PELVIS. 17 
 
 What occupies this broad expanse ? The internal 
 iliac muscle. 
 
 What do we find at the posterior margin of this up- 
 per portion ? An articulating surface for junction 
 with a portion of the sacrum. 
 
 What is the general shape of the inferior portion ? 
 Triangular. 
 
 What opening exists, about the centre of this 
 lower portion ? The obturator foramen, or subpubic 
 opening. ^ 
 
 What constitutes the point of division between the 
 upper and lower portions of the ossa innominata ? 
 The linea-ilio-pectinea, running from the crest of the 
 pubis, backwards towards the junction with the sacrum. 
 
 What is to be observed on the external or femoral 
 surface of the os innominatum ? First, the external 
 iliac fossa ; secondly, the acetabulum ; thirdly, the 
 subpubic, or obturator foramen, surrounded by the 
 edges of the pubis, the ischium and the ischio-pubic 
 ramus. 
 
 What occupies the external iliac fossa ? The glutei 
 muscles'. 
 
 What is noticed on the upper edge of the os inno- 
 'minatum ? The crest of the ilium. 
 
 What is attached to this crest ? Muscles in its cen- 
 tral portion, Poupart's ligament at the anterior, and 
 the sacro-iliac ileo lumbar ligaments at the posterior 
 extremity. 
 
 What is seen on its anterior edge ? First, the antero- 
 superior spine of the ilium, next a small semilunar 
 notch, then the inferior anterior spine of the ilium, 
 the groove for the psoas and iliacus muscles, then the 
 ileo-pectineal eminence for the insertion of the psoas 
 parvus muscle, then a triangular smooth surface, the 
 spine of the pubis. 
 
 What is the arrangement of the posterior edge of 
 
 this bone ? First, the posterior spine of the ilium ; a 
 
 small irregular notch ; the posterior inferior spine of 
 
 the ilium ; which articulates with the sacrum, then the 
 
 2* 
 
18 ANATOMY OF THE FEMALE PELVIS. 
 
 great ischiatic notch, and lastly the posterior portion 
 of the tuberosity of the ischium. 
 
 Of how many distinct bones is the os innominatum 
 originally composed ? Three, the ilium above, the 
 ischium directly below, the pubis in front of the last, 
 and rather below the first. 
 
 At what points are these bones consolidated into one 
 at a later period of life ? In the acetabulum, or co- 
 tyloid cavity, at the pectineal eminence and at the 
 middle of the ischiopubic ramus. 
 
 At about what period of life, does this consolidation 
 take place ? The age of puberty. 
 
 What are the principal articulations or symphyses 
 of the pelvis ? One for the two pubic bones to each 
 other in front, and one for each ilium to the sacrum 
 behind. 
 
 What is the mode of articulation of the symphysis 
 pubes ? The two articular surfaces are applied to 
 each other, and sustained firmly in that position, by 
 strong ligamentous fibres, before and behind. Under- 
 neath, the fibrous arrangement is so abundant, as to 
 give to it the character and name of sub-pubic liga- 
 ment. 
 
 Is the symphysis pubes of the adult female suscepti- 
 ble of spontaneous separation, or of having one ex- 
 tremity moved upon the other ? There are strong 
 reasons for believing that no perceptible degree of 
 motion can be efi'ected in a healthy condition of the 
 parts. 
 
 What is the character of the posterior or sacro-iliac 
 symphysis ? The sacrum is placed like an inverted 
 key-stone at the top of an arch, between the two iliac 
 bones ; strong bands of ligamentous fibres extend 
 across from the sacrum to the ilium on each side, and 
 thus a strong fibro cartilaginous symphysis is effected. 
 
 Is there a bursa, or synovial sac, found in either of 
 these symphyses ? In the symphysis of the pubes, 
 there is to be seen an approximation to a bursa ; it is 
 however far from complete. In each of the sacro-iliac 
 
ANATOMY OF THE FEMALE PELVIS. 
 
 19 
 
 junctions there are found some small points of con- 
 densed fatty matter, but no regular bursa. 
 
 Does the pelvis derive support from any other 
 points than those at which the bones are articulated ? 
 It is decidedly fortified by the addition of the ileo- 
 lumbar ligaments — sacro-iliac and sacro-ischiatic liga- 
 ments. 
 
 Where is Poupart's ligament situated ? It com- 
 mences at the anterior superior spinous process of the 
 ilium, and extends to the crest of the pubis, crossing 
 to a small extent beyond the symphysis. 
 
 Where is the obturator membrane found ? Filling 
 up nearly the whole of the obturator foramen, admit- 
 ting merely of space sufficient to allow the transmis- 
 sion of small vessels, nerves and muscles. 
 
 If we divide the pelvis into two equal parts, by a 
 section through the acetabula, what will be found in 
 the anterior portion ? The bodies and rami of the 
 pubes, the arch of the pubes, the rami of the ischia, 
 and the obturator foramina. 
 
 Fig. 5. 
 
 What will be found in the posterior half ? The sa- 
 crum and coccyx, the bodies of the ischia and ilia, 
 sacro-sciatic notches. 
 
20 
 
 ANATOMY OF THE FEMALE PELVIS. 
 
 What do the lateral portions of the pelvis include ? 
 The ischia and ischiatic notches with a part of the 
 obturator foramina. 
 
 Fig. 6. 
 
 How is the pelvis divided above and below ? Into 
 false pelvis above, and true pelvis below. 
 
 What forms the boundary line between the two ? 
 The linea-ilio-pectinea. 
 
 What is the upper portion called ? Pavilion ; false 
 pelvis ; and abdominal pelvis. 
 
 What is its general description ? It is defective 
 directly in front, is expanded and elevated at the 
 sides, while posteriorly it is again diminished except 
 in the central portion, where it is somewhat filled up 
 by the promontory of the sacrum and the lower lum- 
 bar vertebrae. 
 
 What influence do these lumbar vertebrae, and the 
 promontory of the sacrum exert on the position of 
 the child ? They project so far into the cavity of the 
 abdominal pelvis as to divide it into two portions, and 
 cause the child to slide off to one side. 
 
 What is the distance between the superior anterior 
 
ANATOMY OF THE FEMALE PELVIS. 21 
 
 spinous process of one ilium and that of the other? 
 From nine to ten inches. 
 
 What is the distance between the middle point of 
 one crest and that of the other ? From ten to eleven 
 inches. 
 
 What is the depth of the upper or abdominal pel- 
 vis, that is, from the top of the crista to the linea- 
 ilio-pectinea ? From three and one fourth, to three 
 and a half inches. 
 
 Which is of most importance in obstetrics, the su- 
 perior or inferior pelvis ? The inferior, or emphati- 
 cally the pelvis. 
 
 PELVIS PROPER. 
 
 What is its general shape ? Conoidal, with its base 
 upwards. 
 
 What are its principal openings ? - One above, and 
 one below. 
 
 What are these openings called ? Straits. 
 
 Why ? Because they are rather more contracted 
 than the space between them. 
 
 What is the space between the straits called? The 
 cavity or concavity, basin, etc. 
 
 Are these straits just alluded to, not identical with 
 the cavity ? They are the initial and terminal por- 
 tions of the true pelvis, but should always be distin- 
 guished from the cavity itself. 
 
 What is the shape of the superior strait ? Cor- 
 diform, or somewhat elliptic, with one end of the 
 ellipse depressed. 
 
 What constitutes the superior strait ? The top of 
 the symphysis pubes, the linea-pectinea, the linea-ilea, 
 and promontory of the sacrum. 
 
 What is the circumference of the superior strait ? 
 From thirteen inches to thirteen and a half. 
 
 W^hat number of diameters of this strait are recog- 
 nized in practice ? Four. 
 
 What are they ? First, antero-posterior, or sacro- 
 pubic, measuring from four, to four and a half inches. 
 
22 
 
 ANATOMY OF THE FEMALE PELVIS. 
 
 Second, oblique, from points in tlie linea-ileo-pectinea 
 (c) diagonally to the sacro-iliac symphysis, {g) measur- 
 ing five inches. Third, the transverse, or bis-iliac, on 
 the transverse median line, from one point of the linea- 
 ileo-pectinea (e) to the opposite (/), measuring five 
 and one fourth inches. 
 
 Fig. 7. 
 
 What is the direction of the axis of the superior 
 Btrait ? It commences about the point of the coccyx : 
 passes at right angles with the plane of the strait 
 through its centre, and would make its exit through 
 the abdominal parieties about the umbilicus. 
 
 What relation does this axis hold to the pelvis, and 
 to that of the body ? It is always uniform with re- 
 gard to the pelvis, but it is variable with regard to the 
 body. 
 
 How is the inclination of the superior strait best de- 
 fined ? Professor Meigs says, when the woman 
 stands erect, or lies at length on her back, the plane 
 of the strait dips at an angle of 50° below the con- 
 jugate diameter. It must clearly appear that the 
 plane of the superior strait dips at a variable angle 
 in various positions of the trunk of the body ; for if 
 
ANATOMY OF THE FEMALE PELVIS. 
 
 23 
 
 the subject be standing it dips as above at 50° ; but 
 •if the trunk be inclined forwards, the dip will be 
 lessened : or, if the trunk be inclined far backwards, 
 it may be increased. Now this is an important item 
 of obstetrical knowledge, since upon it is founded our 
 advice as to the decubitus of the patient, whom we 
 
 Fig. 8. 
 
 may direct to extend the trunk, or to flex it more or 
 less, as we may or may not desire to bring the plane 
 of the superior strait into a position that may favour 
 both the entrance of the presenting part into the 
 strait and its passage through it. 
 
24 ANATOMY OF THE FEMALE PELVIS. 
 
 By figure 8, it may be shown that the plane may 
 give different angles with the spine, according as the 
 spine is brought more forward, or carried further 
 backwards — {e e e) is a circle of which the diameter 
 (6/) represents the inclination of the plane of the 
 upper strait equal to an angle of 135° (fee) which is 
 the ordinary altitude of the spinal column or axis of 
 the trunk. If the patient, lying on her back, should 
 have her shoulders raised, so as to carry her spine for- 
 ward to (<?), equal to 22.30°, the angle would be re- 
 duced to 112.30°. But if the shoulders should be 
 still more elevated to {d) the axis of the trunk, 
 would be at right angles to the plane of the strait 
 
 Place the woman on her left side in bed, and by the 
 same reasoning the accoucheur may direct the patient 
 to modify the inclination or dip of the inlet of the 
 pelvis, by inducing her to keep the spinal column 
 strait or curving it forwards. 
 
 What practical hint is derived from a know- 
 ledge of this variability ? That in difficult or tedious 
 labors we should oblige the patient to incline her body 
 forward to make its axis more nearly correspond with 
 that of the superior strait. 
 
 What is the shape of the plane of the inferior 
 strait ? It is oval, or slightly cordiform, if we allow 
 the coccyx to encroach upon its posterior extremity. 
 
 What are the boundaries of the inferior strait ? 
 The sub-pubic ligament in front, the rami of the pu- 
 bes and ischia on each side, and the sacro-ischiatic 
 ligaments and coccj^x behind. 
 
 What is the circumference of the inferior strait ? 
 Twelve inches. 
 
 From what points do we reckon the antero-posterior 
 diameter ? From the posterior portion of the sub- 
 pubic ligment, to the point of the coccyx, or better 
 still, to the apex of the sacrum. 
 
 What is the distance ? Four and a half inches ; 
 (a to b) fig 9. 
 
ANATOMY OF THE FEMALE PELVIS. 25 
 
 From what points do we reckon the transverse dia- 
 meter ? From the posterior part of the tuberosity 
 of one ischium, to that of the other, {c to d) fig. 9. 
 
 Fig. 9. 
 
 What sjnonyme have we for this diameter ? Bis- 
 iscliiatic diameter. 
 
 What does it measure ? Four inches. 
 
 What oth(*r diameters should be remarked in the 
 inferior strait ? Two oblique. 
 
 Whence are they measured ? From the junction 
 of the ramus of the pubis, and the ramus of the 
 ischium on either side across to the centre of the 
 sacro-ischiatic ligaments on the opposite sides, {e to / 
 e to/) fig. 9. 
 
 What is the space ? Four inches ; the same as the 
 transverse diameter. 
 
 What is the direction of the axis of the inferior 
 strait ? Commencing just below the promontory of 
 the sacrum, it passes downwards perpendicularly 
 through the centre of the plane of the inferior strait, 
 at the point of intersection of the antero-posterior 
 and transverse diameters, and thus out about the 
 posterior commissure of the undilated, or through the 
 centre of the dilated vagina. 
 3 
 
26 ANATOMY OF THE FEMALE PELVIS. 
 
 What is the difference between the transverse dia- 
 meters of the superior and inferior straits ? The 
 transverse diameter of the superior strait is one half 
 or three fourths of an inch longer than that of the 
 inferior strait. 
 
 If we push back the coccyx, and thus make the an- 
 tero-posterior diameter of the inferior strait equal to 
 tliat of the oblique, or transverse of the superior strait, 
 with what body might we compare the cavity of the 
 pelvis ? That of a cylindroid, twisted one sixth of its 
 circumference upon its axis. 
 
 What are 'the supero-inferior measurements of the 
 pelvis ? From the top of the symphysis to the lower 
 edge of the sub-pubic ligament, one and a half inches. 
 From the top of sacrum to the point of coccyx, five 
 inches ; when the coccyx is pushed back, from five 
 and a half to six inches. From the linea-ilio-pectinea 
 to the tuberosity, three and a half inches ; from the 
 crest of ilium to the bottom of tuberosity of the 
 ischium, seven inches. 
 
 What is the distance from the bottom of the sub- 
 pubic ligament to the top of the promontory of the 
 sacrum ? Four and a half inches. 
 
 What is the distance from the bottom of sub- pubic 
 ligament to the hollow of the sacrum ? Four and three- 
 fourth inches to five inches. 
 
 What is the distance from the bottom of the tube- 
 rosity of one ischium to the linea-ilio-pectinea directly 
 opposite ? Six inches. 
 
 What is the height of the arch of the pubes, from a 
 line drawn on a level with the tuberosities of the is- 
 chia ? Two inches. 
 
 INCLINED PLANES. 
 
 Into what peculiar arrangement is the interior of 
 the pelvis distributed ? On each side of the antero- 
 posterior median line are found two lateral inclined 
 planes. 
 
 What is the direction of the anterior inclined planes 
 
ANATOMY OF THE FEMALE PELVIS. 
 
 27 
 
 on each side ? Commencing nearly or exactly at the 
 sacro-iliuc symphysis, they occupy all the space be- 
 tween that point and the symphysis pubes, and pass- 
 ing downwards and forward just in front of the spines 
 of the ischia, over the obturator foramina, they termi- 
 nate on the anterior edge of the rami of the pubes 
 and ischia, and at the symphysis of the pubes ; the 
 space between A, B, and C, fig. 10, represents the 
 right anterior inclined plane. 
 
 Fig. 10. 
 
 What is the arrangement of the posterior inclined 
 planes ? Commencing at the sacro-iliac junctions, at 
 or below the linea-ilio-pectinea, they occupy the space 
 between those points and the middle line of the sa- 
 crum, then pass downwards and backwards behind 
 the spines of the ischia, over the sacro-sciatic fora- 
 mina and sacro-ischiatic ligaments, to terminate upon 
 the posterior edges of the tuberosities of the ischia, 
 the lower edges of the sacro-ischiatic and coccygeo- 
 ischiatic ligaments, and also the point of the coccyx. 
 
 Which of these occupies the greater space in tho 
 
28 
 
 ANATOMY OF THE FEMALE PELVIS. 
 
 pelvic canal, the anterior or posterior inclined planes ? 
 The anterior, being both longer and wider. 
 
 What influence do these planes exert upon the me- 
 chanism of labor? Rotation. They direct the pre- 
 senting part of the fetus. Thus if the occiput happen 
 to be brought in contact with the pelvis anterior to the 
 spine of the ischium, it must pass down upon the an- 
 terior inclined plane, and emerge under the arch of the 
 pubes ; but if the occiput happen to enter the pelvis 
 behind the spine of the ischium, the posterior inclined 
 plane compels it as it passes down, to rotate into the 
 hollow of the sacrum, that it may escape at the pos- 
 terior commissure of the vulva. 
 
 AXIS OF THE PELVIS. 
 Regarding the pelvis as constituted of a series of 
 planes, extending from the sacrum to the pubes, from 
 
ANATOMY OF THE FEMALE PELVIS. 29 
 
 the linea-ilio-pectinea to the coccyx and sub-pubic lig- 
 ament, how can we represent the axis of the pelvis ? 
 As a curved line, resembling that of a catheter adapted 
 to the adult male, as shown in fig. 11, where (BB) rep- 
 resents the prolonged axis of the superior strait, (AA) 
 that of the inferior strait, (EE) the plane of inferior 
 strait prolonged beyond the arch of the pubes ; (GF) 
 the plane of the superior strait, somewhat extended, 
 while the several lines radiating from (G) represent 
 the planes of difi"erent segments of the cavity of the 
 pubes, then the curved line (FF), passing at right 
 angles through the several planes represents the 
 curve of the catheter, while the extended line to (B), 
 represents the straight portion of the catheter, as sug- 
 gested. 
 
 Who has most beautifully delineated the curved 
 direction of the axis of the various ^acro and coccy- 
 pubal planes of the pelvis ? Professor Carus of Dres- 
 den. 
 
 How should you describe it ? Set one leg of a pair 
 of compasses in the middle of the posterior edge of 
 the symphysis pubes of a bisected pelvis as in the ac- 
 companying figure 12 — the other leg of the instru- 
 ment being opened to the distance of the semidia- 
 meter of the sacro-pubal diameter of the superior 
 strait. Commencing at this point in the diameter, de- 
 scribe a circle. Extend the sacro-pubal diameter by 
 a dotted line, till it reaches the circumference ; from 
 the end of the coccyx, a little extended, produce a 
 line to the end of the pubes, then continue it dotted 
 till it reach the outer periphery of the circle : — draw 
 also a line from the centre of the concavity of the 
 sacrum through the inner periphery to the centre. 
 Continue this as a dotted line to the outer periphery. 
 It will be found that these three dotted lines will meet 
 precisely in the same point in the outer periphery. 
 This circle, according to Carus, will, for all ordinary 
 purposes, sufficiently faithfully represent the axis of 
 the various sacro-pubal, coccy-pubal and perinseo- 
 
80 ANATOMY OF THE FEiMALE PELVIS. 
 
 pubal planes of the pelvis. It is in the line of this 
 curve that the centre of any body will be propelled, 
 during its passage through the pelvis. 
 
 Fig. 12. 
 
 Of what value to practical midwifery is a know- 
 ledge of this disposition of the axis of the pelvis ? It 
 is indispensible to success and safety in all manual in- 
 strumental operations, whether for the delivery of the 
 fetus or placenta. 
 
 What are the general points of difference between 
 the pelvis of the female and the male adult ? The 
 capacity of the female pelvis is greater than that of 
 the male, its diameter being larger, though its depth 
 is less. In the male, the arch is narrow and high, 
 while in the female it is broad, low, and well formed. 
 
 OF THE CONTENTS OF THE FEMALE PELVIS. 
 
 What muscles line the upper pelvis ? The iliaci 
 interni and the psose muscles. 
 
 What are the origin and insertion of the iliacus in- 
 ternus muscles ? They rise from the anterior two- 
 thirds of the crest of the ilium, in front of the psose 
 muscles, and filling up the iliac fossa, are inserted with 
 the psoas muscles into the small trochanter of the 
 femur. 
 
 In what respect do these muscles affect the diame- 
 
ANATOMY OF THE FEMALE PELVIS. 31 
 
 ters of the superior strait in the recent pelvis ? They 
 diminish the lateral and oblique diameters from one 
 fourth to one half of an inch. 
 
 Which diameter is the longer in the recent pelvis — 
 the oblique or transverse ? Ramsbotham says the ob- 
 lique — Hodge the transverse diameter, while Cazeaux 
 declares that the oblique diameters are not diminished 
 in length by the presence of the muscles. 
 
 What muscles and fascia line and close up the infe- 
 rior strait of the pelvis ? The pelvic fascia, including 
 the internal iliac vessels and branches*— the internal 
 obturator and part of the levatores ani, transversus 
 perinei, and ischio- coccygeal muscles. 
 
 What are the origin and insertion of the levatores 
 ani muscles ? They arise from the inner part of the 
 pubes, the superior part of the obturator foramen, and 
 the spine of the ischium. Inferiorly the middle and 
 anterior fibres unite beneath the rectum, envelop- 
 ing this intestine, and they are inserted into the 
 sphincter ani and perineum in front. 
 
 What is to be understood by the phrase, " floor of 
 the pelvis ?" All the tissues found extending from 
 the lower part of the pelvis, and closing more or less 
 the inferior strait. It is composed of the levator ani 
 and ischio coccygeal muscles, which constitute the 
 superior plane, and which is concave above ; the sphinc- 
 ter-ani, transversalis perinaei, ischio-cavernosus and 
 sphincter vulvae muscles, and the aponeuroses, which 
 are less resisting in the female than in the male, com- 
 pose the inferior plane of the floor of the pelvis. The 
 pubic vessels and nerves with cellular membrane and 
 the integuments complete this floor. 
 
 What is observed on the antero-posterior median line 
 of the exterior surface of the floor of the pelvis ? The 
 raphe of the perinseum, the point of junction of the sev- 
 eral constituent tissues of the perinaeum, and one whose 
 rigidity in some cases, as well as its relative feeble- 
 ness, subjects it to the risk of laceration, under 
 powerfully distending forces. 
 
32 
 
 ANATOMY OF THE CONTENTS 
 
 What influence may the constituents of this pelvic 
 floor exert upon the process of labor ? They may, 
 owing to the rigidity of the parts or spasm of the mus- 
 cles, retard the exit of the presenting part of the child. 
 
 What viscera are contained in, and attached to, the 
 pelvis ? The rectum behind, the bladder in front, the 
 uterus and its appendages in the middle and lateral 
 portions of the cavity. The vagina, and other por- 
 tions of the organs of generation occupy the lower 
 portion of, and are attached to, the pelvis. Fig. 13 
 gives a lateral section of the contents of the pelvis, 
 showing the rectum next the sacrum ; next, and in 
 the middle, the uterus and the vagina, and in front, 
 the bladder in a state of partial distention. 
 
 Fig. 13. 
 
 GENITALIA, OR ORGANS OF GENERATION. 
 
 Do we speak of the whole group of organs of gene- 
 ration in a general or special sense ? It should be un- 
 derstood in a general sense only. 
 
OF THE FEMALE PELVIS. 33 
 
 How are the organs of generation classified ? Into 
 those of external, and those of internal organs of ge- 
 neration. 
 
 What are called the external organs ? Pudenda, 
 labia externa, clitoris, nymphse, orifice of vagina, and 
 perinaeuni. 
 
 What is usually included in this list, though it does 
 not pertain to generation ? The meatus urinarius. 
 
 What is the mons veneris or pudenda, and where is 
 it situated ? It is composed of a dense fibro-cellular 
 adipose substance, covering the pubes and extending 
 up to a line drawn between the anterior inferior spinous 
 processes of the ilia. , 
 
 By what is it covered ? By thick strong hairs. 
 
 Where are the labia externa situated, and how are 
 they arranged ? Commencing upon the front of the 
 symphysis pubes, they extend doAvnwards and back- 
 wards to the perinaaum ; they are thick and prominent 
 at their upper portion, but gradually diminish and be- 
 come flattened as they pass towards their posterior ter- 
 mination. 
 
 What are the anterior and posterior points of junc- 
 tion of the labia called ? The anterior and posterior 
 commissures of the vulva. 
 
 What is the texture of the labia ? Principally cel- 
 lular and vascular. 
 
 What kind of investment has the labia ? It is cu- 
 ticular but passing into the mucous state. 
 
 What are the boundaries of the vulva ? They em- 
 brace all the parts immediately surrounding the genital 
 fissure. 
 
 What is found within the upper half of the labia 
 majora ? The nymphse, or labia minora, or the labia 
 interna. 
 
 What is the situation of the labia minora or nymphse ? 
 They arise from nearly the same point at the anterior 
 commissure, and pass obliquely downwards and back- 
 wards about an inch, and then are lost in the general 
 lining of the labia externa. 
 
34 ANATOMY OF THE CONTENTS 
 
 What is the general shape of the nymphse ? Tri- 
 angular. 
 
 What modifications of size or shape are they inci- 
 dent to ? In the infant they are always comparatively 
 large ; and they may become greatly elongated and 
 enlarged, and consequently sufier much alteration in 
 shape at later periods of life. 
 
 Is a knowledge of this enlargement of consequence 
 to the practitioner ? Enlarged nymphse may be en- 
 tangled within the obstetric forceps and be torn, or 
 otherwise they may embarrass the use of instruments. 
 
 What is the anatomical structure of the nymphse ? 
 It is cellular, very vascular, and has the properties of 
 an erectile tissue. 
 
 What kind of external covering has it ? A very de- 
 licate dermoid, or perhaps mucous membrane. 
 
 What is to be found at the superior extremity of 
 the nymphae ? A little hemispherical body, called the 
 glans clitoridis. 
 
 What is this glans the termination of? The clitoris, 
 which appears to be a rudimental penis. 
 
 In what respect does it differ from the male organ ? 
 It is much less than it, and has no corpus spongiosum 
 urethrse. 
 
 What overhangs the glans clitoridis ? A fold of 
 membrane, called the preputium clitoridis. 
 
 How low do the nymphge descend ? To the middle 
 of the orifice of the vagina nearly. 
 
 What is the space between the nymphse called ? 
 The vestibulum. 
 
 What are the characters of the vestibulum ? It is 
 a smooth, triangular surface, covering the facette of 
 the symphysis pubes and is bounded on each side by 
 the base of the nymphge, having the clitoris as its apex, 
 and a line drawn from the lower terminal extremity of 
 one nymphge to that of the other, through a perforated 
 caruncle. 
 
 What is that tubercle or caruncle called? The 
 meatus urinarius, or orifice of the urethra. 
 
OF THE FEMALE PELVIS. f& 
 
 URETHRA. 
 
 What is the position of the urethra, with regard to 
 the arch and symphysis of the pubes ? Mostly imme- 
 diately below the one and behind the other. 
 
 Is the tubercle or caruncle of the urethra always 
 well developed and easily to be recognized by the 
 touch ? Considerable variety is observable in the in- 
 vestigation of many cases. Sometimes, for example, 
 the orifice is very thin, merely membranous. Some- 
 times, it is very patulous and funnel shaped. 
 
 Does the urethra pass off in a strait or curved line 
 from the body of the bladder ? In a line curved down- 
 wards and forwards. 
 
 What circumstances may modify the direction of the 
 orifice and the course of the canal ? , In some degrees 
 of prolapse of the uterus or vagina, the urethra is more 
 curved — in extreme cases it is nearly inverted — while 
 in advanced pregnancy, retroversion of the uterus, or 
 in cases of enlarged pelvic tumors it is often drawn 
 up tightly behind the symphysis of the pubes. 
 
 How long is the female urethra ? About one inch. 
 
 By what is it lined ? Mucous membrane. 
 
 In what direction do the folds of the mucous mem- 
 brane of the urethra run ? Longitudinal and not 
 usually transverse. 
 
 What is there in the female urethra, analogous to 
 the prostatic portion in the male ? A thickened con- 
 dition of the vagina, anteriorly, and a developement 
 of the cellular membrane on the posterior part of the 
 urethra. 
 
 What is to be found at the orifice of the urethra ? 
 A little caruncle generally, sufficiently prominent to 
 offer some resistance to the touch of the finger. 
 
 What little folds exist in the canal of the urethra ? 
 Folds of mucous follicles, which are sometimes con- 
 siderably developed. 
 
 What is the general shape of the empty bladder in 
 the female ? Globular. 
 
36 ANATOMY OF THE CONTENTS 
 
 VAGINA. 
 
 What is found immediatelj below the meatus urina- 
 rius ? The orifice of the vagina. 
 
 What are the boundaries of the orifice of the va- 
 gina ? All that portion just in front of the part em- 
 braced within the sphincter vagina muscle. 
 
 What is the vulvo-uterine canal ? It is the vagina, 
 a canal leading from the vulva to the uterus. 
 
 What muscle surrounds the vagina near its ori- 
 fice ? The sphincter vaginae. 
 
 What are its origin and insertion ? It arises from 
 the posterior portion of the vagina near the perinaeum, 
 thence it runs up the sides of the vagina near its ex- 
 ternal orifice opposite to the nymphae, and covers the 
 corpus cavernosum vaginae, and is inserted into the 
 crus and body of the clitoris, on each side. 
 
 What influence can it exert ? It is often feeble, but 
 sometimes so powerful as to close firmly the anterior 
 portion of the canal. 
 
 What is the length of the vagina, or vulvo-uterine 
 canal? From four to six inches. Sometimes it is 
 much less than this. 
 
 What is its direction in the pelvis ? It is curved up- 
 wards. 
 
 What are the directions of its long diameters ? At 
 its external extremity the long diameter is in the di- 
 rection of the genital fissure, antero-posterior — near 
 its middle the long diameter is transverse and longer 
 tlian the first, while at the upper part it is still longer. 
 
 What is the length of the antero-posterior diameter 
 of the orifice of the vagina ? From half an inch to 
 an inch, in its undistend»3d state. 
 
 Is the vagina susceptible of becoming much en- 
 larged ? Not only may its circumference be increased 
 to that of the cavity of the pelvis during parturition, 
 but it may, and sometimes does become sufficiently 
 large and long to contain the entire fetus between the 
 uterus and the vulva, during part of the parturient eff'ort. 
 
OF THE FEMALE PELVIS. 37 
 
 What part of the vagina has most sensibility ? The 
 external orifice, just at the point of union or transition 
 of dermoid and mucous tissues. 
 
 What is the anatomical structure of the vagina ? 
 Cellulo-fibrous, with a mucous lining membrane. 
 
 Whence is the mucous secretion furnished in the va- 
 gina ? From a large number of mucous follicles ar- 
 ranged within the canal. 
 
 What is the arrangement of the lining mucous mem- 
 brane ? Arborescent — though some of the folds are 
 longitudinal, particularly those anterior and posterior, 
 while others are transverse, and are sometimes called 
 columns of the vagina. 
 
 What supply of blood-vessels has the vagina ? Be- 
 sides the arteries which carry blood to it, the canal is 
 nearly surrounded by a plexus of veins. 
 
 In what respect is the texture of the vagina differ- 
 ent from that of the nymphse ? It is non erectile, and 
 some portions of it probably contain thin muscular fibres. 
 
 What is the condition of the vagina in the virgin fe- 
 male ? It is small, and near ifcs orifice is partially closed 
 by a duplication of lining membrane called the hymen. 
 
 HYMEN. 
 
 What is the shape of the orifice of the hymen ? It 
 IS variable. Sometimes triangular ; sometimes oval, 
 round, lunated, and even cribriform, or pierced with 
 several holes. 
 
 Is it always present In the virgin female ? It is 
 sometimes perhaps congenitally absent, but most pro- 
 bably because it has been destroyed in infancy by in- 
 judicious management in washing and wiping the parts. 
 
 Is it ever thrown so completely across the orifice of 
 the vagina as to close it up entirely ? In some cases 
 this condition is found to exist. 
 
 About how far within the vulva is the hymen in the 
 adult female ? Half an inch. 
 
 What becomes of the hymen after it is ruptured ? 
 The lacerated surfaces cicatrize, and form several little 
 4 
 
38 ANATOMY OF THE CONTENTS 
 
 eminences upon the surface of the vagina, which have 
 been called carunculge mjrtiformes. 
 
 Is it a settled matter that all the mulberry-like ca- 
 runcles are formed in this way ? Velpeau, at least, 
 thinks that two or more of them exist originally and 
 independently of this cicatrization of the ruptured por- 
 tions of the hymen. 
 
 What is found at the inferior portion of the hymen 
 and anterior to it ? A depression, called the fossa na- 
 vicularis. 
 
 What is its inferior boundary ? The frenum labio- 
 rum, frenulum perinei, or the fourchette. 
 
 PERINEUM. 
 
 What is found posterior to the orifice of the vagina ? 
 The perinseum. 
 
 How long is it when undistended ? About one and 
 a half inch. 
 
 To what extent may the term perinseum be applied ? 
 To every portion of the distensible parts found at the 
 inferior opening of the female pelvis. 
 
 What is the shape of the perinseum ? As usually 
 described it is triangular. 
 
 What are its boundaries ? As viewed by some ob- 
 stetricians, as including all the distensible parts of 
 the inferior opening of the pelvis, its boundaries should 
 be those of the inferior strait of the pelvis. 
 
 What is the composition of the perinseum ? Several 
 muscular layers, as the transversus perinaei, the leva- 
 tores and sphincter ani muscles, &c., then a con- 
 siderable portion of distensible cellular and dermoid 
 tissue, &c. 
 
 Of what degree of dilatation is the perinasum sus- 
 ceptible ? Nearly or quite sufficient to cover the head 
 of the child when extruded beyond the inferior 
 strait. 
 
 What may be seen in the recent female subject, if 
 the anterior parietes of the abdomen and the intes- 
 tines are removed ? The bloodvessels and the vis- 
 
OF THE FEMALE PELVIS. 
 
 39 
 
 cera of the pelvis. Thus in fig. 14, are seen at A, the 
 aorta ; B, vena cava ; C, one of the internal iliac ar- 
 teries descending into the cavity of the pelvis ; D and 
 E, one of the external iliac arteries and veins ; F, G, 
 the psoas muscles ; H, the rectum ; I, the fundus of 
 the uterus ; K, the urinary bladder. 
 
 Fig. 14. 
 
 UTERUS. 
 
 What kind of organ is the uterus ? It is a gestative, 
 not a generative organ. 
 
 What is the particular shape of the uterus ? Pyri- 
 form, or conical, somewhat flattened antero-posteriorly. 
 
 Which is the flatter surface, the anterior or the pos- 
 terior ? The anterior. 
 
 For general purposes of description, what shape may 
 we assume for the uterus ? Triangular. 
 
 How many sides and angles has it ? Three sides 
 and three angles. 
 
 What go off" from the superior angles ? Two ap- 
 pendages called fallopian tubes. 
 
 What name is given to the part above these tubes ? 
 Fundus of the uterus. 
 
 What proceed from the antero-lateral surfaces just 
 
40 
 
 ANATOMY OF THE CONTENTS 
 
 below the fallopian tubes? The round, anterior or 
 utero-pubal ligaments. 
 
 Fig. 15, B, shows the portion of the uterus which 
 projects into the vagina ; H, the vagina, opened on 
 its upper or anterior portion, and spread out laterally ; 
 C C, represent the fallopian tubes, the fibriated ex- 
 tremity of one of which is shown at D ; E E indicate 
 the ovaries ; while F points to the right ovarian liga- 
 ment, which for convenience is here shown as above 
 the fallopian tube ; G G, the segment of the round 
 anterior or superpubal ligaments. 
 
 Fig. 15. 
 
 What portion is called the body of the uterus ? All 
 that part between the superior angles and the cylin- 
 drical portion ; in other words, all the truly triangular 
 portion of the whole organ. 
 
 What portion is called the neck ? All the cylindri- 
 cal portion. 
 
 What covers the uterus externally ? Peritonaeum. 
 
 What is meant by the terms broad ligaments of the 
 uterus ? They are lateral expansions of peritonoeuin 
 from the sides of the uterus towards the lateral 
 and posterior portions of the inner surfaces of the 
 pelvis. 
 
OF THE FEMALE PELVIS. 41 
 
 What is the shape of the cavity of the uterus ? Tri- 
 angular. 
 
 What relation do the anterior and posterior portions 
 of the walls of the uterus hold to each other ? They 
 are so nearly in contact, that there is very little space 
 between them. 
 
 What is found at each angle of this cavity ? The 
 orifice of each fallopian tube at the two upper angles, 
 and the internal mouth of the uterus at the lower 
 angle. 
 
 What kind of lining membrane has the cavity of 
 the uterus ? It appears to be a mucous membrane. 
 
 How is it ascertained that the lining consists of a 
 mucous membrane ? Both from its physiological func- 
 tions and its pathological derangements. 
 
 What cavity is situated below the, internal orifice 
 of the uterus ? The cavity of the neck. 
 
 What is the shape of this cavity ? It is somewhat 
 elliptical, or barrel shaped. 
 
 What is the arrangement of the lining or internal 
 surface of the neck ? Arborescent. 
 
 What are found in the folds of the neck ? A num- 
 ber of mucous follicles formerly called ovula nabothi. 
 
 What is the character of the external mouth of the 
 uterus ? It is somewhat elliptical, with its longer di- 
 ameter transverse ; it presents an anterior and a 
 posterior smooth rounded lip, and more or less pro- 
 minent. 
 
 Which of these lips is the larger ? The anterior is 
 larger and broader than the posterior. 
 
 What is the usual shape of the orifice of the uterus 
 in the virgin female ? Rounded and very small. 
 
 At A, fig. 16, is represented the fundus of the ute- 
 rus ; B, the triangular cavity. All the internal geni- 
 talia having been cut in two, so that the cut surface 
 of the anterior half is here shown. B is the triangular 
 cavity, which as may be observed, terminates in the bar- 
 rel-shaped neck with the arborescent arrangements of 
 its internal lining, c. D D gives a view of the inte- 
 4* 
 
42 ANATOMY OF THE CONTENTS 
 
 rior of the fallopian tubes, E E, the fringelike extre- 
 mities. 
 
 Fig. 16. 
 
 How may we distinguish one which has been the 
 subject of one or more pregnancies or deliveries ? By 
 the fact that it is more elliptical and somewhat jagged 
 at the internal edges of the lips of the external os 
 uteri. 
 
 What technical name is sometimes given to the ex- 
 ternal OS uteri? That of os tineas, from its resem- 
 blance to the mouth of a tench fish. 
 
 How is the vagina reflected from the os uteri ? An- 
 teriorly it passes off so directly and apparently at 
 right angles, that the anterior lip appears to be on a 
 level with it. Posteriorly it passes off in a duplica- 
 tion from near the middle portion of the neck, and 
 thus presents a cul-des-ac, and at the same time gives 
 an impression to the finger that the posterior lip is 
 longer than the anterior. 
 
 How long is the uterus ? Two and a half inches. 
 
 How wide at the upper angles ? One and a half 
 inches. 
 
 What is the length of the neck ? One inch. 
 
 What is the thickness of the uterus ? Its body is 
 nearly an inch thick. 
 
 What sensation should a healthy living uterus com- 
 municate to the touch ? The os tincse should present a 
 smooth surface with regular surface of lips, and about 
 
OF THE FEMALE PELVIS. 
 
 4» 
 
 the density of a dead uterus hardened in alcohol, or 
 an impression similar to that of the tip of the nose. 
 
 What is the texture of the uterus ? It is essentially 
 fibrous, but susceptible of great development during 
 pregnancy. 
 
 From what circumstance do we infer the exist- 
 ence of muscular fibres in the uterus ? The pheno- 
 menon of alternate contractions during parturition. 
 
 What has been observed by Professor Hodge, of the 
 direction in which the fibres contract during the 
 effort to expel the placenta ? That they flatten the 
 uterus and shorten its antero-posterior diameter. 
 
 What is the arrangement of the muscular fibres ? 
 They appear to originate in a median line, at the 
 front, back and sides of the uterus, and to run off 
 towards the fallopian tubes and round ligaments, &c. 
 
 Where are the circular fibres distributed ? About 
 the neck, and around the upper angles or cornua of 
 the uterus. 
 
 Fig. 17. 
 
 Who has best succeeded in demonstrating the ar- 
 rangement of the muscular fibres ? The late Ma- 
 .dame Boivin of Paris. 
 
44 ANATOMY OF THE CONTENTS 
 
 BLOOD VESSELS OF THE INTERNAL ORGANS OF 
 GENERATION. 
 
 What arteries supply the internal genital apparatus 
 with blood ? The spermatic and hypogastric arteries. 
 
 Do these two vessels distribute their blood equally 
 to all parts of the uterus and ovaries ? The sperma- 
 tics, after sending branches to the tubes and ovaries, 
 pass on to the uterus to anastomose freely with the 
 ulterior uterine branches of the hypogastrics; the 
 greater portion of blood in the upper part of the ute- 
 rus is furnished by the spermatics, while the hypogas- 
 trics alone supply this fluid to the body, neck and the 
 vagina. 
 
 How are the uterine veins distributed ? The veins 
 of the uterus, which constitute portions of the sper- 
 matic tracts passing from the inner to the outer sur- 
 face, form a great net-work in the muscular tissue of 
 the organ as is shown in 
 
 Fig. 18. 
 
 NERVES OF THE UTERUS AND APPENDAGES. 
 
 From what sources do the uterus and its appen- 
 dages derive its nervous filaments ? From the great 
 sympathetic and the intercostal nerves. 
 
OF THE FEMALE PELVIS. 
 
 45 
 
 To whose patient and laborious investigation are we 
 principally indebted for the best illustration of the 
 distribution of the nerves upon the internal organs of 
 generation ? To Dr. Robert Lee, who has, in con- 
 junction with the history and demonstration of the 
 nerves of the uterus, given the accompanying diagrams 
 and explanations, which show the posterior and late- 
 ral view of the gravid uterus in the fourth month of 
 pregnancy, of the vagina, rectum, and bladder, with 
 
 Fig. 19. 
 
 their ganglia and nerves. A, the fundus and body of 
 the uterus covered with peritoneum. B, the vagina. 
 C, the bladder. D, the rectum. E F, the ovaries. G, 
 
46 ANATOMY OF THE CONTENTS 
 
 the great sympathetic nerve, where it divides into the 
 two hypogastric nerves and plexuses. The arteries 
 and veins of the great sympathetic are all injected in 
 the preparation from which the drawing has been 
 made. A little above the bifurcation of the great 
 sympathetic nerve there is a deposit of cineritious 
 matter in its substance, and the nerve itself is en- 
 larged as high as the kidneys. H, the right and left 
 hypogastric nerves and plexuses. The artery of the 
 right is injected, and accompanies the nerve to the great 
 ganglion at the cervix, in which it terminates. I, the 
 left hypogastric or great utero-cervical ganglion, with 
 an artery passing into it near the centre. J, the third 
 and other sacral nerves, sending numerous larga 
 branches into the posterior border of the ganglion, 
 and the whole of its outer surface. K, the hemorr- 
 hoidal nerves accompanying the arteries to the rec- 
 tum, and sending numerous branches to anastomose 
 with nerves sent off from the posterior edge of the 
 ganglion. L, branches of nerves with ganglia sent 
 off from the left hypogastric nerve, which pass down 
 on the inside of the ureter to the trunks of the ute- 
 rine artery and veins, and enter ganglia which sur- 
 round these bloodvessels. M, the left ureter, with a 
 nerve accompanying it, which passes into the vesical 
 ganglion, situated on the anterior part of the ureter. 
 N, rings of nerve, surrounding the uterine bloodves- 
 sels. 0, the middle vesical ganglion, into which large 
 nerves enter, which are sent off from the anterior 
 of the left hypogastric ganglion, and pass on the out- 
 side of the ureter. P, broad flat ganglia, formed on 
 the great plexus of nerves which covers the upper 
 part of the vagina. Q, the orifices of the divided 
 veins of the vagina, which are completely encircled 
 with ganglionic plexus of nerves. E, filaments of va- 
 ginal nerves passing under the sphincter. S, large 
 nerves covering the posterior wall of the vagina, and 
 anastomosing with the hemorrhoidal nerves. 
 
OF THE FEMALE PELVIS. 
 
 4T 
 
 What is represented on the anterior and latter 
 faces of the uterus dissected for this purpose ? A, 
 the right hypogastric nerve. B, the sacral nerves. 
 C, the right hypogastric ganglion. D, nerves from 
 
 Fig. 20. 
 
 the hypogastric nerve to the ganglia on the bloodves- 
 sels of the uterus. E, ganglia surrounding the ute- 
 rine arteries and veins. F, ganglionic plexus, under 
 
48 ANATOMY OF THE CONTENTS 
 
 tlie peritoneum on the fore part of the uterus. G, 
 filaments from this plexus passing out with the round 
 ligament. H, the round ligament. I, the right ureter 
 and trunk of the vaginal and vesical veins surrounded 
 with nerves. J, ganglia and nerves of the vagina. 
 K, nerves passing between the vagina and rectum. 
 L, ganglia and nerves of the bladder. M, vaginal 
 nerves passing into the bladder around the ureter. 
 N, bloodvessels and nerves of the upper part of the 
 bladder. 0, plexus of nerves under the peritoneum 
 on the left side of the uterus, the bloodvessels of 
 wdiich have not been injected. P, filaments from this 
 plexus passing out with the round ligaments. Q, the 
 peritoneum of the anterior part of the body and cer- 
 vix of the uterus reflected upwards, to expose the 
 ganglionic plexuses situated below. 
 
 OVARIES. 
 
 Where are the ovaries situated ? In the folds of the 
 lateral or broad ligaments, at a little distance from the 
 uterus, one on each side. 
 
 "What office do these bodies perform ? They mature 
 for fecundation, the germ of the new being. 
 
 How are they connected with the uterus ? By a liga- 
 mentous attachment only. They project from the pos- 
 terior portion of the broad ligament, but are covered 
 by it and are suspended only by one edge. 
 
 What is the shape of the ovaries ? They are oval 
 bodies, slightly flattened antero-posteriorly. 
 
 What is the usual size of the ovaries ? Rather 
 smaller than the testicles of the male. 
 
 What other investment have they beside the perito- 
 naeum ? A proper tunica albuginea. 
 
 What is the texture of this coat ? Sometimes thick, 
 sometimes thin. 
 
 What is found in the parenchyma of the ovary, 
 after the seventh, eighth, or ninth year of female life ? 
 Ten, twenty or thirty or more, little bodies called the 
 Graafian vesicles. 
 
OF THE FEMALE PELVIS. 49 
 
 What are the vesicles ? The capsules, which con- 
 tain the ovules. 
 
 FALLOPIAN TUBES. 
 
 How long are the fallopian tubes ? From four to 
 five inches. 
 
 What is their general shape ? That of a trumpet, 
 having the small end at the angles of the uterus, and 
 the larger floating free in the cavity of the pelvis. 
 
 What is the general arrangement of the cavity of 
 the fallopian tubes ? At their termination in the uterus 
 the duct or canal is large enough to admit of a middle 
 sized probe, it then diminishes towards the middle, so 
 that at this part scarcely a bristle could pass along 
 it, after which, it continues to increase somewhat 
 irregularly, until it acquires a diameter. of two or three 
 lines. 
 
 What is the outer extremity called ? The pavilion. 
 
 What is the peculiar mode of termination of the 
 fallopian tubes ? They have a digitated or fimbriated 
 extremity caJled, the corpus fimhriatum, or morsus 
 diaholi. 
 
 What direction do the tubes take in the cayity of 
 the pelvis ? They go ofi" nearly horizontally, but are 
 exceedingly tortuous, and curve backwards, and to- 
 wards the ovary, to some part of which the largest 
 of the fimbriae is sometimes attached. 
 
 What is the anatomical structure of the tubes ? Its 
 principal tissue is-fibrous, having perhaps some mus- 
 cular fibres interspersed. It is lined by mucous mem- 
 brane and covered by a peritonaeal coat. 
 
 Into what cavity do the fallopian tubes open ? 
 Into the cavity of the pelvic portion of the perito- 
 naeum. 
 
 In what part of the female system do the mucous 
 and serous tissues unite ? At the fimbriated extremity 
 of the fallopian tubes. 
 
 5 
 
50 CONTENTS OF THE FEMALE PELVIS. 
 
 ANTERIOR AND POSTERIOR UTERINE LIGAMENTS. 
 
 What other ligaments has the uterus besides the 
 "broad ligaments ? The anterior, or round ligaments, 
 and the posterior, or utero-sacral ligaments. 
 
 What are the points of origin and insertion of the 
 round ligaments ? They arise from the superior part 
 of the body of the uterus, just below and a little in 
 advance of the fallopian tubes, and pass horizontally 
 forwards through the abdominal canal, to be distri- 
 buted beneath the mens veneris, upon the bodies and 
 symphysis of the pubes. 
 
 Where are the posterior uterine ligaments situated ? 
 They spring from the posterior portion of the neck 
 near its middle, and diverging, they ascend towards 
 the middle portion of the lateral edges of the sacrum, 
 and are lost in the cellular membrane which covers that 
 bone. 
 
 With what are all the uterine and ovarian ligaments 
 invested ? Peritonaeum. 
 
 In what direction do the nerves, blood-vessels, 
 and absorbents reach the uterus and appendages ? 
 Through the folds of the peritonaeum or the lateral 
 ligaments. 
 
 Does the peritonaeum extend below the posterior 
 part of the neck of the uterus ? It is not only spread 
 over the whole of the posterior part of the uterus, 
 but also upon the vagina to nearly or quite one third 
 of its entire length, and thus makes a peritoneal cul- 
 de-sac in consequence of its being reflected back from 
 that point upon the rectum. 
 
 What precaution should the knowledge of the ex- 
 treme tenuity of the vagina and its proximity to the 
 large serous sac, suggest to the mind of the obstetric 
 physician ? Delicacy of manipulation in all cases 
 which requires that a hand or instrument should be 
 ^ introduced along this portion of the canal into the 
 uterus. 
 
MENSTRUATION. M 
 
 FUNCTIONS OF THE GENITAL ORGANS. 
 
 What is the condition of the internal organs of ge- 
 neration in the fetus ? Thej are very small, the ute- 
 rus is almost lost in the broad ligaments. The same 
 may be said of the ovaries. 
 
 At about what age do the ovaries appear to become 
 vascular ? Seven years. 
 
 What physiological changes have taken place at 
 the period of life called puberty ? All the internal 
 organs have become more developed, more vascular ; 
 the uterus has acquired greater size, and is more soft ; 
 the mons veneris is covered by hair; there is an 
 increased flow of blood to the pelvic viscera, and to 
 the head ; the face becomes more or less flushed ; the 
 voice is altered, and the moral sensibility is more 
 acute. 
 
 At what period of life do these changes occur? 
 At the fourteenth or fifteenth year in temperate cli- 
 mates. 
 
 What function is the genital organs then capable of 
 performing ? That of reproduction. 
 
 MENSTRUATION. 
 
 What function does the uterus actually perform 
 when all these physical changes have regularly oc- 
 curred? That of menstruation. 
 
 What is to be understood by the function of mens- 
 truation ? That in which the uterus at regular periods 
 secretes a certain amount of sanguinolent fluid. 
 
 What are the synonyms of menstruation? Cata- 
 menia, menses, courses, monthlies^ terms, monthly 
 terms, monthly periods, the reds, being unwell, indis- 
 posed, has her troubles, ^c. 
 
 Whence is this fluid furnished ? From the internal 
 surface of the uterus. 
 
 What proof have we that it is derived from this 
 source ? It is always accompanied by some degree 
 of uterine iritation : when occlusion of the orifice of 
 
52 MENSTRUATION. 
 
 the uterus exists, the secretion is still eliminated l»y 
 the capillaries, but retained within the cavity of the 
 uterus. 
 
 What are the characteristics of the menstrual fluid ? 
 It is a sanguinolent fluid, of a peculiar quality and 
 odour, of a color usually between that of venous and 
 arterial blood ; it is not coagulable, nor does it pu- 
 trify readily. 
 
 At what periods of life does this secretion usually 
 commence ? In hot countries from nine to ten years ; 
 in temperate climates, from fourteen to fifteen years ; 
 in cold regions, from eighteen to twenty years. 
 
 At how early a period are females of tropical cli- 
 mates known to be capable of bearing children ? At 
 ten years old. 
 
 What influence have these hot climates upon the 
 continuance of the power of reproduction ? Females 
 who begin this function early, also decline early. 
 
 What is observed in this respect in regard to cold 
 countries ? That the capability of reproduction, 
 though beginning later, is continued to a much more 
 advanced age. 
 
 What difference is observable in the condition of 
 females residing at the top, and those at the bottom 
 of high mountains ? Those on the top are more tardy, 
 but continue much longer, w^hile those at the foot, 
 have the function of menstruation begin and end 
 much sooner. 
 
 What difference is observed between the girls re- 
 siding in a country place, and those who inhabit large 
 cities ? That those in the country do not usually be- 
 gin as soon to menstruate as those who live luxuriantly 
 in large towns. 
 
 What influence does temperament usually exert? 
 Those of a nervous temperament usually menstruate 
 earlier and more abundantly than those of phlegmatic 
 temperament. 
 
 What are the general symptoms accompanying a 
 menstrual effort ? An unpleasant feeling of languor, 
 
MENSTRUATION. 8% 
 
 "weariness about the loins, sense of fulness in the hypo- 
 gastrium, a disposition frequently to urinate and. defe- 
 cate. Sometimes great nervous excitement, perhaps 
 even hysteria ; the breasts swell and feel more or less 
 tight and painful ; there is headach, palpitation, and 
 a peculiar odour of the breath in some cases. 
 
 What is the usual color of this fluid at the first 
 time it is discharged ? Pale red or pink color. 
 
 How long does the first discharge continue ? Some- 
 times only a few hours, and rarely ever more than 
 two or three days. 
 
 At what period do these symptoms and the dis- 
 charge return ? At the end of one lunar month. 
 
 When the menstrual function is fairly established, 
 how many days are usually occupied in the discharge ? 
 In temperate climates from five to seven days. 
 
 What influence does the health of the patient exert 
 upon the menstrual function ? Delicate women usu- 
 ally menstruate more abundantly than the more robust, 
 but in some diseases it is altogether interrupted. 
 
 What is the usual quantity discharged at each pe- 
 riod ? In temperate climates, probably from four to 
 six ounces. In tropical climates, from ten to fifteen 
 ounces ; while in frigid zones, the quantity is very small. 
 
 What is observed in corpulent women in reference 
 to menstruation ? That they usually have a greater 
 discharge than those who are thin. 
 
 Is the menstrual function easily disturbed ? In those 
 of nervous temperaments and irritable constitutions, it 
 is very easily disturbed by physical and moral causes. 
 
 What is the usual duration of the menstrual period 
 of female life ? About thirty years. 
 
 TERMINATION OF THE MENSTRUAL FUNCTION. 
 
 At what age does this function usually subside ? At 
 from forty-five to fifty ; but much earlier in hot 
 countries. 
 
 What is the period of female life at which this 
 function subsides usually called ? Change of life. 
 5* 
 
54 MENSTEJIATION. 
 
 What is observed in reference to the subsidence of 
 this function at this period of life ? It becomes very 
 irregular, sometimes profuse for one time, then passes 
 over a month or more, then returns profusely, and 
 finally subsides altogether ; when slight, it is usually 
 painful ; and when profuse debilitating. 
 
 Into what character of discharge does menstrua- 
 tion often pass before it ceases altogether ? Into that 
 of a leucorrhoeal or sero-mucous, or albuminoid fluid. 
 
 What physical changes are observed to take place 
 in the female upon the arrival of this period of her 
 life ? Her capillary circulation becomes less active, 
 the cellular and adipose matters of the mammae are 
 absorbed, there is a general shrinking of her person, 
 and that beautiful rotundity of her form disappears. 
 
 What alteration does her pulse undergo ? It be- 
 comes slower and feebler, and it acquires more of a 
 congestive, or apoplectic character. 
 
 In w^hat respect is this period to be regarded as the 
 critical period of life ? Because it is observed that 
 generally, if there be no local predisposition to dis- 
 ease, women usually have their health improve after 
 the cessation of menstruation : but if strongly dis- 
 posed to any malignant aftection, this disease is liable 
 to become more rapid in its course to a fatal termina- 
 tion. 
 
 What precise knowledge have we respectmg tne 
 cause of the function of menstruation ? None what- 
 ever, notwithstanding the numerous speculations on 
 this subject. Until within the last quarter of a century, 
 ideas of the causes of the periodical flow of bloody 
 matter from the genitalia of females, were exceedingly 
 vague and often perfectly absurd. The patient and 
 laborious investigations of Purkinje, Von Baer, Pro- 
 vost and Dumas, Coste, T. Wharton Jones, Wagner, 
 Bischofl", Raciborski, Gendrin, Negrier, Lee, Bouchet 
 and some others, have contributed greatly towards 
 the establishment of the belief that menstruation is 
 dependent upon ovulation, that it is mostly if not al- 
 
MENSTRUATION. 5S 
 
 ways coincident with the perfection of the female germ 
 or ovule, and its separation from its nidus, the 
 Graafian cell, to be conveyed into the uterus, when 
 should it have become fecundated it would remain 
 during its allotted period of gestation, but from which 
 it is carried with the fluid eliminated from the mucous 
 or blood membranes. 
 
 What condition does the ovary usually exhibit at 
 the menstrual epoch ? One of the Graafian cells is 
 found to be turgid and ready to be ehminated from 
 the cyst, or there is to be found a little lacerated spot 
 which is the opening of a small cavity containing a 
 clot of blood. 
 
 CORPUS LUTEUM. 
 
 What is a corpus luteum ? It is a yellow body 
 found in the ovaries of animals that have recently 
 been in sexual heat, and in those of the human fe- 
 male, and shortly after they have menstruated, or be- 
 come pregnant. 
 
 What has hitherto been the estimate put upon the 
 discovery of this yellow body in the ovary ? That 
 the woman had surely eliminated a fecundated germ 
 from the Graafian cell in which the corpus luteum was 
 found occupying. 
 
 What is the opinion of Professor Meigs on this 
 subject ? That the existence of this yellow body in 
 the ovary is an evidence of finished ovulation and not 
 necessarily of fecundation : — that is, the corpus lu- 
 teum exists in the ovary at the close of every mens- 
 truation, because at that time an ovule has been ma- 
 tured, and separated from the ovarian stroma, whether 
 it has been fecundated or not. 
 
 What is his opinion of the physical qualities of the 
 corpora lutea ? That they are vitellary, in all re- 
 spects resembling the yolks of eggs. 
 
 What is to be found in the Graafian cells, by lay- 
 ing them open ? A small drop of fluid like water. 
 
 What are the microscopic properties of the contents 
 
66 GENERATION. 
 
 of a Graafian vesicle ? A transparent fluid containing 
 a vast number of granules, surrounding an albumin- 
 ous fluid, at a point in the periphery of the granular 
 layer, may be found a spot, indicated by Purkinje, 
 and called by him the germinal vesicle. On one side 
 of this vesicle is an opaque spot, called also the ger- 
 minal spot. The germinal vesicle is about one six- 
 tieth of a Paris line in diameter, while the germinal 
 spot is from the one hundredth to the one three hun- 
 dredth of a line in diameter. Fig. 21 is a diagram 
 of a section of the Graafian vesicle and its contents, 
 showing, the situation of the ovum, a represents the 
 granulary membrane; 5,- the accumulation, called by 
 Baer, the proligerous disc, c, the ovum, or the germi- 
 nal vesicle ; the dotted lines running to d, represent 
 two walls, inner and outer of the Graafian vesicle, 
 while e points out the indusium or sub-peritoneal tis- 
 sue, directly underneath which, again is the stroma 
 of the ovary so condensed as to make the tunica al- 
 buginea. 
 
 Fig. 21. 
 
 REPRODUCTION OR GENERATION. 
 
 What is generation ? It is the function of repro- 
 ducing the species after the form originally impressed 
 upon it. It is therefore the function peculiar to ani- 
 mated or living beings. 
 
 What is the simplest form of generation ? Fissi- 
 parous generation, which does not require sexual or- 
 
GENERATION. 5T 
 
 gans — it is in other words, generation by spontaneous 
 division ? 
 
 What is the next higher grade or kind of genera- 
 tion ? That which is called germniparous, consisting 
 in the formation of buds or germs on some parts of 
 the body, either internally or externally. 
 
 . What are the germs in the female of the higher 
 order of animals ? The ovules, situated within the 
 ovarian vesicles. 
 
 At what period of life do these germs in the human 
 female exist? Between that of puberty and the 
 " change of life." 
 
 W^here is the male germ found in vegetable life ? 
 In the pollen of plants. 
 
 What is the male germ in animals ? It exists in 
 the fluid secreted by the testicles. 
 
 What is necessary to constitute fecundation ? The 
 contact of the male and female germs. 
 
 What may be said of the theories of generation ? 
 That they are numerous and some of them vague, and 
 it is true that the whole subject is shrouded in an im- 
 penetrable mystery. 
 
 What are the two principal theories in reference to 
 conception ? 1. That of epigefiisis, which is probably 
 the oldest, and which supposes that it depends upon 
 the conjunction of the male and female germs in the 
 uterus, and that each contributes its portion to the 
 formation of the new being. 2. That of evolution, 
 in which it is assumed that the mother furnishes the 
 entire molecule, and that the stimulus of the male 
 sperm only excites it into vital activity. 
 
 Which appears to be the most rational theory of ge- 
 neration ? 1. That of the ovulg-r, in which it is be- 
 lieved that the elements of the new being reside in 
 the ovule, secreted by the ovary. 2. That of evolu- 
 tion, in which the sperm of the male operates merely 
 by its stimulus upon the female germ or ovule within 
 the ovarium. 
 
58 
 
 GENERATION. 
 
 FECUNDATION. 
 Is the semen masculinum, in its totality, necessary 
 to produce a fecundation of the female germ ? Yes. 
 
 What were the experiments of Spallanzani, of Pre- 
 vost and Dumas, in reference to this ? They found 
 that it was necessary that the fluid they used for arti- 
 ficial fecundation, should contain the peculiar animal- 
 cules or molecules existing in the semen masculinum. 
 
 Is there any analogy in the modes of fecundation 
 in vegetables and animals ? The presence of the pollen 
 is necessary to the developement of the germ. 
 
 How does fecundation take place in the fish ? By the 
 
 deposite of the male sperm upon the spawn of the females. 
 
 What is the mode of fecundation in the frog and other 
 
 of the batracian animals ? The male sperm is thrown 
 
 upon the female eggs, as they pass from her body. 
 
 Is a true copulation necessary in the mammiferous 
 animals ? Yes. 
 
 Is it necessary that the male 
 germ be deposited within the fe- 
 male body ? It is. 
 
 Is it most probable that the 
 ovary is the point at which the 
 two germs meet ? That idea is 
 generally embraced by physiolo- 
 gists of the present day. 
 
 What changes take place in 
 the ovary after a fecundating 
 copulation ? One of the vesi- 
 cles enlarges rapidly, soon rises 
 above the surface of the organ, 
 absorption of its peritonaeal cov- 
 ering takes place, and it is soon 
 embraced by the fallopian tube, 
 and carried toward the cavity 
 of the uterus. Fig. 22. 
 
 What is the appearance of an ovarium after the ovule 
 has been removed ? First, there is an eflfusion of blood 
 
 Fig. 22. 
 
GENERATION — C£)NCEPTION. 59 
 
 into the cavity, whence the ovule was taken — then a yel- 
 low cicatrix called the corpus luteum, or yellow body. 
 
 CONCEPTION. 
 
 What distinction does Professor Meigs make be- 
 tween fecundation and conception ? 1. Fecundation 
 is the vivifying and vitalizing of a maturated ovum 
 by the application to it of certain elements produced 
 by the male, no matter where they may be brought in- 
 to contact, whether in the ovaries, the fallopian tubes 
 or the uterus itself. 
 
 2. The term conception is restricted by him to the 
 " fixation of a fecundated ovum upon the living surface 
 of the mother." 
 
 PREGNANCY. 
 
 What is pregnancy ? The retention and development 
 of an embryo or fetus, within some part of the female. 
 
 How many kinds of pregnancy are there ? Two — 
 uterine or normal, and extra uterine or abnormal preg- 
 nancy. 
 
 What is the character of, or what constitutes a 
 uterine or normal pregnancy? The fact that the 
 ovule when fecundated, is removed from the ovary, 
 carried along the fallopian tube and deposited in the 
 cavity of the uterus, in which it is retained and ma- 
 tured till capable of living after parturition. 
 
 What would you consider to be preternatural, ab- 
 normal, or extra uterine pregnancy? The circum- 
 stances of the development of the fecundated ovule in 
 the ovarium, the fallopian tube, in the cavity of the 
 peritonaeum. 
 
 Into how many varieties is true uterine pregnancy 
 divided ? Simple pregnancy with one ovum. Double, 
 triple, &c. pregnancy, when there are two, three, or 
 more fetuses. Complicated pregnancy, when there 
 exists a polypus, great quantity of water, or any dis- 
 eased state of the product of conception, or of the 
 womb itself. 
 
60 GENEKATION — PREGNANCY. 
 
 What varieties does extra uterine, irregular or ab- 
 normal pregnancy present? Four varieties, deter- 
 mined bj the seat occupied by the fecundated germ. 
 1st, Ovarian ; 2d, Abdominal ; 3d, Tubal; 4th, Mixed 
 or interstitial pregnancy. 
 
 What changes take place in the genital system, after 
 a fecundating copulation ? The tubes which were 
 erect during the copulation, continue so ; the uterus 
 participates in the general turgescence, and is pre- 
 pared to undergo a new development for the accommo- 
 dation of the ovum. 
 
 ALTERATIONS IN THE CERVIX AND OS UTERI. 
 
 What is the usual size of the neck of the uterus in 
 the unimpregnated adult female ? One inch long, half 
 inch thick. 
 
 What size does it acquire during the first two months 
 of pregnancy ? It is somewhat thicker, and nearly 
 two inches long. 
 
 How long does this development of the neck con- 
 tinue after the commencement of gestation ? Until 
 the fourth month. 
 
 When does it begin to shorten again? During the sixth. 
 
 How much shorter is it at the end of the sixth 
 month ? One-fourth. 
 
 How much at the end of the seventh month? One-half. 
 
 How much less at the end of the eighth month ? 
 Three-fourths. 
 
 What is the state of the neck at the end of the 
 ninth month ? Nearly all expanded. 
 
 Is this a rule without exceptions ? No, it is true in 
 general, but cannot always be relied on as a positive 
 sign of the advancement of pregnancy. ' 
 
 What minute description has Dr. Chailly, ex-Chief 
 of the Obstetric Cllnique of the Faculty of Paris, given 
 or^the changes which the uteri undergoes in the dif- 
 ferent months of gestation ? In a work, the use of 
 which was authorized by the Royal Council of Public 
 Instruction, in France, he says, the transverse orifice 
 of the primipara becomes circular about the end of the 
 
GENERATION — PREGNANCY. 
 
 61 
 
 third month of pregnancy ; it is regular in its contour 
 and closed, the os tincse is smooth and polished ; 
 the two lips are nearly on the same line, in conse- 
 quence of the shortening of the anterior lip ; the entire 
 neck measures about two inches, as is shown in 
 
 Fig. 23. 
 
 Fig. 24. 
 
 in which and all the following diagrams, intended to illus- 
 trate this subject, (and which have been reduced to one- 
 third of the natural size) the space between the transverse 
 lines represents the super vaginal 
 portion of the neckof the uterus. 
 
 In the woman who has had chil- 
 dren the orifice is also rounded, 
 as in fig. 24, but it is irregular and 
 presents a number of cicatrices es- 
 pecially on the left. It is some- 
 times open, and will admit the 
 extremity of the finger. The 
 neck is much larger than in the 
 primip, it is also shorter, softer, and less smooth. 
 
 The changes in the vaginal portion of the uterus, 
 after the end of the third month, do not exhibit such 
 defined differences as to be readily appreciated ; it is 
 not until the end of the fifth month that marked 
 alterations in this part of the uterus can be re- 
 cognised. The diagram 25, representing the condition 
 G 
 
62 GENERATION — PREGNANCY. 
 
 Fig. 25. 
 
 Fig. 26. 
 
 of the cervix in a primip, at the end of the fourth 
 is not apparently changed from that at the end of 
 the third month. The same may 
 be said in comparison of the 
 condition of the multipara at 
 an equal period, rig.26. 
 
 At the end of the fifth 
 month, the uterus being ele- 
 vated above the superior strait, ^ 
 the finger, in seeking the neck, 
 will have to pass higher up 
 than at the previous period. 
 The fundus being slightly inclined to the right 
 and in front, the neck will of course be directed a 
 little backward and to the left: the neck, in its 
 totality, still measures from fifteen to eighteen lines, 
 and this diminution of its length is eff'ected at the ex- 
 pense of its vaginal portion only ; the portion of the 
 neck above the vagina, having undergone no diminu- 
 tion, which circumstance can sometimes be ascer- 
 tained at this period by introducing a finger into the 
 cul-de-sac of the vagina. 
 
 In primiparse, the vaginal 
 portion has preserved a cer- 
 tain regularity of its form : it 
 is however softer, and the two 
 lips are on a level ; but the 
 orifice is still closed. Fig. 27. 
 In women who have borne 
 children, the neck is consi- 
 
 Fig. 27. 
 
GENERATION — PREGNANCY. 
 
 63 
 
 In women who have 
 
 derably softer and shorter : the external orifice, which 
 is irregular, begins to open, and will permit the intro- 
 duction of half of the first pha- 
 lanx of the fore-finger, and 
 sometimes more, (see fig. 28.) 
 
 At the end of the sixth 
 month, the vaginal portion of 
 the uterus continues to soften, 
 and diminish in length; the 
 orifice also opens more and 
 more ; the first phalanx may 
 be introduced in the os uteri, 
 (as shown in fig, 29,) of the 
 primip, in some few instances, 
 borne children, the finger will 
 penetrate to one half the neck, 
 as may be seen in the diagram ; 
 it will occasionally even reach 
 the internal orifice, but will not 
 pass beyond it, (see fig. 30.) 
 
 At the end of the seventh 
 month, the neck is carried far 
 
 backward and to the left: it is sometimes difficult 
 to reach, and measures in 
 its whole length from twelve 
 to fifteen lines. This di- 
 mension is effected at the 
 expense of the vaginal por- 
 tion only, which has become 
 larger, and in primiparse 
 measures but a few lines ; (fig. 
 31,) it is at this period almost 
 completely eff*aced in women who have had children, 
 (as represented in fig. 32.) In the primip, the vaginal 
 orifice will sometimes allow the finger to penetrate to 
 one half of the neck, w4iile in the multiparous woman 
 the finger can often reach to the internal orifice, 
 into which indeed it may enter if the woman has had 
 many children. 
 
 Fig. 30. 
 
64 
 
 GENERATION — PREGNANCY. 
 
 the neck itself. 
 
 At the end of the eighth month the vaginal neck is 
 almost entirely effaced : in pri- 
 miparae however, the lips still 
 measure a few lines. It is 
 directed considerably back- 
 ward and to the left, and this 
 circumstance renders it difficult 
 to reach. This difficulty, how- 
 ever, depends more upon the 
 anteversion of the body of the 
 uterus than upon the height of 
 In women who have borne a number 
 of children the vaginal ori- 
 fice is so soft and open that 
 it becomes confounded with 
 the walls of the vagina : and 
 the orilj certainty that the 
 accoucheur has that he has 
 reached the neck is, that the 
 finger penetrates an orifice 
 widely open, in front of which 
 is nothing more than the rudiment of the anterior 
 lip. This orifice is found 
 shaped, and the finger pene- 
 trates it deeply in order to 
 pass the internal opening, 
 which is more or less di- 
 lated, (fig. 33.) In primi- 
 parse, the neck less soft and 
 dilated, permits the finger 
 to reach only as far as the in- 
 ternal orifice, (fig. 34, p. 65.) 
 In women who have had chil- 
 dren, there is no neck at the 
 end of the ninth month. 
 The internal and external 
 orifices become confounded 
 and are dilated so as to allow the finger to feel through 
 the i^nembranes the presenting part of the fetus, (fig. 
 
GENERATION — PREGNANCY. 
 
 65 
 
 15.) In primips the supravaginal portion of the neck 
 till preserves a few lines in 
 
 Fig. 34. 
 
 Fig. 35. 
 
 85.J 
 
 still preserves 
 
 length, which do not become 
 effaced until after labor has com- 
 menced, the vaginal portion alone 
 is completely obliterated ; a very 
 slight thickness of tissues sepa- 
 rates the two orifices, the exter- 
 nal is open, but the finger cannot 
 enter the internal, (see fig. 36.) 
 
 Does Dr. Chailly mean, by his careful description 
 of the state of the cervix, to 
 establish the fact that it is easy 
 to decide upon the positive ex- 
 istence of pregnancy in the early 
 months? He candidly declares 
 that, it is not always easy to 
 distinguish the difference in the 
 characters presented by the os 
 uteri. Certain circumstances, as 
 painful condition of the abdomi- 
 nal walls, tumefaction of the la- 
 bia majora and sensibility of 
 womb, will occasionally render it 
 impossible to detect these signs. 
 And again, if in their absence, 
 it is at least, in a majority of 
 cases, possible to deny the ex- 
 istence of pregnancy, yet we 
 cannot always, when the signs 
 are present, positively affirm 
 that pregnancy exists ; for at 
 this period of gestation, as has 
 already been observed, all that 
 we can do is to ascertain 
 tliat the uterus is enlarged ; 
 but whether this development 
 depends on the presence of 
 a fetus or upon an abnormal 
 6* 
 
66 GENERATION — PREGNANCY. 
 
 condition is a point possible it is true to establish in 
 some instances; while in others the whole matter rests 
 in doubt until additional symptoms render the diag- 
 nosis positive. 
 
 In fact, at the approach of the menstrual period of 
 some women, the uterus in consequence of its con- 
 gested condition, occasionally becomes as large as in 
 the third month of pregnancy, and we are never liable 
 to error, because in this case the neck is slightly 
 softened and open. At other times the menses 
 retained in the cavity of the uterus, in consequence 
 of the closing of its internal orifice, distend, by their 
 accumulation, the walls of this organ, -and thus give 
 rise, sympathetically, to many of the presumptive 
 signs, such as tumefaction and pain in the breasts, 
 disturbance in the digestive functions, &c., &c., cir- 
 cumstances which increase the chances of error. 
 
 RANGES IN THE FORM OF THE UTERUS. 
 
 What change takes place in the form of the uterus ? 
 It becomes more regularly pyriform, and even ovi- 
 form. 
 
 What portions then become most rapidly developed ? 
 The anterior and posterior surfaces. 
 
 Which of these two surfaces developes the most ra- 
 pidly ? The posterior. 
 
 At what period of pregnancy does the body of the 
 uterus become completely spherical ? At the end of 
 the fifth month. 
 
 Has the neck begun to shorten at this time ? Yes, 
 slightly ; it is mammillated, being like a nipple on a 
 mamma. 
 
 What is the original position of the uterus in its 
 non-gravid state ? It is situated in the axis of the su- 
 perior strait, with its fundus just above the brim of 
 the pelvis. 
 
 Does it descend a little during the first and second 
 months ? Yes — but chiefly because of its develop- 
 ment. 
 
GENERATION — PREGNANCY. 67 
 
 Does it continue to bear the same relation with the 
 axis of the pelvis as it is precipitated ? It does. 
 
 Does this precipitation ever extend as far as to the 
 vulva ? Yes, in some rare cases. 
 
 Does its orifice then point forwards ? It points for- 
 wards in the direction of the axis of the vagina. 
 
 Where is the fundus usually found at the third 
 month of pregnancy ? A little above the margin of 
 the superior strait. 
 
 What is the situation of the uterus at the end of 
 the fourth month ? A large portion of it is out of the 
 cavity of the pelvis. 
 
 How high is the top of the fundus at the end of the 
 fifth month ? Generally half way between the pubes 
 and umbilicus of the mother. 
 
 IIow high at the end of the sixth month? On a 
 level with the umbilicus. 
 
 How high at the end of seven months? Two or 
 three fingers' breadth above the umbilicus. 
 
 How high at the end of the eighth month ? It has 
 reached the epigastric region. 
 
 Where is the fundus at the end of the ninth month ? 
 Usually rather lower than at the end of the eighth, in 
 consequence of the rapid anterior development of the 
 organ. 
 
 What relation does the gravid uterus hold with the 
 intestines ? It carries them upwards and backwards, 
 being itself in contact with the parieties of the ab- 
 domen. 
 
 What are the dimensions of the uterus at the full 
 period of utero-gestation ? Twelve to fourteen inches 
 from fundus to orifice, nine to ten in the widest part, 
 and eight to nine antero-posteriorly. 
 
 Is the axis of the uterus liable to be modified by 
 the pressure of the abdominal muscles ? It is so, par- 
 ticularly in first pregnancies. 
 
 Does the tension of these muscles in a first preg- 
 nancy usually retain the axis of the uterus more nearly 
 parallel with the axis of the body ? Yes. 
 
68 GENERATION — PREGNANCY. 
 
 What other circumstances or causes, modify the di- 
 rection of the axis of the uterus during gestation ? The 
 uterine ligaments, abdominal viscera, and spinal 
 column. 
 
 Is the orifice of the uterus always directed to the 
 portion of the pelvis opposite to that towards which 
 the fundus presents? It is mostly nearly so, though 
 sometimes it is rather posterior to this right line, and 
 sometimes it appears to be retained upwards and back- 
 wards, in consequence of the want of development of 
 the fibres of the posterior part of the cervix. 
 
 Is the orifice of the uterus sometimes thrown so far 
 back into the hollow, or above the promontory of the 
 sacrum, in cases of anterior obliquity as to be out of 
 reach of the finger ? When there is anterior obliquity 
 it is always so. 
 
 Are the walls of the gravid uterus thicker than 
 when in the unimpregnated state ? Very slightly 
 thicker. 
 
 What changes does the uterine parenchyma pass 
 through in this development ? It becomes softer, the 
 muscular fibres are developed, the nerves, blood ves- 
 sels, and lymphatics all increase in size. 
 
 By how many times are the blood-vessels enlarged ? 
 Arteries four times, and the veins even more than this. 
 
 What is meant by what are called venous sinuses ? 
 Enlargements and duplications of the veins merely, 
 whose orifices are patulous upon the internal surfaces 
 of the gravid uterus. 
 
 Is the sensibility or irritability of the uterus increased 
 with gestation ? It is so, and this is important to be 
 borne in mind in the management of pregnant women. 
 
 ALTERATIONS OF SIZE AND POSITION OF THE PELVIC 
 AND ABDOMINAL VISCERA CAUSED BY PREGNANCY. 
 
 Does the embryo enlarge the uterus by the irrita- 
 tion of its presence ? It probably does, not however 
 so much by mechanical distension, as by exciting the 
 vital process of development, a result of irritation or 
 
GENERATION — PREGNANCY. 69 
 
 excitement caused by fecundation ; as the ovum en- 
 larges it keeps up the excitement within the uterus. 
 
 If the ovum be accidentally ruptured and discharged, 
 is not the development of the uterus arrested ? It is 
 pirobably in all cases. 
 
 How is the vagina affected during the process of 
 uterine developement ? It becomes rather shorter 
 during at least two months ; and from the fourth 
 month it becomes longer and larger. 
 
 How is the peritonaeum, which is spread over the 
 uterus and its appendages, enlarged during gestation ? 
 By development! and not mere stretching. 
 
 Do the fallopian tubes and ovaries remain vascular 
 after conception ? They do for some time. 
 
 How are they situated in reference to the uterus at 
 the end of pregnancy ? They hang alongside of this 
 organ in the folds of the peritonoeum. 
 
 Do the round ligaments assume a muscular character ? 
 They do — Velpeau says he has seen them contract 
 during labor, and they often draw the uterus forward 
 during pregnancy. 
 
 What effect has advanced pregnancy upon the uri- 
 nary bladder ? It is mostly carried upwards and for- 
 wards as the uterus enlarges. 
 
 What effect has this upon the situation of the 
 urethra ? It then becomes nearly perpendicular. 
 
 Where may you expect to find the meatus in this 
 case ? Drawn a little back from its usual situation. 
 
 How would you introduce the female catheter under 
 these circumstances ? By depressing the handle and 
 carrying the point under the sub-pubic ligament. 
 
 Is the straight catheter always sufficient to pass in- 
 to the cavity of the bladder ? It is sometimes better 
 to use the curved or male catheter, in consequence of 
 the direction which the cavity is forced to take by the 
 pressure of the uterus. 
 
 What effect does the pressure of the gravid uterus 
 Bometimes exert on the functions of the pelvic viscera ? 
 
70 GENERATION — PREGNANCY. 
 
 It often causes obstructions to the natural functions of 
 the bowels as well as bladder. 
 
 Is the rectum sometimes more free after the fourth 
 month ? Yes — but very frequently it is beyond the 
 influence of the abdominal muscles, and hence is often 
 the seat of great fecal accumulations. 
 
 In what manner are the respiratory organs affected 
 during the latter months of pregnancy ? During the 
 eighth and part of the ninth month, the fundus of the 
 uterus presses the diaphragm, liver, &c. upwards, and 
 thus shortens the vertical diameter of the chest and 
 expands its base. 
 
 What effect is sometimes produced by the distension 
 of the skin of the abdomen ? Sometimes its texture 
 is modified, leaving resemblances to cicatrices. 
 
 Is the liability to crural hernia diminished as preg- 
 nancy advances ? Yes, because the intestines are car- 
 ried up above the abdominal rings, and their place is 
 occupied by the uterus. 
 
 Is the woman more subject to umbilical hernia ? 
 Yes. 
 
 At what period of pregnancy does the navel pout 
 out ? About the fifth and sixth months. 
 
 Why does it flatten again after this ? Because the 
 fundus of the uterus rises above it. 
 
 Why are women during pregnancy particularly dis- 
 posed to varicose veins, and to edema or anasarca ? 
 Because of pressure upon the vena cava and absor- 
 bents. 
 
 Does this varicose state of the limbs sometimes con- 
 tinue after delivery ? Yes — and is then increased at 
 every subsequent pregnancy. 
 
 While all these changes are going on externally, 
 what is taking place in the cavity of the uterus ? Its 
 lining membrane becomes more developed, more villous 
 and vascular. 
 
GENERATION — PREGNANCY. Tl 
 
 DECIDUAL MEMBRANE OF THE UTERUS. 
 
 What is secreted by the lining of the uterus ? A 
 layer of coagulable lymph, gelatinous in character, 
 which speedily becomes organized, vascular, and red- 
 dish. 
 
 What is this membrane called ? Decidua or ca- 
 duca. 
 
 How long does it remain next the uterus ? During 
 pregnancy. 
 
 When and how is it disengaged ? At the time of 
 parturition, when it is thrown off by uterine contrac- 
 tions at the same time with the placenta, or shortly 
 after in small pieces with the lochia. 
 
 How low down the cavity of the uterus does this 
 lining extend ? To the internal os uteri. 
 
 What is the character of its external surface? Vil- 
 lous or shaggy. 
 
 What does Velpeau call this membrane ? Anhistous, 
 and considers it unorganized. 
 
 What are the proofs of its organization ? Its vas- 
 cularity ; it was injected by Ruysch, Burns, &c. The 
 decidua of a cat has been injected by Drs. Goddard 
 and Betton. 
 
 Is its growth or development another proof of its 
 organization? Yes — it is also subject to diseases, and 
 it becomes very thin towards the last, like serous or cel- 
 lular tissue. A, the decidua reflexa, with a few of the 
 smooth orifices of the canals passing between the cells of 
 the chorion and decidual cavity — natural size. The 
 opening had almost entirely closed in that part of the 
 decidua reflexa which was most remote from the pla- 
 centa, and the villi of the chorion had here also dis- 
 appeared. B, the openings in the decidua reflexa, as 
 seen through a simple lens of an inch focus. C, the 
 inner surface of a small portion of the uterine deci- 
 dua or decidua vera, unusually thick and rugous. D, 
 a magnified view of the same membrane, witli a few 
 small orifices of vessels. Fig. 37, p. 72. 
 
72 
 
 GENERATION — DECIDUA. 
 
 Fig. 37. 
 
 In figure 38 are represented the openings in the 
 decidua reflexa and uterine decidua, as seen in another 
 
 Fig. 38. 
 
GENERATION— DECIDUA. 
 
 78^ 
 
 ovum of an earlier age. A, a small portion of deci- 
 dua reflexa magnified. B, inner surface of uterine 
 decidua, with the veins passing obliquely through the 
 membrane to the uterine surface. 
 
 In fig. 39, the orifices of the veins of the uterine 
 decidua opening into the decidual cavity : natural 
 size. 
 
 Fig. 39. 
 
 ^^^ 
 
 In fig. 40, a portion of the same membrane, as seen 
 through a good lens. 
 
 Fig. 40. 
 
 Is it a complete lining to the uterus ? It lines the 
 whole cavity of the body of the uterus, and by many 
 
 7 
 
74 
 
 GENERATION — DECIDUA. 
 
 Fig. 41. 
 
 Fig. 42. 
 
 physiologists it is believed 
 that it covers the orifice 
 of the tubes and the inter- 
 nal OS uteri, (fig. 41.) 
 
 What is the use of this 
 decidua ? It forms the me- 
 dium of contact between 
 the uterus and the ovum. 
 
 After how many days 
 from fecundation does it 
 line the cavity ? Probably 
 four, five, or six. 
 
 As the ovum cannot fall 
 into the cavity of the ute- 
 rus at its first approach to 
 it, in what manner is it ac- 
 commodated upon its arri- 
 val at the end of the fallo- 
 pian tube ? As it becomes 
 developed it adheres to, and 
 causes a growth of, that part 
 of the membrana decidua, 
 which is in contact with that 
 angle of the uterus. 
 
 Does this action give rise 
 to the apparent formation of 
 two membranes ? It has that 
 efi"ect, (fig. 42.) 
 
 DECIDUA UTERI AND DECIDUA REFLEXA. 
 
 What names have been given to these ? That with 
 which the ovum is in contact, is called the decidua 
 reflexa, or decidua ovi ; and that which is next the 
 uterus, the decidua vera, or decidua uteri. 
 
 Does this arrangement correspond with that of tho 
 pleura pulmonalis, and the pleura costalis ? It does, 
 I'or like the lungs, the ovule is thus really exterior to 
 the sack of decidua, though apparently enclosed by it. 
 
 Are the two layers of the decidua, viz. : decidua re- 
 
GENERATION — OVUM. ?S 
 
 flexa, and decidua vera at once in close contact with 
 each other ? No, one is closely attached to the 
 ovum, while the other is loose around it. 
 
 What is interposed between the two layers ? The 
 interspace is filled with fluid. 
 
 At about what period of pregnancy do these two 
 layers come in contact ? About the fourth month. 
 
 CONSTITUTION OF THE OVUM. 
 
 What is the arrangement of the ovule in reference 
 to its investments ? It has two membranes ; the 
 chorion externally, and the amnion internally, sur- 
 rounding it. 
 
 Are these membranes endowed with vitality ? They 
 are. 
 
 What does the inner membrane contain ? A fluid 
 in which is suspended a corpuscle, or cicatricula. 
 
 What is the probable size of the ovum at the time 
 of its entrance into the uterus from the fallopian 
 tube ? It is supposed to be about the size of a hemp 
 seed. 
 
 What length of time does it probably require for the 
 ovule to pass along the tube from the ovary to the 
 uterus ? A week, or a little more. 
 
 Does any portion of the shaggy surface of the 
 chorion come in contact with the uterus ? No, for 
 the two layers of the caduca or decidua are inter- 
 posed. 
 
 How, then, does the ovum derive its support from 
 the uterus ? The decidua receives the blood from the 
 uterus, and transmits it to the ovum through the 
 shaggy surface or the radicles of the chorion. 
 
 What are the anatomical characters of the chorion ? 
 It is a serous or white membrane, and does not carry 
 red blood ; its internal surface is smooth, but exter- 
 nally it is villous or shaggy ; its little flocculi being 
 like so many radicles. 
 
 Are these radicles vessels? Some physiologists 
 consider that they are vascular, and others regard 
 
70 GENERATION — OVUM. 
 
 them as areolar spongioles, and not permeable con- 
 duits. 
 
 Does the chorion increase in thickness and strength 
 as it becomes developed ? It is believed that it 
 does at the same time that the decidua becomes 
 thinner. 
 
 Poes the chorion form the basis of the placenta ? 
 This point is not well settled, though in the opinion 
 of Rigb}^ Hodge, Dewees, and some others, it does. 
 
 What are the characteristics of the amnion ? It 
 is a delicate small sac situated within the chorion. 
 
 Is it different in any respect from the chorion ? 
 Yes ; it is smooth and transparent, though it is slightly 
 adherent in places to the chorion by means of mu- 
 cous filaments or lamellae which covers its outer sur- 
 face. 
 
 What fluid does it enclose ? The liquor amnii." 
 
 Is the amnion originally in contact with the chorion 
 throughout ? No ; originally it is smaller than the 
 chorion. 
 
 What is interposed between the two membranes ? 
 A kind of vitriform substance, enclosed in a delicate re- 
 ticulated sac. 
 
 At about what period of gestation does the amnion 
 come in contact with the chorion ? After the second 
 month ; though agreeably to Velpeau there is much 
 difference in different individuals, in this respect. In 
 some cases, it is known to have a considerable amount 
 of fluid between it and the amnion at the full term of 
 gestation, the escape of which has led to the idea 
 that the liquor amnii had passed off. 
 
 Is the amnion a stronger membrane than the cho- 
 rion ? It is usually much stronger. 
 
 What is the character of the liquor amnii ? It is 
 peculiar ; unctuous, and rather more consistent than 
 pure water ; has also rather greater specific gravity. 
 
 What circumstances may modify its color and odor ? 
 The excretions from the fetus. 
 
 What is the relative quantity of the fluid during the 
 
GENERATION—OVUM. 77 
 
 whole period of gestation ? At first it forms but a 
 thin stratum, but it increases rapidly till the second 
 month. At three months it weighs more than the 
 fetus. After this period the quantity of the fluid rel- 
 atively diminishes. 
 
 What is the quantity usually present at birth of the 
 fetus ? A pint ; sometimes quarts, and in a few rare 
 cases even gallons. 
 
 Does this increased quantity appear to exert any 
 influence on the health of the child ? It usually pro- 
 duces no manifest effect. 
 
 What appear to be the uses of this fluid ? Although 
 its intrinsic use is not known, it is evidently adapted 
 to allow space and facilities for motion, development, 
 &c., of the fetus. 
 
 May the presence and increase of the liquor amnii 
 be regarded as a concentric stimulus to the develop- 
 ment of the uterus,? This opinion is entertained by 
 some highly respectable authority. 
 
 Is the liquor amnii subject to any changes in color 
 and quality ? It is modified in this respect by various 
 causes ; as diseases, &c. 
 
 What does Velpeau suppose to be located between 
 the amnion and chorion, until they are approximated 
 by the developement of the amnion ? The reticulated 
 tissue, containing a sort of vitreous humor. He calls 
 it the reticulated body, which after the chorion and 
 amnion come together, corresponds to the allantois of 
 inferior animals. 
 
 What is Muller's description and magnified drawing 
 of an ovum which he supposed to be about twenty-eight 
 days old? A, fig. 43, the natural size. B,fig. 44, the mag- 
 nified view. C, fig. 45, a view still more highly magnified, 
 with the membranes restored, and references to the sev- 
 eral parts, a, a, chorion laid open and reflected ; 5, 5, 5, 
 albuminous space betwixt the amnion and chorion ; c, 
 amnion ; d, umbilical vesicle ; d\ pedicle of the um- 
 bilical vesicle ; e, noose of intestine communicating 
 with d^ ; ^, heart ; A, lower jaw ; i, ear ; k, cerebel- 
 
GENERATION — EMBRYO. 
 
 lum ; h^^ hemispheres ; P, corpora quadrigemina ; Z, 
 anterior, and, m, posterior extremity ; n^ point where 
 
 Fig. 43. 
 
 Fig. 44. 
 
 Fig. 45. 
 
GENERATION— EMBRYO. 79 
 
 the allantois and chorion have coalesced ; n\ umbilical 
 cord ; p, liver ; r, eye ; 1, 2, 3, branchial fissures. 
 
 How does Professor Meigs describe the allantois ? 
 *' This is a small vesicle or bladder, which rises from 
 the pelvic extremity of the embryo, and springing for- 
 wardg from the still open belly proceeds to place itself 
 betwixt the outer chorion and the inner amnion, en- 
 larging itself and at length attaching itself to the 
 chorion, carrying with it the blood-vessels which create 
 it, and which are umbilical arteries which it applies by 
 their distal extremities to the inner aspect of the 
 chorion. This chorion they pierce and go through to 
 seek an attachment as placental tufts, on the inner 
 wall of the womb. This bladder is the allantois. 
 When the belly of the embryo becomes closed in, this 
 bladder becomes strictured at the navel, and in the 
 tractus of the umbilical cord. The narrow strictured 
 part of the vesicle is now a long cylindrical tube. The 
 part retained within the now closed abdomen is the 
 bladder of urine ; the long cylindrical part is the ura- 
 chus, and the outer expanded, or to speak correctly, 
 uncompressed and unstrictured portion is the allan- 
 tois." 
 
 What is his opinion of the uses of the allantois or 
 sausage-shaped vesicle ? " The urine secreted in the 
 kidney passes by the ureters into the bladder of urine, 
 and in the early stages of uterine life flows through 
 the urachus into the bag of the allantois." 
 
 What is the vesicula alba or umbilical vesicle ? 
 Dr. Meigs, who has given a more full account than any 
 other American writer, of what is known of the 
 changes of the ovum early after impregnation, after 
 reminding his reader that the human yelk is micro- 
 scopic globule filled with vitellary corpuscles, says, 
 *' When the blastoderm has partly undergone the 
 morphological changes that convert it into the 
 earliest rudiraental embryon, part of the yelk cor- 
 puscles still remain unappropriated ; and as they are 
 still contained in their original vitelline membrane, they 
 
80 
 
 GENERATION — EMBRYO. 
 
 Fig. 46. 
 
 Fig. 47. 
 
 constitute a small but visible "ball, 
 called the umbilical vesicle." He 
 illustrates this statement by the ac- 
 companying diagrams. Originally 
 the vitellus was a sphere, of 
 which fig. 46 represents * seg- 
 ment. The blastoderm is devel- 
 oped upon a segment of this sphere 
 as in fig. 47. When the blas- 
 toderm doubles or folds its edges 
 inwards it pinches a portion of the vitellary ball as 
 in fig. 48. In a still farther 
 progress as may be shown by 
 fig. 49, the portion of the vitel- 
 lary ball that remains outside 
 of the embryon is connected 
 with the embryo by a delicate 
 tube or vitellary duct." 
 
 Into what portion of the intes- 
 tines does it open? Velpeau says 
 it comes from the ileum ; Oker, 
 Rigby and Ludlow consider 
 the appendicula vermifor- 
 mis as the remains of it. 
 
 Is it situated between 
 the chorion and amnion ? 
 Some teachers think it is 
 outside of the chorion. Vel- 
 peau says it is between the 
 chorion and amnion. 
 
 Fig. 49. 
 
GENERATION — EMBRYO. 
 
 81 
 
 How is it composed ? It consists of two, perhaps 
 of three membranous layers. 
 
 What appears to be its use ? To supply the embryo 
 with nutriment during the early periods of its develop- 
 ment, and until the placental circulation is established. 
 
 At what time does it totally disappear ? By the 
 end of the third or fourth month of gestation. 
 
 Are there any blood-vessels distributed through it ? 
 Yes ; both arterial and venous. 
 
 What are these called ? Yitello-mesenteric, or om- 
 phalo-mesenteric vessels. 
 
 How does Professor Meigs describe and illustrate 
 
 Fig. 50. 
 
 the omphalo-mesenteric vessels and cord ? " In per- 
 fect ova, averted at the period of two months, or a 
 little later, the student will readily distinguish the um- 
 
82 GENERATION — PLACENTA. 
 
 bilical vesicle shining through the chorion and lying 
 betwixt it and the delicate amniotic membrane. I add 
 here a figure that may serve to explain its arrangement. 
 Let a, a, fig. 50, be a portion of the abdomen and the 
 embryo, and c, c, the navel or umbilical ring ; 5, 5, 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, /, the 
 two umbilical arteries of the fetus ; A, the umbilical 
 vesicle or vitelline sac, whose pipe conduit or efferent- 
 duct runs along the umbilical cord to the navel, and 
 passing into the belly empties itself in the ileum ; g^ g, 
 Avhich bends up to receive the discharge ; k, I, repre- 
 sents the omphalo-mesenteric vessels." 
 
 By what means is the embryo connected with the 
 membranes ? By the umbilical cord. 
 
 What is the composition of this cord ? It consists 
 of two arteries and one vein, of a layer of amnion, 
 and perhaps also chorion, with some albuminous or 
 gelatinous matter interposed. 
 
 Whence do these vessels originate, and in what do 
 they terminate ? The arteries are continuations of the 
 primitive iliacs, while the vein goes to pass under the 
 edge of the liver and enter the cava. They terminate 
 in a great number of branches at the circumference 
 of the ovum, upon a portion of the chorion. 
 
 PLACENTA. 
 
 What is this congeries of vascular radicles called ? 
 Placenta. 
 
 What is the usual size of the placenta at the full 
 period of utero gestation ? Its diameter is from six 
 to eight inches ; its circumference, from eighteen to 
 twenty-four inches ; and its thickness from a few lines 
 at the circumference to an inch or two in its centre. 
 
 What is the character of its inner or fetal surface ? 
 It is smooth, lined with the amnion, through which 
 the larger vessels of the placenta can be felt and 
 seen. Fig. 51. 
 
GENERATION — PLACENTA. 
 Fig. 51. 
 
 What arrangement exists on its external or uterine 
 surface ? It is arranged in convolutions or sulci, 
 which are distributed in masses, sometimes called pla- 
 centules. Fig. 52. 
 
 Fig. 52. 
 
 Is there any membrane thrown across the uterine 
 surface of the placenta? The decidua is believed by 
 many physiologists to extend over its whole surface. 
 
 Can the amnion be removed from the inner surface 
 of the placenta ? It can be readily peeled off from 
 the inner surface. 
 
84 GENERATION — PLACENTA. 
 
 Is the chorion more firmly attached to it? It is 
 almost inseparably so. 
 
 What is the mode of communication between the 
 embryo and uterus during the first week of its uterine 
 existence ? Through the membranes entirely. The 
 decidua receives blood from the uterus, transmits the 
 elements of nutrition, through the fetal membranes to 
 the embryo. 
 
 What is Professor Hodge's theory of the mode of 
 formation of the placenta ? " The shaggy surface 
 of the chorion enlarges at the point at which the 
 ovule happens to come in contact with it, and at 
 that point the placenta is formed, chiefly out of the 
 shaggy surface of the chorion, and also of the decidua, 
 which may be regarded as the uterine portion of the 
 placenta." 
 
 What is the composition of the placenta ? Its 
 tissue is peculiar ; it is somewhat cellular, but is made 
 up chiefly of ramifications of the cord. 
 
 Is this susceptible of proof by injection ? The tis- 
 sue of the placenta may be distended by injecting the 
 arteries, and when these vessels are filled, the fluid 
 passes out by the vein. 
 
 Is it proper to consider the placenta as composed 
 of two parts, the fetal, and the uterine portions ? It 
 will admit of that mode of demonstration, particularly 
 during the early part of pregnancy. 
 
 What are these two portions ? One, the fetal, is 
 composed of the chorion, and the other, the uterine, 
 is derived from the decidua. 
 
 Can these portions be readily separated from each 
 other ? The process can be eff'ected by maceration, as 
 late as the second month of pregnancy. 
 
 Do any large blood vessels pass from the uterus into 
 the placenta ? No : the communication between the 
 uterus and the decidua, is by capillary veins and arte- 
 ries only. 
 
 What are the proofs of this ? The decidua may be 
 
GENERATION — PLACENTA. 85 
 
 injected from the uterus during the early periods of 
 pregnancy. 
 
 How many kinds of circulation are carried on in 
 the placenta ? Two ; one through the very minute 
 utero-placental vessels for the purpose of sustaining 
 the vitality and nutrition of the placenta ; the minute 
 vessels extending from the substance of the uterus 
 into the placenta; and the other, a large circulation, 
 through the vessels of which the placenta is chiefly 
 composed ; the blood coming from and returning to 
 the fetus, in a manner analogous to that in which a 
 small supply of blood is sent to the substance of the 
 lungs for their nutrition, while the whole mass which 
 is to be sent over the body, is passed through the 
 great vessels of the lungs, during extra^ uterine life. 
 
 What becomes of the blood of the fetus, after it 
 has been carried out through the umbilical arteries ? 
 It returns to the fetus through the umbilical vein. 
 
 Do the uterine veins increase in size as they ap- 
 proach the placenta ? They usually increase very 
 greatly. 
 
 Do they open directly into the placenta ? No ; 
 they open upon the decidua by patulous orifices — this 
 membrane therefore acts like a valve over them, to 
 prevent the blood from escaping into the cavity of the 
 gravid uterus. 
 
 "What is the proof of the arrangement ? The fact 
 that if the placenta be separated before the uterus 
 contracts, more or less venous hemorrhage occurs as a 
 consequence. 
 
 What were Lee's observations in reference to this 
 vascular arrangement ? " If air be forcibly thrown 
 into either the spermatic arteries or veins, the whole 
 inner membrane of the uterus is raised by it ; but 
 none of the air passes across the deciduous membrane 
 into the placenta, nor does it escape from the semilu- 
 nar openings in the inner membrane of the uterus, 
 until the attachment of the deciduous membrane to the 
 uterus is destroyed. There are no openings in the 
 8 
 
86 GENERATION — PLACENTA. 
 
 deciduous membrane corresponding with the valvular 
 apertures in the internal membrane of the uterus." 
 
 Upon which individual, mother or child, does the 
 placenta depend for its organic vitality? Upon the 
 mother. 
 
 What proofs have we of this ? First, the fact that 
 if the placenta be separated from the uterus, it be- 
 comes atrophied. Secondly, the placenta may be- 
 come diseased ; it may become inflamed, and subse- 
 quently adherent to the uterus. Thirdly, the pla- 
 centa may sometimes be kept alive after the death of 
 the fetus. 
 
 To what changes is it mostly subjected under such 
 circumstances ? It generally becomes carneous and 
 somewhat shrivelled, in consequence of the failure of 
 the fetal circulation through it. 
 
 Is the placenta very easily separated from the in- 
 ternal surface of the uterus when it is in a healthy 
 state ? It is — by passing up the fingers between the 
 uterus and placenta, it may be very easily separated. 
 Slight jars, shocks, and any thing which excites ute- 
 rine contraction, may be a means of causing a sepa- 
 ration of the placenta, and giving rise to uterine hem- 
 orrhage. 
 
 To what part of the uterus is the placenta mostly 
 attached? According to the experience of some^ 
 mostly to one of the sides of the uterus. 
 
 Are there any nerves in the placenta ? None have 
 yet been satisfactorily discovered. 
 
 Is this mass supplied with lymphatics ? It is be- 
 lieved by many that they exist in this body in consid- 
 erable amount. 
 
 What is the length of the cord at the end of the 
 third or fourth week ? Half an inch. Yelpeau, how- 
 ever, says he has mostly found the cord about the 
 length of the embryo or fetus, throughout every 
 period of gestation at which he has been able to dis- 
 sect it. During the very early period it appears like 
 a gelatinous bag. 
 
GENERATION — PLACENTA. 87 
 
 What is the usual length of the umbilical cord of 
 the child at term ? About eighteen or twenty inches, 
 though it is sometimes much longer or much shorter 
 than this. 
 
 What inconveniences are liable to result from the 
 cord being much longer than this ? It is then apt 
 to become tied into knots by the various movements 
 of the fetus. It is also liable to become prolapsed 
 during labor when of greater length than that men- 
 tioned. 
 
 What are some of the consequences of too short a 
 cord ? Delivery may be retarded, or the placenta may 
 be pulled down, and hemorrhage follow, or the uterus 
 may be inverted. 
 
 Have the vessels of the umbilical cord any valves ? 
 No ; an injection passed into the arteries will return 
 by the veins, and vice versa. 
 
 Is the cord composed of these three vessels only ? 
 No ; it has also a greater or less amount of gelatinous 
 matter in it. 
 
 When you take hold of the umbilical cord, how 
 many tissues are between your fingers ? Amnion, 
 chorion, and the two arteries and one vein. 
 
 Is the chorion very intimately attached to the 
 cord? Yes, it appears almost inseparable from the 
 reticulated tissue which contains the vessels and the 
 gelatine. 
 
 Is the cord capable of bearing much force applied 
 to it ? It sometimes is broken by the weight of the 
 child at birth ; but occasionally it possesses great 
 strength. 
 
 What is the arrangement of the membrane in case 
 of twins ? Each embryo has its own membranes and 
 its own placenta, (see fig. 53.) 
 
 In cases of twin ova, when an ovule is conveyed 
 into the uterus by each fallopian tube, how many mem- 
 branes are interposed between each fetus ? Six — 
 amnion, chorion, decidua, decidua, chorion and amnion. 
 
 What number in case the two ovules pass down 
 
88 GENERATION — SUPERFETATION. 
 
 one fallopian tube ? Then there are probably but 
 four, viz. — amnion, chorion, chorion and amnion. 
 
 FiV. 53. 
 
 SUPERFETATION. 
 
 What opinions are entertained by most physiolo- 
 gists respecting superfetation, admitting the theory 
 of generation, now generally believed in, to be cor- 
 rect? That it would be impossible for impregnation 
 to take place, after the uterus becomes occupied by a 
 decidua, and perhaps also an ovum. 
 
 How are the facts, however, of women giving birth 
 to two or more children at once, of different sizes, and 
 apparently of diff"erent ages, to be accounted for ? 
 Upon the idea that originally it was a twin pregnancy, 
 but that some cause had suspended the development 
 of one of the fetuses. 
 
 What is the probable explanation when the fetuses 
 are born at diff'erent periods, and well developed? 
 That there has been a double uterus, one of which 
 contained the ovum first fecundated, and the other the 
 second. 
 
 What in case of the delivery at the same time of 
 
GENERATION — EMBRYO. 89 
 
 two children, one white and the other black ? That 
 the woman had been the subject of two fecundating 
 copulations in quick succession by men, one white, 
 and the other black. 
 
 May not superfetation take place in cases of pre- 
 existing extra-uterine pregnancy ? It may, indeed, 
 at any time when the uterine cavity is not filled with 
 any substance, and so long as the tubes are open. 
 
 EMBRYO. 
 
 How long does the new being retain the name of 
 embryo ? During the first, second, and third months 
 of gestation ; for up to this period its formation is in- 
 complete. 
 
 What is the earliest period at which an embryo 
 can be seen within its investments? About the 
 tenth day, and then only by the aid of a magnifying 
 glass. 
 
 What does it appear to be at this time ? A mere 
 amorphous vesicle. 
 
 Does it quickly undergo considerable changes ? It 
 soon enlarges, and presents two bodies or vesicles at- 
 tached to each other. 
 
 Of what are these two bodies the elements ? The 
 head and body of the future fetus. 
 
 Which of these two bodies or vesicles is the head ? 
 The larger of the two. 
 
 What does the embryo resemble in the next or se- 
 cond degree of its development ? A kidney-bean, or 
 a grub-worm or maggot curved upon itself. 
 
 What probably is first developed in the embryo ? 
 Some think the spine and the heart. 
 
 What recent English writer on obstetricy, who, 
 like Professor Meigs in this country, has enriched his 
 work by clear illustrations of the manner in which 
 physiologists have observed the early development of 
 the embryo ? Dr. Edward Rigby. 
 
 What is the mode of addition of the different parts 
 of the embryo, to constitute the fetus ? Professor 
 
90 
 
 GENERATION — FETUS. 
 
 Hodge and some others think it is by super-addition, 
 puUutation or generation, and not by evolution, or un- 
 folding. We are ourselves, however, inclined to be- 
 lieve in the latter mode of development. 
 
 From what part of the curved embryo is this gener- 
 ation carried on ? From the concave, and never the 
 convex surface. 
 
 What is the general order of succession in this pro- 
 cess of pullutation or generation of parts ; admitting 
 this idea to be correct ? First the features appear, 
 though rather indistinctly ; then the roots of the upper 
 extremities, then the coccyx, and then the lower ex- 
 tremities. 
 
 Which portion of the limbs appears first ? The arm 
 and thigh, or the fore-arm and leg, &c. According 
 to those who believe in pullutation, the arm and thigh, 
 and not the fore-arm and leg, with the hand and foot, 
 as Yelpeau has it. 
 
 FETUS. 
 
 Does the embryo change its name at the end of 
 three months ? Yes ; it is then called fetus. 
 
 What is the extent of its development at this time ? 
 The teguments are distinct, though very soft and rose- 
 colored ; the head is still proportionately very large, 
 the nose prominent, though both the mouth and eye- 
 lids remain closed : the osseous system begins to be 
 observable, through the gelatinoid coverings, and the 
 digits of the extremities are quite distinct, and even 
 exhibit a surface for the future nail ; the intestines 
 are also included in the abdominal varieties. 
 
 What is the length of the head and body of the fe- 
 tus at this time ? From vertex to coccyx, it measures 
 about three inches. 
 
 At about what period of gestation, does the muscu- 
 lar S3^stem become sufficiently developed, to exert the 
 power of motion ? From the middle to the end of 
 the fourth month. 
 
GENERATION — FETUS. 91 
 
 VIABILITY OF THE FETUS. 
 
 "What is to be understood by the expression, the 
 viability of the fetus f That the fetus, which has hi- 
 therto enjoyed only a sort of vegetable life in utero, is 
 now sufficiently developed to admit of living indepen- 
 dently of the uterus, or in other words, to enjoy extra 
 uterine and animal life. 
 
 At what period of fetal existence does this viability 
 occur ? At about the end of the sixth month. 
 
 Are fetuses very likely to live when born at the end 
 of the seventh month ? It is the experience of some 
 that they rarely live. 
 
 Are children, born at the end of the eighth month 
 less likely to live, than those born at the seventh 
 month ? Professor Hodge thinks not, though that 
 opinion was entertained by Professor James. 
 
 What is the condition of the eye of a fetus at seven 
 months ? It has been supposed that from the fourth 
 to the seventh month, the eye was closed by what was 
 called the membrana pupillaris. That at this time the 
 membrane bursts, and that vision becomes possible to 
 the child born at this time. 
 
 What is Velpeau's view of this condition of the eye ? 
 He appears to think that the iris is not developed until 
 the seventh month, that it originates at first as a sim- 
 ple ring, which grows concentrically so as at last to 
 leave the opening commonly called the pupil of the 
 eye. 
 
 FETAL ELLIPSE. 
 
 In what manner is the fetus usually situated in the 
 cavity of the uterus, at the full period of gestation ? 
 Its general form is that of an ellipse, its limbs crossed 
 and flexed in front of the abdomen. 
 
 What is the long diameter of this ellipse ? From 
 vertex to coccyx. 
 
 What is its measurement ? About twelve inches. 
 
92 GENERATION — FETUS. 
 
 WEIGHT OF THE FETUS. 
 
 What is the average weight of a fetus at term ? 
 From. seven to eight pounds; perhaps seven pounds 
 for the male, and six for the female child. In Phila- 
 delphia, Dr. Hodge weighed one thirteen and a quar- 
 ter pounds ; and Dr. Condie one, fifteen pounds 
 nine ounces. 
 
 What was about the greatest weight noted bj Ma-- 
 dame Lachapelle, in four thousand cases ? Less than 
 twelve pounds. 
 
 In twin cases, are each of" the children as large as 
 in single pregnancy ? No, each fetus is usually smaller, 
 but the sum of the twins is greater than in a single 
 pregnancy. 
 
 POSITION OF UMBILICUS. 
 
 Is there any difference at different periods as to the 
 point of insertion of the umbilical cord ? In the early 
 part of fetal existence the cord is inserted near the 
 pelvis, but this point becomes more remote as the body 
 becomes developed. 
 
 Where is the umbilical cord situated at term ? 
 About half way between the pubes and ensiform car- 
 tilage. 
 
 Do the viscera of the fetus bear the same relation 
 of size to each other as those of the adult ? No — 
 the liver is much larger — the lungs smaller and dense, 
 they are very slightly if at all porous or crepitous. 
 
 THYMUS GLAND. 
 
 Is there any structure in the fetus which is peculiar 
 to it, and useless to extra uterine life ? Yes — the thy- 
 mus gland. 
 
 Where, is it situated ? In the anterior portion of 
 the superior mediastinum. 
 
 How many lobes has it ? Two, but no excretory duct. 
 
 Does it remain developed long after birth ? No — 
 it diminishes rapidly after the extra uterine functions 
 become established. 
 
GENERATION— FETUS. 93 
 
 "What is the object of the gland ? Its uses are not 
 known. 
 
 FETAL HEART— CIRCULATION. 
 
 Is there any peculiarity in the fetal heart ? It is 
 like a single heart, both auricles receiving blood from 
 the veins, and both ventricles simultaneously propelling 
 it into the arteries. 
 
 Is the septum between the ventricles complete at 
 term ? Yes — but it is imperfect between the auricles. 
 
 What is the name of the orifice between the two 
 auricles ? Foramen ovale, or foramen of Botal. 
 
 Is there any valve-like formation connected with it ? 
 Yes, there is an arrangement of this kind situated on 
 the left side of the foramen ovale. 
 
 How does the blood from the placenta get into the 
 fetal heart ? It enters the umbilicus of the fetus 
 through the umbilical vein, which passes up under the 
 edge of the liver, where it empties into the left 
 branch of the sinus venae portarum, giving off several 
 branches to the liver. Some portion of the blood 
 then passes along what is called the ductus venosus, 
 into the left hepatic vein, which runs into the ascend- 
 ing vena cava. The blood then mixed with that in 
 the cava, is carried up the cava until it reaches the 
 eustachian valve, which directs a large portion of it 
 through the foramen ovale into the left auricle, at the 
 same time that the right auricle receives the blood 
 which comes down from the descending cava. 
 
 How is the blood disposed of, after it has been thus 
 carried into the heart ? The two ventricles, supplied 
 with blood at the same instant from each auricle, now 
 contract and force blood along the pulmonary artery 
 and aorta. 
 
 Is the pulmonary artery well developed during fetal 
 life ? It is adapted only to carry blood sufficient to 
 nourish the lungs, but it is not large enough to carry 
 all the blood of the general circulation. 
 
 What route is presented as a substitute for the pul- 
 
94 GliNERATION — FETAL CIRCULATION. 
 
 monary circulation ? A short duct is given oiF from 
 the pulmonary artery to the aorta a little below its arch. 
 
 What is this vessel called ? The ductus arteriosus. 
 
 How then is the fetal blood carried back to the pla- 
 centa ? That which is forced out of the right ventri- 
 cle is carried through the ductus arteriosus. That 
 from the left ventricle passes the usual route of the 
 arch of the aorta. At the point of insertion of the 
 ductus arteriosus, the blood from the two ventricles 
 continues to pass through the aorta as low as the iliac 
 arteries, which give off branches; which under the 
 name of internal iliacs, turn upwards, one on each 
 side of the bladder and pass out at the umbilicus and 
 proceed to the placenta, under the name of the um- 
 bilical arteries. At the same time, a sufficient quan- 
 tity is carried along the primitive iliacs to nourish 
 the lower extremities. Fig. 54 is a diagram by Drs. 
 Neill and Smith, representing the fetal circulation, 
 which is thus described : (1) the umbilical cord, con- 
 sisting of the umbilical vein and two umbilical arte- 
 ries, proceeding from (2) the placenta ; (3) the umbilical 
 vein dividing into three branches ; two of which (4) 
 (4), to be distributed to the liver; and one, (5) the 
 ductus venosus, which enters (6) the inferior vena 
 cava ; (7) the portal vein, returning the blood from 
 the intestines, and uniting with the right hepatic 
 branch ; (8) the right auricle ; the course of the blood 
 is denoted by the arrow, proceeding from (8) to (9) 
 the left auricle ; (10) the left venticle, the blood fol- 
 lowing the arrow to (11) the arch of the aorta, to be 
 distributed through the branches given off from the 
 arch of the aorta to the head and upper extremities. 
 The arrows (12) and (13) represent the return of the 
 blood from the head and upper extremities through 
 the jugular and sub-clavian veins to (24) the superior 
 vena cava to (8) the right auricle, and in the course 
 of the arrow, through (15) the right ventricle to (16) 
 the pulmonary artery ; (17) represents the ductus ar- 
 teriosus, which appears to be a proper continuation of 
 
GENERATION — FETAL CIRCULATION. 95 
 
 the pulmonary artery ; the ofF-set on each side are the 
 initials of the right and left pulmonary artery ; these 
 vessels being of extremely small size when compared 
 
 with the ductus arteriosus. The ductus arteriosus joins 
 (18, 18) the descending aorta, which farther down 
 divides into the common iliacs, which become (19) the 
 umbilical arteries, and return the blood along the 
 
OG GENERATION — FETAL CIRCULATION. 
 
 umbilical cord to the placenta, while the other divi- 
 sions (20) the external iliacs are continued to the lower 
 extremities. The arrows at the termination of these 
 vessels mark the return of the venous blood by the 
 veins to the inferior cava. 
 
 Is the circulation of the fetus carried on within, or 
 without the cavity of its peritonaeum ? Outside of 
 it at all points. This large membranous sac covers 
 the inner and lateral portions only of the circulatory 
 apparatus. 
 
 CHANGES IN THE "MODE OF CIRCU'LATION AFTER BIRTH. 
 
 What changes take place in this circulation, after 
 the birth of the child ? The air rushes into the lungs, 
 upon the effort to respire ; the column of blood, which 
 before passed along the ductus arteriosus from the 
 right ventricle, now passes along the pulmonary ar- 
 tery, into the lungs ; thence it returns through the 
 pulmonary vein, into the left auricle. The effect of 
 this is to render the ductus arteriosus useless, and it 
 consequently becomes filled with a coagulum. The 
 current of blood coursing from the lungs through the 
 loft auricle, closes down the valvular formation on the 
 left side of the foramen of Botal or the foramen 
 ovale, and thus cuts off the direct connection, which 
 heretofore had existed between the right and left 
 auricles. From this moment, the action of the heart 
 becomes double ; that is, the right auricle and right 
 ventricle, act as it were independently of the left 
 auricle, and left ventricle. The lungs now perform- 
 ing the function of aeration, or decarbonization of the 
 blood, the placental circulation becomes no longer ne- 
 cessary, and the ductus venosus is obliterated. 
 
 What becomes of the vessels which were peculiar 
 to the fetus ? Upon the establishment of the extra- 
 uterine circulation, they become first obliterated by 
 coagula, and then either remain in the character of 
 ligaments, or are entirely absorbed. 
 
GENERATION — FETUS. 97 
 
 PHYSIOLOGICAL CHARACTERS OF THE FETUS. 
 
 What are the physiological characters of the fetus ? 
 While yet an embryo, it grows, is nourished, and it 
 has fluids to sustain it. It is endowed with vitality 
 from the period of its detachment from the ovary. 
 
 Does it form its own blood ? It does. 
 
 What is the color of the fluid which it first circu- 
 lates ? White. 
 
 How small an amount of red blood can be seen 
 about the heart, while the embryo is in a transparent 
 or translucent state ? A mere drop or two, about the 
 region of the heart. 
 
 Is the blood of the fetus exactly like that of the 
 mother ? No, it is peculiar ; its color is between that 
 of maternal, arterial, and venous blood ; it is said to 
 resemble the menstrual fluid. 
 
 Is its consistence as firm as that of adult blood? 
 No ; its coagulum is softer, its red globules are 
 smaller. 
 
 Does it contain so large a portion of phosphoric 
 salts ? It does not. 
 
 If the fetus then forms and circulates its own blood, 
 does it not require a relatively greater force to propel 
 it through the placenta and umbilical vessels ? Yes, 
 and hence the simultaneous action of the two ventri- 
 cles to carry the blood with double force. 
 
 Does the blood of the mother circulate at all 
 through the ^ fetal vessels? No; it is probable that 
 the decidua receives blood from the uterus, but returns 
 it again to that organ without transmitting it to the 
 other portions of the placenta, at least not more than 
 to supply it with nutriment. 
 
 Would the circulation of the mother, be too strong 
 for that of the embryo or fetus ? Yes, it is highly 
 probable that it would destroy it by the momentum 
 with which the blood would be impelled into it if there 
 were a direct communication between the mother and 
 fetus. 
 
 9 
 
98 . GENERATIOX— FETUS. 
 
 What proofs have we, that the maternal blood is not 
 circulated in the fetus ? 1. Injections cannot pass 
 from the vessels of the mother into those of the fetus ; 
 nor if the vessels of the fetus be injected, can the 
 matter of injection be conveyed through the placenta 
 into the vessels of the uterus, at least not without pre- 
 vious lesion of structure. 2. If after the birth of the 
 child, the umbilical cord be cut, there is no continuous 
 hemorrhage from the placental extremity of it, — only 
 a part of the blood it had contained, is squeezed out 
 by contraction of the uterus. 3. The fetus cannot 
 be poisoned through the mother. The child may die 
 from rupture of the cord, without the mother being 
 afiected. 4. The entire ovum has been thrown oif by 
 the uterus, and when deposited in warm water, has 
 been known to live many minutes, perhaps an hour ; 
 its circulation going on without any effusion of blood. 
 
 What eifect does hemorrhage from the mother, 
 have upon the fetus ? None, whatever, directly ; the 
 woman may suddenly die from very profuse hemor- 
 rhage, and yet the child will survive some time ; — if 
 however, she be exhausted by constant discharge, 
 the fetus will suffer much thus, and fail to become 
 Avell developed, even though the mother may survive. 
 
 Is the circulation of the fetus more rapid than that 
 of the mother ? It is ; the motions of the heart 
 have been determined by the stethoscope to be nearly 
 or quite twice as frequent as tliose of the mother's 
 heart. 
 
 What part of the fetus receives pure placental 
 blood ? The left side of the liver only, because every 
 other portion has the blood from the fetal veins mixed 
 with it. 
 
 What is the proportion in which the difierent or- 
 gans receive the placental blood? This has not yet 
 been satisfactorily ascertained ; it may be proposed as 
 a matter of interesting calculation. 
 
 Why are the upper parts of the fetus better de- 
 veloped than the lower extremities ? Because more 
 
GENERATION — FETUS. 99 
 
 blood is carried through the carotids and sub-clavians, 
 than through the lower branches of the aorta. 
 
 Is more pure blood carried into the left than into 
 the right ventricle ? In consequence of the arrange- 
 ment of the eustachian valve, blood which is brought 
 from the placenta, mingled, it is true, with a part of 
 the blood in the portal circulation, is thrown into the 
 left auricle through the foramen of Botal. From this 
 ventricle it is thrown into the arterial branches of the 
 aor4a, which go to supply the head and upper extre- 
 mities, while the blood in the right ventricle is thrown 
 out into the root of the pulmonary artery, and thence 
 through the ductus arteriosus into the aorta, below 
 the branches which supply the upper portions of the 
 body. The right ventricle receives from the aorta 
 the blood of the vena cava descendens. 
 
 What is the apparent object of the placenta ? To 
 aiford the changes necessary in the blood for the nu- 
 triment and development of the fetus. 
 
 What changes are probably effected in the placenta? 
 Those similar to that effected in the lungs by respira- 
 tion, in other words, hematosis. 
 
 Is it probable that oxygen is eliminated in the 
 placenta and transmitted to the blood through its 
 tissue ? A suppty of oxygen is necessary to hema- 
 tosis. It is indispensable to all animals, to the chick 
 in ovo, &c. 
 
 Is there any difference of color in the blood circu- 
 lating in the vessels of the fetus ? It is redder in the 
 arteries than veins, although the difference is not so 
 great as in the adult. 
 
 How does pressure upon the cord cause the death 
 of the fetus ? By interrupting the process of hema- 
 tosis, and 'not by suspending the circulation merely, 
 because this may go on, to some extent at least, in 
 the fetus independently of a cord or placenta, or when 
 these are compressed. 
 
 Is it probable that the fluid in which the fetus is 
 suspended affords it any nutriment ? This is an un 
 
100 GENERATION — FETUS. 
 
 settled question. Professor Hodge and some others 
 think not. They suppose that the placenta is in some 
 manner the medium of nutriment. 
 
 ANIMAL LIFE OF FETUS DORMANT. 
 
 Has the fetus any of the functions of animal life ? 
 Its faculties are dormant ; although the different 
 organs of this kind of life are developed in succes- 
 sion — as ears, eyes, nose, &c., yet it is doubtful 
 ■whether they are brought into exercise during intra- 
 uterine life. 
 
 What is the condition of the cerebrum, during the 
 latter part at least of fetal life ? The brain is soft 
 and less consistent at birth than afterwards. 
 
 Does the brain appear to be of any physiological 
 importance to the fetus ? No : some children have 
 been born without any brain, and yet had all the 
 other organs developed. 
 
 Is it probable that the fetus has sensation while in 
 utero ? Of the touch or tact only ; and it most likely 
 does not suffer from ordinary compression during par- 
 turition, as it is then probably comatose. 
 
 Does it probably suffer under severe obstetric ope- 
 rations upon it ? It is probable that it does suffer 
 from such causes, since under such processes the 
 pressure is usually less uniform than that effected by 
 the contractions of the uterus. 
 
 Is there any probability that the child may cry in 
 utero ? Not the least, unless probably when the 
 mouth of the child can come in contact with the 
 atmospheric air. 
 
 OSSEOUS SYSTEM OF THE FETUS. 
 
 What is the general condition of the osseous sys- 
 tem of the fetus ? The middle portions of the bodies 
 of the bones are usually pretty well developed, though 
 somewhat flexible, while the extremities are still car- 
 tilaginous and very pliant. 
 
 What advantages result from this circumstance in 
 
GENERATION — FETUS< 101 
 
 practice ? A greater degree of flexibility ot' the child, 
 both during labor, and for a short time after its 
 birth. 
 
 DIMENSIONS OF SKELETON. 
 
 What is the usual length of a fetus at term ? From 
 eighteen to twenty-two inches. 
 
 What is the distance from the tip of one acromion 
 process to that of the other ? Four or more inches. 
 
 May this diameter be diminished without danger ? 
 It may be diminished an inch or more without hazard 
 to the child, as it passes through the pelvis. 
 
 What is the antero-posterior, or dorso-thoracic dia- 
 meter of the child ? Three and a half or four inches — 
 but it may be reduced to two inches. 
 
 What are the general measurements of the breech 
 of the child when flexed ? From trochanter to tro- 
 chanter, from two and a half to three; from sacrum 
 to anterior part of thigh when flexed forward, three 
 inches. 
 
 What is the antero-posterior diameter of the pelvis 
 alone ? From one and a half to two inches. 
 
 What portion of the fetus is most important in an 
 obstetric point of view ? The head. 
 
 COMPOSITION OF THE CRANIUM. 
 
 How is the fetal cranium constituted ? Of several 
 different bones, so arranged as to present an ovoid 
 figure. 
 
 How are the sutures constituted ? They consist 
 of membranous interspaces between the several move- 
 able bones of the fetal head. 
 
 How is the cranium arranged as to its compressibi- 
 lity ? Part of it is compressible, the bones being 
 moveable upon, or capable of being slided over, each 
 other, — and the other portion is incompressible, or 
 not admitting of such alteration in the position of the 
 bones. 
 
 Which of the cranial bones are compressible or 
 9* 
 
102 GENERATION — FETUS. 
 
 moveable ? The occipital, and the two parietal, and 
 the inferior maxillary, — the frontal bone is partially so. 
 
 "Which may we consider as incompressible and im- 
 moveable ? The temporal, sphenoid, ethmoid, malar, 
 nasal, and superior maxillary bones. 
 
 What is to be understood by the term vault of the 
 cranium ? The vault of the cranium is composed of 
 occipital, parietal, and frontal bones. 
 
 OVOID FOllM— EXTREMITIES— SURFACES OF THE CRA- 
 NIUM. 
 
 The head being of an ovoid form, what names are 
 given to the two extremities of it ? Posterior and 
 anterior, or occipital and mental. 
 
 How many surfaces do we count upon the head of 
 the fetus ? A superior, an inferior, two lateral, a 
 posterior and an anterior surface. 
 
 What is the boundary of the superior surface ? A 
 horizontal line, bounded by the upper part of the 
 orbits. 
 
 What is the base of the head ? All the immove- 
 able part of it, viz. — the sphenoid in the centre, the 
 temporal bones laterally, together with the bones of 
 the face. 
 
 What part of the fetal head resembles a hemis- 
 phere ? The posterior or occipital extremity. 
 
 What is the composition of the os frontis ? Al- 
 though it is divided nearly or entirely by a suture 
 during early life, yet it is usually considered as one 
 bone. 
 
 How in regard to the occipital bone ? Originally 
 it was in several separate pieces, but these so soon 
 become fused together, that it is usual and proper to 
 consider it as only one bone. 
 
 What position do the parietal bones occupy ? The 
 lateral positions of the head, above the temporal, and 
 between the frontal and occipital boneS. 
 
GENERATION — FETUS. 103 
 
 INTEROSSEOUS SPACES OR SUTURES IN THE CRANIUM. 
 How many principal sutures are there, and what 
 are they called ? 1. The Lambdoid Suture^ running 
 from the bases of the occipital and parietal bones, 
 between these bones, and along the entire lateral and 
 upper portions of the occipital bone. 2. The Sag- 
 gital Suture^ extending forward from the upper point 
 of the occipital bone, between the two parietal bones, 
 to their anterior angles. 3. The Coronal Suture^ 
 extending along the anterior edges of. the parietal 
 bones, between them and the frontal bone, from their 
 base. 4. The Frontal Suture, extending forward be- 
 tween the two upper edges of the frontal bone, 
 continuous with the saggital suture to the root of the 
 nose. 
 
 FONTANELLES. 
 
 What is found at the upper and anterior angles of 
 the parietal bones, and at the upper and posterior an- 
 gles of the frontal bone ? A quadrangular or kite- 
 shaped membranous space, called the anterior fonta- 
 nel! e, or the bregma. 
 
 What is found at the posterior extremity of the 
 saggital suture ? A triangular or cruciform mem- 
 branous space, called the posterior or occipital fon- 
 tanelle. 
 
 Is this posterior or occipital fontanelle always well 
 marked on the fetal head ? By no means — sometimes 
 it is readily perceived, buf more frequently it cannot 
 be recognized as a triangular membranous space— it 
 is therefore often merely linear. 
 
 Is a knowledge of these fontanelles of much impor- 
 tance in the practice of midwifery ? They are of 
 great value, as they are the chief means of diagnosti- 
 cating the positions of the head during labor. 
 
 If no perceptible membranous space exists at the 
 top of the occiput — how are we to recognize the pre- 
 sentation of the occipital extremity of the head ? By 
 
104 GENERATIONS"— FETUS. 
 
 the aTiLles at the upper and posterior ends of the pa- 
 rietal bones, and the rounded margin of the occiput. 
 
 What other fontanelles may be found on the fetal 
 head ? Two inferior ones at the posterior inferior 
 edges of the parietal bones, and between them and 
 the edge of the occipital bone. 
 
 What influence may these exert in diagnosis ? With- 
 out care they may lead to error. 
 
 What are the boundaries of the posterior or occi- 
 pital surface of the fetal cranium? From a point 
 half way between the promontory of the occiput to 
 the foramen magnum of that bone, round over the 
 parietal protuberances, to a point near the anterior 
 extremity of the saggital suture. 
 
 What is the situation of the posterior fontanelle in 
 reference to the centre of this posterior surface ? It 
 is not usually in the centre, but mostly a little poste- 
 rior to it. 
 
 VERTEX OF CRANIUM. 
 
 What is meant by the term vertex in obstetrics ? 
 It is applied to that part of the fetal head exactly in 
 the centre of the posterior surface of the occipital 
 extremity. 
 
 What figure does a plane of the occipital extremity 
 present ? Nearly that of a circle. 
 
 By what particular name is it known ? Occipito- 
 bregmatic circumference. 
 
 DIAMETERS OF THE CRANIUM. 
 
 What is the transverse diame- 
 Fig. 55. ter of this circumference called, 
 
 and what does it measure? The 
 bi-parietal diameter, and it mea- 
 sures from three, to three and a 
 half inches, a to h fig. b^. 
 
 Whgt is the perpendicular dia- 
 meter called, and vrhat does it mea- 
 sure ? Occipito-bregmatic, and it 
 measures from three, to three and 
 a half inches, g to i fig. bQ. 
 
GENERATION — FETUS. 105 
 
 What is the horizontal circumference of the head ? 
 That which commences at the centre of the occipital 
 protuberance, and passes round on each side of the 
 parietal and frontal bones, till its ends meet in the 
 root of the nose. It is shewn in outline fig. 55. 
 
 What is the long diameter of this circumference 
 called, and what does it measure ? Occipito-frontal, 
 and measures four inches, d to e fig. 56. 
 
 What is the name of the transverse diameter, and 
 what does it measure ? Bi-parietal, and measures 
 from three, to three and a half inches, a to b fig. 55. 
 
 What is the trachelo- 
 bregmatic circumference ? Fig. 56. 
 
 That which commences in 
 front of the cervical ver- 
 tebrae, and passes round 
 over the temporal, and 
 portions of the parietal 
 bones, and terminates in 
 the bregma or top of the __ 
 
 head. k^^-^ ^^ 
 
 What are its diameters 
 called, and what do they measure ? 1. Trachelo- 
 bregmatic, measuring three and a half inches, h to c, 
 fig. 56. 2. Bi-temporal, measuring two and a half 
 inches, c to d, fig. 55. 
 
 For all practical purposes, what should w^e consider 
 the diameter of the base of the cranium ? The same 
 as those of the occipito-mental and the bi-parietal 
 circumferences, of which the first diameter mea- 
 sures five inches, and the second, three and a half 
 inches. 
 
 What diameters present within the circumference 
 of a perpendicular longitudinal section of the cra- 
 nium, and what do they measure ? 1. The occipito- 
 mental, five inches, a to b fig. 56. 2. The occipito- 
 frontal, four inches, d to e fig. 56. 3. The occipito- 
 bregmatic, three and a half inches, c to h fig. 56. 
 4. The trachelo-bregmatic, three and a half inches, 
 g to i fig. 56. 
 
106 GENERATION — FETUS. 
 
 What is the situation of the neck of the child, with 
 regard to the cranium ? It is situated a little poste- 
 rior to a vertical line drawn through the middle of the 
 long diameter. 
 
 Which represents the longer end of the lever, the 
 mental or occipital extremity of which, the neck is a 
 point or centre of motion ? The occipital extremity. 
 
 What results from this when the body and head are 
 equally compressed ? A marked degree of flexion. 
 
 What is the relative size of the face with that of 
 the head ? Very small. 
 
 What is the facial circumference in obstetric lan- 
 guage ? From the top of the forehead to the end of 
 the chin, over the lateral portions of the malar bones. 
 
 What are the two diameters of this facial circum- 
 ference, and what do they measure ? 1. The fronto- 
 mental diameter, measuring three inches. 2. Bi-ma- 
 lar, two and a half inches. 
 
 Where is the centre* of this circumference ? In the 
 root of the nose. 
 
 Although the diameters of the facial circumference 
 are smaller than those of any other measurement, 
 what diameters really are presented to the plane of 
 the superior strait, in face presentation of the fetus ? 
 The trachelo-bregmatic, measuring three and a half, 
 and the bi-parietal diameter, measuring three and a 
 half inches. 
 
 What obstacle is added to the passage of the head 
 in such cases ? Part of the neck of the fetus, mak- 
 ing the occipito-bregmatic diameter at least an inch 
 longer. 
 
 When the forehead presents to the centre of the 
 superior strait of the pelvis, what circumference pre- 
 sents to that of the pelvis ? That which passes from 
 the posterior fontanelle round upon the bi-parietal dia- 
 meter to the chin. 
 
 What is the long diameter of this circumference ? 
 From chin to posterior fontanelle, measuring from four 
 to four and a half or five or more inches. 
 
PREGNANCY — FETUS. 107 
 
 Whea the occiput presents favorably to ohe of the 
 pelvic planes, or which is the same thing, when the 
 vertex presents to the centre of the pelvis, what 
 circumference prese*nts to that of the pelvis? The 
 occipito-bregmatic circumference, which includes 
 the occipito-bregmatic, and the bi-parietal diam- 
 eters. 
 
 What relation does this circumference hold to the 
 pelvis in every stage of its passage through the pel- 
 vis ? Uniformly the same with the planes of the 
 straits and cavity of the pelvis, especially when the 
 occiput descends on either of the anterior inclined 
 planes. 
 
 COMPRESSIBILITY OF THE CRANIUM, 
 
 To what shape is the compressible portion of the 
 fetal cranium reducible ? To that of a conoid. 
 
 To what length may the occipito-mental diameter 
 be elongated ? From five, to six or seven inches. 
 
 To what may the bi-parietal diameter be dimin- 
 ished by compression? From three and a half, to 
 three inches. 
 
 When strong compression is effected upon the head 
 in the pelvis, in what direction does it usually carry 
 the bones ? The os frontis and the parietal bones are 
 carried backwards, and the occiput forwards. 
 
 DR. MEIGS' STATISTICS OF MENSURATION OF FETAL 
 CRANIA. 
 
 To whom are we indebted for the results of the 
 measurements of the greatest numbers of fetal heads 
 ever yet reported in America ? To Professor C. D. 
 Meigs. 
 
 What does he say as to the result of his measure- 
 ment ? "I have carefully measured and recorded the 
 size of three hundred crania of mature children that 
 I received in the course of my obstetric practice. In 
 a single series of one hundred and fifty heads I 
 found the occipito frontal diameter in fifty-two of 
 them to exceed five inches. In 11, it was 63^3; in 8, 
 
108 GENEHATION — SIGNS OF PREGNANCY. 
 
 5/5; in 3, it was 5j\ ; in 1, S,'*^; in 1, 5/^; in 2, 
 5/2? ^^^ 1? 5]|. The sum of my occipito-frontal 
 measurements was seven hundred and twenty-nine 
 and seven twelfths of an inch for oW hundred and fifty 
 crania. The mean was four inches and ten twelfths. 
 The sum of the bi-parietal diameters of the said one 
 hundred and fifty crania, was five hundred and eighty- 
 six inches and seven twelfths — the mean, three inches 
 and eleven twelfths of an inch. The bi-parietal dia- 
 meters exceeded four inches in sixty-eight of the 
 children. In 19, it was 4.1 ; in 5, it was 4.2 ; in 6, 
 4.0 ; in 3, 4.4 ; in 1, 4.5 ; in only one case was it 
 less than 3.6, the usual estimate, and in that case it 
 fell to 3.4. I measured one hundred and twenty-six 
 occipito-mental diameters of neonati at term, of which 
 the sum was six hundred and ninety-nine inches and five 
 tenths ; so that the tnean or average, of the one hundred 
 and twenty-six diameters was five inches and a half. I 
 know of no one who has measured so many, and I am 
 sure that greater accuracy is not to be attained by 
 any person. Upon these grounds, therefore, I am to 
 inform the student that the occipito-mental diameter 
 of the fetus, is five inches and a half; the occipito- 
 frontal four inches and ten twelfths, and the bi-parie- 
 tal three inches and eleven twelfths. The above state- 
 ment ought to show that it is not a matter of small 
 moment whether the head presents in labor by the 
 vertex, the crown, or the forehead." 
 
 SIGNS OF PREGNANCY. 
 
 Into how many classes may the signs of pregnancy 
 be divided ? Two — rational or sympathetic, or phy- 
 siological ; and positive, physical (or mechanical) signs. 
 
 What is usually regarded as the first rational sign ? 
 Suppression of the menses. 
 
 Can this sign be relied upon ? Not positively. 
 
 What other causes may suppress or suspend the 
 menstrual function ? Exposure to cold, uterine con- 
 gestions, or structural diseases of the organ. 
 
PREGNANCY — DEVELOPMENT OF UTERUS. 109 
 
 Are the menses always suppressed by pregnancy ? 
 Not always during the first months. 
 
 Are there any cases in which women menstruate 
 only during pregnancy ? Such cases are very rare, 
 but have been mentioned by Dewees, Daventer, and 
 Baudelocque. 
 
 When do the mammary glands become sympatheti- 
 cally affected ? One or two months after conception, 
 these glands enlarge, become the seat of slight pains 
 or pricking sensations. 
 
 When do they begin to secrete milk ? Usually to- 
 ward the latter end of pregnancy. 
 
 Is milk never found in the mammae, unless the female 
 be pregnant or nursing ? Milk is sometimes secreted 
 by old women, and occasionally by very young girls. 
 
 Do the breasts never become tumid, or painful, ex- 
 cept during, or as a consequence of, pregnancy ? 
 They are liable to become tumid and painful from 
 other causes — as cold, uterine irritation, &c. 
 
 What changes do the nipples or papillae undergo, 
 during pregnancy ? They become enlarged, developed, 
 more tumid, darker colored. 
 
 Do any changes occur in the areola ? It becomes 
 larger and darker colored — in brunettes it becomes 
 almost black. The mucous follicles, about the nip- 
 ples, become more prominent, and the veins more blue. 
 
 May not these changes occur from other causes than 
 pregnancy ? They may arise from mechanical irrita- 
 tion, as frequent handling, &c. — also, from sympathe- 
 tic irritation in the uterus, &c. 
 
 What changes take place in the uterus during the 
 early weeks or months of pregnancy ? It enlarges, 
 becomes developed, at first in all directions. 
 
 DEVELOPMENT OF THE UTERUS CAUSED BY 
 PREGNANCY. 
 
 At what time does the development of the uterus 
 begin to form a tumor in the abdomen ? In the third 
 and fourth months. 
 
 10 
 
110 PREGNANCY — DEVELOPMENT OF UTERUS. 
 
 Do young married females mostly become consider- 
 ably developed about the pelvic region, before they 
 are impregnated ? Yes, not only their hips, but their 
 breasts also, are apt to become enlarged. 
 
 Is there any diiference in the direction of the ab- 
 dominal tumor in different women, or in the same wo- 
 man at different pregnancies ? Yes — in women whose 
 abdominal muscles are relaxed, the uterine tumor is 
 more prominent. 
 
 Is the tumor of which we have been speaking, a 
 positive evidence of pregnancy? It is not a positive 
 evidence, because some women become very fat, inter- 
 nally, after marriage. 
 
 Have women any power to conceal the abdominal 
 development, when they wish to appear not pregnant ? 
 They can frequently succeed in doing so, by their 
 manner of carriage and dress. 
 
 What is the order of development of the abdomi- 
 nal tumor, in cases of pregnancy ? There is no 
 great enlargement till the third month; at this time 
 there is a fulness in the hypogastrium — at four months 
 the tumor is larger — at five months the uterus is above 
 the pubes, &c. 
 
 Is there any alteration in the size of the abdomen 
 during the first two months ? No — there should be 
 no distinct tumor found in the abdomen during the 
 first and second months. 
 
 • Is there any tumefaction in the hypogastric region, 
 during the third month ? Yes — there is usually. 
 
 Upon what does it depend ? Partly upon the de- 
 velopment of the abdominal parieties, and partly upon 
 the circumstance, that the intestines are carried up by 
 the fundus of the uterus. 
 
 What is the general condition of the upper and 
 lateral portions of the abdomen, at the third month ? ^ 
 It is flat above, and rather puffy in the iliac fossae. 
 
 Has this usually been regarded as a valuable diag- 
 nostic sign of pregnancy ? By many, it has been so 
 
PREGNANCY — QUICKENING. Ill 
 
 considered. The French have the adage — " En ven- 
 tre plat, enfant il j a." 
 
 Where is the top of the uterus situated, in the fourth 
 month ? It is immediately above the superior strait, 
 and the tumor can then be just felt. 
 
 Does the woman usually experience a fluctuation or 
 fluttering about the end of the fourth month? She does. 
 
 QUICKENING. 
 
 What is this sensation called ? Quickening. 
 
 Is it proper to regard this as the period at which 
 the child becomes quickened into life ? The child 
 is endowed with life at all its stages of uterine existence. 
 
 Should it not be viewed as an evidence that the de- 
 gree of the development of the fetus is such, that it 
 can exert muscular movement at this time ? This 
 would be the proper view to take of it ; though some 
 have thought that it arose from the fact that the fetus, 
 capable of motion at much earlier periods, now made its 
 impression upon the sensation of the mother in conse- 
 quence of the womb being, at this stage of its develop- 
 ment, in more intimate contact with the abdominal 
 nerves. 
 
 Is this period of quickening always fixed at four or 
 four and a half months ? No ; some women feel the 
 fetus earlier, and some later than this. 
 
 Upon what does this diff"erence of time probably 
 depend? Either upon difference in degrees of de- 
 velopment, or upon the diff"erent degrees of sensibility 
 in mothers. 
 
 When does quickening realli/ take place ? At the 
 time of conception. 
 
 What other movements take place during preg- 
 nancy which is apt to excite the attention of the wo- 
 man ? The slipping up of the uterus out of the pelvis. 
 
 When does this happen ? Almost invariably be- 
 tween the fourth and fifth month. 
 
 Does the occurrence of this sensation of " quicken- 
 ing," with the other signs enumerated, remove all doubts 
 
112 PREGNANCY — PHYSICAL EXPLORATION. 
 
 as to the existence of pregnancy ? No — some women 
 have all these signs, and are not pregnant ; even some 
 who think they not only feel, but see the movements of 
 the child through the abdominal parieties. 
 
 May a woman be pregnant, when none of these 
 symptoms occur ? Yes — when if they have occurred 
 at all, they have been very slight, and no motion what- 
 ever has been noticed. 
 
 Where is the top of the tumor in the fifth month ? 
 Half way up to the umbilicus. 
 
 Where at the sixth month ? At the umbilicus. 
 
 Where at the seventh month ? Three fingers' breadth 
 above the umbilicus. 
 
 Where at the eighth month ? At the epigastric 
 region. 
 
 Where at the ninth month ? It does not rise higher 
 during this month, but usually expands more into the 
 lateral portions of the abdomen and pelvis. Towards 
 the end of the gestation, it seems even to descend a 
 little. 
 
 Is the protrusion of the navel always a diagnostic 
 sign of pregnancy ? No — though usually perhaps al- 
 ways present at certain stages of true pregnancy, 
 yet it may occur from other causes than pregnancy ; 
 as the existence of large tumors, &c. 
 
 May enlargements of the abdomen from obesity 
 cause an equal degree of protrusion ? We believe that 
 in fat women, who are not pregnant, the umbilicus 
 is always sunken. 
 
 Is the gait of a female altered by pregnancy ? It 
 is more vacillating ; the feet are placed further apart. 
 
 PHYSICAL EXPLORATION. 
 
 How is the existence of pregnancy to be verified, 
 admitting all the sympathetic signs to be fallacious ? 
 By physical examination. 
 
 In what does this examination consist ? In exami- 
 nation by the hand of the external surface of the ab- 
 domen, &c. 
 
PREGNANCY — TOUCH. 113 
 
 What is to be gained by this ? A knowledge of the 
 size and kind of tumor which occupies the cavity, 
 and sometimes also of its contents. 
 
 How can you appreciate the existence of any thing 
 within the cavity of the tumor, by such an external 
 examination ? By applying the bare cold hand upon 
 the surface of the abdomen, a shock is transmitted 
 to the contents of the uterus, which if endowed with 
 vitality will sometimes move with a force which can 
 be felt. 
 
 What position is most suitable for this purpose ? 
 The patient should be on her back ; have her shoulders 
 raised, her limbs and abdomen flexed. 
 
 May she contract the abdominal muscles ? No ; she 
 should keep every thing as flaccid as possible, she 
 should breathe easy, and make no straining effort. 
 
 Should the hand of the examiner be removed im- 
 mediately after it has been applied to the abdomen ? 
 No ; it should be kept some moments in contact with 
 the surface, that it may appreciate any movements 
 which may take place. 
 
 Is this external examination sufiicient to enable the 
 accoucheur always to diagnosticate pregnancy ? No ; 
 it is liable to fail, from a variety of circumstances. 
 
 What other resource is there ? Examination per 
 vaginam. 
 
 What is this process called in professional language ? 
 
 The touch. 
 
 TOUCH. 
 
 What is the relative importance of this operation 
 to the accoucheur in pregnancy and diseases of the 
 uterus ? By some high authority it is regarded as 
 important to the accoucheur as the lever to the 
 mechanic, and the compass to the mariner. 
 
 What conduct should the accoucheur observe when 
 about to make this kind of examination ? That which 
 has regard to the sense of delicacy on the part of 
 the female. 
 
 10* 
 
114 PREGNANCY — TOUCH. 
 
 To whom should he make the proposition for an ex- 
 amination ? To a third person, as a nurse, the hus- 
 band, or to some matronly female. 
 
 How should he dispose of himself, while such a pro- 
 position is communicated to the patient ? He should 
 retire into another room until the decision is made, un- 
 less his proposition is promptly acceded to. 
 
 AKRANGEMENTS FOR PHYSICAL EXAMINATION. 
 
 What arrangements should be made in order to 
 conduct the examination most satisfactorily ? The 
 room should be darkened, and the patient dressed 
 lightly, and placed in the suitable position. 
 
 Should the physician insist upon having a third per 
 son present? He should always do so if it be at all 
 practicable. 
 
 How should the patient be placed ? The horizontal 
 position will sometimes answer, though many advan- 
 tages are gained by the erect position. 
 
 If she be placed in the horizontal position, upon 
 what part of her body should she recline ? When the 
 simple touch to determine the condition of the neck 
 and mouth of the uterus, is to be resorted to only, 
 she may recline upon her left side : — but if both exter- 
 nal and internal examination is to be made, she should 
 be placed upon her back ,with her hips to the edge of 
 the bed, and her lower extremities flexed, head and 
 shoulders considerably raised. 
 
 What accommodations should the nurse furnish for 
 the physician ? Several napkins, some unctuous mat- 
 ter, a chair by the bed, a basin of warm water, soap, &c. 
 
 How should the accoucheur sit ? At the side of 
 the bed, with his right hand towards tlie hips of the 
 patient, if she be on her ieft side ; but if on her back, 
 he should sit with his face towards her, that he may 
 reach his left hand to her abdomen. 
 
 What is the rule for carrying the hand under the 
 coverings ? The clothes should be properly raised at 
 their lower edges, by the left hand, then the right 
 
PREGNANCY — TOUCH. 115 
 
 hand, with the index finger lubricated, somewhat 
 flexed, and the thumb erect and abducted is next passed 
 cautiously up under the clothes without uncovering the 
 patient. 
 
 Supposing your patient to be standing, how should 
 she be arranged ? She should be allowed to rest her 
 hips against something firm, and then recline forward 
 as if to lean upon the examiner. 
 
 How should the examiner be situated ? Either upon 
 a low seat, or resting upon one knee, in front of the 
 patient. 
 
 To what portion of the genital fissure should the 
 finger be carried ? Always to the posterior commis- 
 sure, avoiding contact with the mons veneris if pos- 
 sible. When the finger has thus gained access to the 
 vagina, it should be turned to present its radial edge 
 to the arch of the pubes. 
 
 Can the touch afi'ord us any good idea of early 
 pregnancy ? Yes ; it may even then appreciate the 
 changes which have occurred in the uterus. 
 
 What is the earliest period however at which any 
 positive information can be acquired ? After the fourth 
 month. 
 
 What can be recognized in the uterus after this ? 
 The existence of a body suspended in a fluid. 
 
 BALLOTTEMENT— HOW PERFORMED. 
 
 What name has been given to the process by which 
 this knowledge is obtained ? Ballottement, or uterine 
 palpation, or percussion. 
 
 How is this performed ? By the application of the 
 index of one hand to the mouth or neck of the ute- 
 rus, while the other hand is applied upon the abdo- 
 men over the fundus of the uterus. The finger in the 
 vagina, is then suddenly to push up the part of the 
 uterus with which it is in contact ; while the palm of 
 the other hand is prepared to receive any impression 
 which such a shock may make ; the percussing finger 
 is to be kept appUed to the os or cervix uteri, that it 
 
116 
 
 PREGNANCY — AUSCULTATION. 
 
 may determine whether any body floating within the 
 cavity, descends upon it. In this way very fre- 
 quently it is possible to determine the existence of a 
 body within the uterus and even to a certain extent 
 the degree of its development. 
 
 Fig. 57. 
 
 AUSCULTATION. 
 
 What other means of diagnosis has the obstetrician, 
 besides that of the external and internal touch ? Aus- 
 cultation. 
 
 What are we to appreciate by auscultation ? The 
 existence or non-existence of the vital actions of the 
 fetus. 
 
 How many modes are there of performing it ? Me- 
 diately through the stethoscope, or immediately by the 
 application of the ear to the surface of the abdomen. 
 
 Does delicacy require that mediate auscultation be 
 used in cases of supposed pregnancy ? It is cer- 
 tainly most proper when it will answer. If immedi- 
 ate auscultation is resorted to, the under dress of the 
 patient should be allowed to cover her person. 
 
 What does auscultation aiford, which ballottement 
 does not ? Ballottement determines the existence or 
 non-existence of a body within the uterus, but does 
 not indicate its vitality — auscultation contributes 
 much to determine the latter, by mostly recognizing 
 
PREGNANCY — AUSCULTATION. 117 
 
 the sounds peculiar to the fetus, &c., when it is alive 
 in utero. 
 
 Is it an important improvement in the means of 
 ohstetric diagnosis ? It should be considered as a 
 very important improvement in obstetric diagnosis. 
 
 How many sounds are to be discriminated by this 
 auscultation ? Two — one depending upon the mo- 
 tions of the fetal heart, and the other said to depend 
 upon the circulation of blood in the placenta. 
 
 What is the difference in these sounds ? The first 
 has a quick double beat or sound, amounting to from 
 one hundred and forty to one hundred and fifty in the 
 minute ; the other is synchronous with the actions of 
 the maternal heart. 
 
 What is the character of the first kind of sound ? 
 It has been aptly compared to the ticking of a watch 
 under a pillow. 
 
 What is the character of the other sound that is 
 heard ? It is like the cooing of a dove, or like the 
 passage of a fluid through a great many cells. 
 
 What is it called ? Placental soufflet, or placental 
 sound. 
 
 Is it proper to rely upon the absence of the sounds, 
 as an evidence of death of the fetus ? Not if other 
 symptoms of its vitality present strongly. 
 
 Upon what does the cooing sound probably depend ? 
 Not upon the circulation of blood in the placenta, but 
 upon the circulation of blood through the uterine vessels, 
 about, or over that part at which the placenta is seated. 
 
 May this sound be confounded with any other ? 
 Yes, with the pulsations in the iliac arteries, &c. 
 
 Is any caution to be used, that the patient's cloth- 
 ing may not confuse the sound ? The friction of the 
 patient's dress may confuse it, unless care is taken to 
 keep it smooth upon the abdomen. 
 
 What may obscure this sound while the child is 
 actually alive ? The existence of the placenta at the 
 posterior part of the uterus ; or there may be a very 
 fat omentum interposed. 
 
118 PREGNANCY — CONDITION OF VAGINA, ETC. 
 
 Is it proper to decide that pregnancy does not ex- 
 ist, if this soufflet cannot be heard ? No — the situa- 
 tion of the placenta maj be such, that although its 
 circulation may be active, it cannot be heard. 
 
 What is the earliest period of pregnancy at which 
 auscultation becomes of any value ? Kennedy is re- 
 ported to have heard it at the twelfth week, but it is 
 scarcely to be relied upon, until at the end of the 
 fourth, or during the fifth month. 
 
 What is the condition of the mother most favor- 
 able for auscultation, as regards corpulency ? The 
 thinner she is, the more readily can the sounds be 
 heard, if the position of the child is favorable. 
 
 What situation of the fetus is most favorable for 
 emitting the sounds of its heart ? That in which its 
 back is applied to the anterior parieties of the uterus. 
 
 At what part of the uterine tumor is the fetal 
 sound most frequently heard ? Generally at the 
 lower and lateral portion of the uterus. 
 
 What would modify the position at which these 
 sounds are most distinctly heard ? A change in the 
 position of the child. 
 
 Suppose the breech presented to the os uteri, where 
 should the fetal sound be most readily heard ? Higher 
 up toward the fundus of the uterus. 
 
 Is auscultation of any value in the diagnosis of com- 
 pound pregnancies ? In twin pregnancies, there would 
 be two points whence the sound should emanate, one 
 above and another below, or one on each side. 
 
 Would the placental soufflet, as it is called, be much 
 altered by a twin pregnancy ? Not necessarily, espe- 
 cially, if the placentae were attached to each other, 
 or the fetuses had one common placenta. 
 
 CONDITION OF VAGINA, URINE, ETC. 
 What other signs have recently been spoken of as 
 evidences of pregnancy ? A blue appearance of the 
 lining membrane of the vagina, dependant probably 
 merely upon venous congestion of the part. 
 
PREGNANCY, DURATION OF. 119 
 
 Is this to be regarded as a certain sign ? Its evi- 
 dence should be received with great caution. 
 
 How should we regard the report of the chemical 
 changes of the urine, resulting in the formation of a 
 gelatinous albumen or a substance called Kiestine, as 
 an evidence of pregnancy ? By no means as posi- 
 tive, inasmuch as there is yet much conflicting testi- 
 mony on this subject. 
 
 DURATION OF PREGNANCY. 
 
 What IS the usual duration of pregnancy, utero- 
 gestation or gravidity? Nine calendar months and ten 
 days, ten lunar months or two hundred and eighty days, 
 from the last appearance of the catamenial discharge. 
 
 May not healthy well developed children be born 
 in a shorter time than that ? There is strong reason 
 to believe that some fetuses are well grown and fully 
 mature for extra-uterine existence in less than two 
 hundred and eighty days after conception. 
 
 Are there not numerous instances on record, suffi- 
 ciently well authenticated to induce the belief that 
 the fetus is either longer than ten lunar months in 
 being sufficiently developed, or that it may be re- 
 tained in a viable condition, in the uterus greatly be- 
 yond that time ? The cases quoted by English, Ital- 
 ian, and American authorities would seem to prove 
 that healthy children may be born between the two 
 hundred and fifty-ninth, and the four hundred and 
 twentieth days — from the time of conception. 
 
 PRECURSORY SIGNS OF LABOR. 
 
 What are some of the precursory signs that the 
 woman has nearly or quite completed the term of 
 utero-gestation ? A subsidence of the abdominal 
 tumor, so that pressure is taken off from the epigas- 
 trium, and the woman feels more buoyant, free, and 
 comfortable : the brain, heart, lungs, and all the su- 
 perior viscera performing their functions more readily. 
 
 What sensation is then usually experienced about 
 
120 PREGXANCY — LABOR. 
 
 the pelvis? One of pressure, uneasiness, constant desire 
 to urinate, or defecate every ten or fifteen minutes. 
 
 LABOR. 
 
 What is meant by the term labor in obstetric lan- 
 guage ? It signifies an effort on the part of the ute- 
 rus and the mother to expel its contents. 
 
 Is it to be regarded as a mere mechanical action, 
 or a vital function ? It is a function, partly depen- 
 dant upon mechanical, though principally on vital ac- 
 tion. 
 
 How many kinds of cause of labor are there? 
 Two — natural, (or spontaneous,) and accidental. 
 
 What is the actual cause of labor ? At present it 
 is unknown to physiologists. 
 
 What are accidental causes? All such as indi- 
 rectly excite the uterine fibres to contraction, whether 
 at full time or prematurely. 
 
 What influence may excitement or injury of any 
 of the viscera have upon the production of labor ? It 
 is mostly liable to excite the contractions of the ute- 
 rus, and thus bring on labor. 
 
 What effect are violent inflammations of any of the 
 viscera, or any febrile condition of the general sys- 
 tem, liable to have upon labor ? They always increase 
 the liability to uterine contraction. 
 
 Does the fetus perform any active part during la- 
 bor ; that is, does it contribute in any way by its own 
 efforts to effect its delivery ? None whatever, unless 
 in some cases strong motions may excite the contrac- 
 tions of the uterus'; otherwise it is in this respect en- 
 tirely passive. 
 
 What is the main agent in the process of labor ? 
 The uterus. 
 
 What may be regarded as important accessory 
 aids ? The abdominal muscles, the diaphragm, and 
 indeed all the voluntary powers of the mother. 
 
 ACTION OF THE UTERUS. 
 
 What evidences have we that the uterus is the prin- 
 
PREGNANCY — LABOR. 121 
 
 cipal, and may be the sole agent in the expulsion of 
 the ovum ? Labor has sometimes taken place, during 
 sleep, and the ovum has been expelled immediately 
 after the apparent death of the patient ; it also has 
 happened while she was comatose and could use no 
 effort. 
 
 What evidences are oifered to the sense of touch, 
 that the uterus contracts ? If you place the hand on 
 the abdomen when the woman complains of pain, you 
 can feel the uterus grow hard and firm. If you ap- 
 ply the finger to the uterus per vaginam, you will feel 
 it tightening itself up when the patient complains of 
 pain. 
 
 Does the state of the mind exert any influence upon 
 the contractions of the uterus in labor ? Although 
 uterine contraction is not subject to the volition of the 
 patient, yet moral causes may exert great influence 
 over it, sometimes increasing the violence of the con- 
 tractions, but more frequently suspending them, or 
 rendering them much more feeble. 
 
 What effect has great anxiety upon labor ? It al- 
 most always retards it, while on the other hand, con- 
 fidence and hope increase and facilitate it. 
 
 To what part of the system may the excitement of 
 the uterine system be translated? - To the brain and 
 spinal marrow. 
 
 What are the usual consequences of such a transla- 
 tion ? Puerperal convulsions. 
 
 To how many kinds of contraction is the uterus sub- 
 ject ? Two : tonic, and alternate or spasmodic. 
 
 What is to be understood by the term tonic contrac- 
 tion ? A regular and permanent contraction of all the 
 muscular fibres of the uterus. 
 
 What synonyme has tonic contraction ? Tonic 
 rigidity. 
 
 What is meant by spasmodic contractions of the 
 uterus ? Those contractions which take place sud- 
 denly, continue a few minutes and then subside. 
 
 What terms are synonymous in reference to the ac- 
 11 
 
122 PREGNANCY—BAG OF WATERS. 
 
 tion of the womb in labor ? Alternate contractions, 
 painful contractions, labor pains, &c. Pains are not 
 however, always proportioned to the degree of the con- 
 tractions in such cases* 
 
 Is not tonic contraction of the uterus painful ? Not 
 usually. 
 
 What are its effects ? It squeezes the blood from 
 the vessels, and regularly diminishes the size of the 
 uterine tumor. 
 
 Where is probably the seat of the pain during the 
 spasmodic contraction ? About the neck of the 
 uterus. 
 
 What is the usual order of frequency of the spas- 
 modic or alternate contractions of the uterus in labor ? 
 At first, about once in half an hour, then gradually 
 more frequently. 
 
 What is the effect of these alternate contractions 
 upon the uterus ? They possibly assist to dilate the 
 orifice, and do gradually force out some portion of the 
 ovum. 
 
 What effect has the dilatation of the os uteri upon 
 the long diameter of the uterus? It allows its long 
 diameter to become shorter. 
 
 What effect has the dilatation of the os uteri upon the 
 membranes which were situated over the cervix and 
 OS uteri ? They necessarily become separated from 
 their connexion with that part. 
 
 BAG OF WATERS. 
 
 What happens to the membranes, as the os uteri be- 
 comes considerably expanded? They mostly pass out 
 into the vagina, and present what is usually called, the 
 " Bag of Waters." 
 
 What influence does the presence of this bag of 
 waters usually exert upon the vagina ? It distends 
 it, and often excites a copious secretion of mucus. 
 
 What becomes of this b;ig of waters under the 
 continued and repeated contractions of the uterus ? 
 It ruptures or bursts, and suddenly discharges its con- 
 
PREGNANCY — ACCESSORY POWERS. 123 
 
 tents, or in some cases remaining entire, it is protracted 
 bejond the vulva, till the entire ovum is expelled. 
 
 Are you to expect always to find a " bag of waters" 
 in the vagina after the woman has been in labor some 
 time ? Not always ; for it sometimes happens that the 
 membranes rupture before the os uteri is dilated to 
 any extent, but even when this does not happen, the 
 presenting part of the fetus may be applied so closely 
 to the membranes at the os uteri, that there is little 
 or no fluid interposed : — again, the size of the ovum 
 may be so great, or the membranes so full, that it is 
 impossible for a segment of the contents of the uterus 
 to pass beyond the level of its orifice until rupture 
 takes place. 
 
 What does the uterus embrace, and act more directly 
 upon, as soon as the waters are forced off ? The fetus. 
 
 ACTION OF THi; ACCESSORY POWERS. 
 
 When are the accessory powers of the mother brought 
 to bear upon the fetus ? Mostly, soon after the expul- 
 sion of the waters. 
 
 In what way do these act ? First, the woman fixes 
 the diaphragm by a deep inspiration, and then sus- 
 pending the respiratory effort, she contracts the ab- 
 dominal muscles so as to bear downward ; then she 
 fixes her lower extremities, which are generally flexed, 
 by putting her feet against some solid body ; after- 
 wards she seizes hold of some immoveable body, if she 
 can reach it, and thus brings into action all her vol- 
 untary powers, for forcible and even violently expul- 
 sive effort. 
 
 Are these accessory powers very important in some 
 cases of labor ? Although some women are delivered 
 by the contractions of the uterus solely, yet in the 
 greatest number of cases, these accessory powers 
 become indispensable for the completion of parturi- 
 tion. 
 
 How is the uterus sustained in situ during the pow- 
 erful effort of the accessory powers ? The lower part 
 
124 
 
 PKEGNANCY — STAGES OF LABOR. 
 
 of it is fixed in and rests upon the margin of the 
 pelvis. 
 
 Can a woman excite the tonic, or bring on the spas- 
 modic contractions of her uterus, by the voluntary ex- 
 ertion of the accessory powers ? By the eifort of the 
 abdominal muscles she can frequently stimulate the 
 uterus into action. 
 
 Are the accessory powers ever necessary to aid in 
 the dilatation of the os uteri ? No : on the contrary, 
 the patient should be prohibited from using them by 
 bearing down during the dilating process. 
 
 What observation would go to give an idea that the 
 accessory powers were not always completely under 
 the influence of the will of the patient ? That of the 
 fact, that when the child is pressing against the os 
 uteri, or some of the soft parts of the vagina, it seems 
 to be impossible for the mother to avoid bearing down. 
 
 DIFFERENT STAGES OF LABOR. 
 
 Into how many stages is labor usually divided? Three. 
 What is the first stage? 
 That in which the os uteri is 
 undergoing the process of dil- 
 atation sufficiently to permit 
 the child to escape through it. 
 Fig. 58. 
 
 What constitutes the se- 
 cond stage ? The expulsion 
 of the child from the uterus 
 through the pelvis and soft 
 parts of the mother. 
 
 What does the third stage 
 include ? The complete ex- 
 pulsion of the appendages of 
 the fetus, viz. : the placenta and membranes. 
 
 What is the usual situation of the fetus in utero, at 
 the commencement of labor, or the full period of ges- 
 tation ? It is flexed upon itself; its back being usu- 
 ally applied to the anterior portion of the uterus, its 
 
PREGNANCY — LABOR. 125 
 
 occiput towards the anterior half of the maternal pel- 
 vis, and the vertex applied to the orifice of the uterus. 
 
 Where are the first pains of labor usually felt ? In 
 the back, or hypogastric region. 
 
 Are they uniform in this respect in the same women 
 at different times ? No : sometimes they begin in the 
 back, and sometimes in the lower part of the abdo- 
 men. 
 
 When may they be considered as most regular ? 
 When they are felt first in the back, and extend round 
 to the pubic region. 
 
 What inconvenience does^ the woman usually expe- 
 rience beside the pain in the early stage of labor ? A 
 sense of weight and of constant inclination to evacuate 
 the bladder and bowels. 
 
 When does the woman begin to express her desire 
 to seize hold of some support, that she may exercise 
 her accessory powers ? Usually at the end of the 
 first stage of labor. 
 
 What is the usual state of the mind during the first 
 stage of labor ? Irritable, petulant, desponding. 
 
 What is her physical condition ? She is often 
 chilly, flatulent, sick at stomach, sometimes vomiting 
 small quantities of food recently taken, but mostly 
 little else than air. 
 
 What is the popular opinion respecting the prog- 
 nosis afforded by sick stomach ? That sick labors are 
 easy labors, and this idea is usually correct, for nausea 
 relieves rigidity. 
 
 What is the condition of the pulse in the first stage ? 
 It is usually small and feeble in the first stage. 
 
 What may be inferred from the fact that there is a 
 secretion of mucus tinged with blood from the vagina ? 
 That the woman is actually in labor. 
 
 What is this secretion called by nurses and other 
 women ? A sliow. 
 
 Whence does it arise ? Probably from the vessels 
 which are ruptured by the separation of the membranes 
 from the mouth and neck of the uterus. 
 11* 
 
126 PREGNANCY — LABOR. 
 
 May a woman have a great deal of pain about the 
 back and abdomen, and jet not be in labor ? She 
 may have spurious, inefficient, though sometimes very- 
 severe pain. 
 
 How are these to be distinguished ? By the touch. 
 
 What sensation do they communicate to the finger 
 of the accoucheur, when introduced against the os 
 uteri ? It is found that tlie uterus does not contract 
 at all, or if at all, the contractions are not accompa- 
 nied by dilatation of the os uteri. 
 
 Is the dilatation of the os uteri regular and uniform, 
 or does it progress more rapidly at one time than 
 another ? It usually dilates very slowly at first, but 
 afterwards more rapidly. 
 
 What is the usual shape of the os uteri during la- 
 bor ? At first it is round, but as it dilates, it assumes 
 the shape of the part of the fetus which is about to en- 
 gage in it. 
 
 PROGNOSIS BY TOUCH. 
 
 What prognosis can be founded upon the condition 
 presented by the os uteri to the touch ? It is very 
 uncertain ; as a general rule, when the os uteri is soft 
 and fleshy, though somewhat thick, the dilatation will 
 proceed rapidly. 
 
 What may be expected, when you find the os uteri 
 firm and thin ? Generally, that the labor will be slow 
 in its first stage. 
 
 Can these conditions be relied on with any confi- 
 dence ? No : practitioners of long experience are 
 often disappointed in them. ^ 
 
 What is the best mode of testing the degree of dila- 
 tion at each pain ? The application of the finger in 
 contact with the os uteri during several successive con- 
 tractions. 
 
 AVERAGE DURATION OF LABOR. 
 What is the average duration of labor ? From com- 
 putations made by Dr. Meigs, who has superintended 
 
PREGNANCY — LABOR. 127 
 
 very many cases, the average duration of labor is four 
 hours, the number of labor pains is about fifty, they 
 last each about half a minute ; so that the parturient 
 woman really suffers from the uterine contractions 
 about twenty-five minutes, and these twenty-five min- 
 utes are distributed through the four hours of a labor 
 of mean duration. 
 
 RELATIVE DURATION OF THE DIFFERENT STAGES. 
 
 What portion of the whole duration of labor, is 
 usually occupied by the first stage ? About ten- 
 twelfths. 
 
 What for the second or expulsive stage ? About one- 
 ninth. 
 
 What for the third stage, or complete expulsion of 
 the placenta, &c. ? One twenty-fourth. 
 
 CONDITION INCIDENT TO THE DIFFERENT STAGES OF 
 LABOR. 
 
 Does the first stage involve mother or child in dan- 
 ger ? Not necessarily, unless the membranes rupture 
 prematurely ; then the child may sometimes suffer 
 from the severity and frequent repetition of the con- 
 tractions. 
 
 May either mother or child, incur any risk during 
 the second stage ? The mother rarely incurs any 
 hazard, unless there be great physical obstacles to the 
 success of the effort, or some disturbance occur in her 
 nervous or vascular system, but the child may be said 
 to be in imminent danger, in many cases. 
 
 What accident may happen to it ? It may become 
 apoplectic from the forcible pressure of the uterus 
 upon it, while its head is retained in the pelvis, pr if 
 expelled too rapidly, it may be in a state of asphyxia. 
 
 Is the mother subjected to any danger, during the 
 third stage ? Her danger at this time is often immi- 
 nent; hemorrhage, inversion of the uterus, &c., are 
 liable to occur. 
 
 What sort of pains usually characterize the first, or 
 
128 PREGNANCY — LABOR. 
 
 dilating stage of labor ? They are usually described, 
 as cutting, grindiyig, or tearing pains. 
 
 In what respect do those of the second stage differ? 
 They a,refo7'cing, hearing down, expulsive. 
 
 What position does the woman usually assume du- 
 ring the first stage, if unrestrained by the presence 
 of those around her ? She will sit, stand, or walk 
 about ; sitting or kneeling down only when she has a 
 pain. 
 
 What attitude does she usually assume, when in the 
 second stage ? She mostly prefers to lie down, flex 
 her body and lower extremities, but extend her arms 
 to embrace something, with which to support the bear- 
 ing down effort she is about to make. 
 
 What is her physical condition during the second 
 stage ? Her pulse becomes excited both by the effort, 
 and the occasional suspension of respiration. She is 
 mostly bedewed with perspiration, and when a pain 
 comes on, her face becomes florid, sometimes almost livid. 
 
 Is the increase of the pulse necessarily owing to 
 febrile excitement ? No ; it is the result of exercise, 
 and should be distinguished from the pulse of inflam- 
 mation. 
 
 What are some of the consequences of this effort ? 
 Mostly an increased secretion of serum from the 
 skin, and mucus from the cavities ; occasionally, also, 
 ecchymosis of the conjunctiva, epistaxis, and even 
 apoplexy, or cerebral congestion. 
 
 What consequences often result if the secretions do 
 not increase under this effort ? The patient is almost 
 sure to become febrile. 
 
 What is the condition of the mind, during the second 
 stage ? It is more calm and confident, the patient 
 now often solicits the return of pains, and she rarely 
 now imagines that she w^ill die before labor is accom- 
 plished. 
 
 What disturbance is she liable to experience in her 
 lower extremities, in this stage ? Severe cramps and 
 pains. 
 
PREGNANCY — LABOR. 129 
 
 Why do these take place ? In consequence of the 
 pressure exerted by the child's head upon the sacral 
 nerves. 
 
 What condition of the brain may supervene in this 
 stage of labor ? Delirium or mania may ensue. 
 
 What urgent sensation takes place when the pre- 
 senting part of the child is brought in contact 
 with the perinseum ? An impulse to evacuate the 
 bowels. 
 
 Should the patient be allowed to rise to comply 
 T»ith such a desire ? It would be unsafe, as well as 
 unavailing for her to rise for that purpose at this stage 
 of the labor. 
 
 To what extent does the perinseum usually 
 stretch over the presenting part of the child ? Gene- 
 rally sufficient to cover the part presenting. 
 
 What takes place in reference to both the moral and 
 physical condition of the patient, immediately after 
 the extrusion of the child ? The uterine pains now 
 usually at once subside ; the woman, in an ecstacy 
 of gratitude expresses herself relieved ; her moral 
 sensibilities are sometimes wTought up to their highest 
 degree. 
 
 What usually occurs soon after this ? The uterus 
 again contracts for the purpose of expelling the pla- 
 centa. 
 
 How many steps or stages are there for the expul- 
 sion of the appendages of the fetus ? Usually three ; 
 one in which the separation of the placenta is effected, 
 and the other in which is thrown into the vagina, and 
 the third, in which it with the membranes is expelled 
 from the vagina. 
 
 By what power is the placenta usually expelled 
 from the vagina ? By the voluntary powers of 
 the mother alone, unless aided by the hand of an 
 assistant. 
 
 What amount of hemorrhage usually attends the 
 expulsion of the placenta, under most favorable cir- 
 cumstances ? Perhaps half a pint, rather more or less. 
 
130 PREGNANCY — LABOR. 
 
 Suppose hemorrhage should become profuse, m 
 what length of time might it destroy the life of the 
 mother ? It is asserted by very respectable authority, 
 that it would require only five or six minutes. 
 
 Whence does this blood escape ? From the patu- 
 lous orifice of the large veins, opposite to the point at 
 which the placenta was situated. 
 
 What are the sources of danger, during the third 
 stage of labor ? Simple exhaustion from the severe 
 efforts made during the second stage, but particularly 
 from hemorrhage. 
 
 What would you call a tedious labor ? One which 
 occupies twenty-four or more hours. 
 
 What are some of the causes of tedious labor ? 
 Rigidity of the soft parts, small size of the pelvis, or 
 deviations of the presenting part of the child ; want 
 also of regular action of the uterus. 
 
 What is the usual and proper direction of the ute- 
 rine forces ? Such as to propel the contents down- 
 ward and a little backward, in the direction of the 
 axis of the superior strait of the pelvis. 
 
 How is the direction of the uterus modified by the 
 efi*ort of contraction ? It is carried more and more 
 into a line with the axis of the superior strait. 
 
 What is to be understood by the term floor, or bot- 
 tom of the pelvis ? The lower end of the sacrum, 
 the whole of the coccyx, and the peringeum. 
 
 When the presenting part of the child is carried 
 down to this part, what direction has it next to take ? 
 It must be propelled forwards along the curvature of 
 the coccyx and perinaeum. 
 
 GENERAL CLASSIFICATION OF LABOR. 
 
 How are labors usually classified ? Into rapid, slow, 
 easy, difiicult or laborious, assisted or unassisted, ma- 
 nual and instrumental, simple and complex, natural 
 or unnatural, eutocia and dystocia. 
 
 What conditions are necessary for the performance 
 of natural labor ? The uterus should contract regu- 
 
PREGNANCY — LABOR. 131 
 
 larly, the child present favorably, and that the pelvis 
 be sufficiently large, and the soft parts of the mother 
 be sufficiently relaxed. 
 
 PRESENTATION AND POSITION. 
 
 What do obstetricians mean by the word presenta- 
 tion ? That some portion of the contents of the 
 ovum becomes situated at the orifice of the uterus, at 
 or near the centre of the pelvis. 
 
 What is meant by the phrase position of tJie fetus 
 in midwifery ? That some part of the presentation 
 is directed towards some particular, or specified part 
 of the maternal pelvis. 
 
 CLASSIFICATION OF PRESENTATIONS. 
 
 How are natural labors classified as to presentation ? 
 First, into those in which the cephalic extremity of the 
 fetal ellipse presents favorably ; and secondly, into 
 those in which the pelvic extremity presents to the 
 pelvis of the mother. 
 
 Why does the cephalic extremity present most fre- 
 quently ? Probably, 1. Because the head is heavier than 
 any other equal bulk of the body, and therefore descends 
 in the liquor amnii. 2. Because in the formation of 
 the peculiar figure of an ellipse the cephalic extremity 
 is better adapted to the small extremity of the ovoid 
 cavity of the uterus. 
 
 GRAND VARIETIES OF OCCIPITAL POSITION. 
 
 How many grand varieties of occipital positions are 
 there ? Two. First, in which the occiput presents 
 to some part of the anterior half of the circle of the 
 superior strait. Second, in which the occiput pre- 
 sents to some part of the posterior half of the supe- 
 rior strait. 
 
 Why is it preferable that the occiput present to the 
 anterior semicircle of the pelvis, in case of cephalic 
 presentations? Because the head can then most 
 readily descend along the planes of the pelvis, and by 
 
132 PREGNANCY — LABOR. 
 
 easy movements upon the neck, pass out under the 
 arch of the pubes. 
 
 PARTICULAR POSITIONS OF CEPHALIC EXTREMITY. 
 
 How many positions of the head are generally 
 recognized ? Six — of which three are anterior, and 
 three are posterior. 
 
 What is the first position of the occiput ? That in 
 which the occiput present to that portion of the linea- 
 ilio-pectinea, which is within the left acetabulum, and 
 at the same time the sinciput or bregma presents to 
 the right sacro-iliac symphysis. 
 
 What diameter of the child's head corresponds to 
 the different parts of the pelvis, in the first position ? 
 The occipito-bregmatic diameter of the head, corres- 
 ponds to that oblique diameter of the pelvis, which 
 extends from the left acetabulum to the right sacro- 
 iliac symphysis — the bi-parietal diameter of the head 
 corresponds to the other oblique diameter of the pel- 
 vis. The occipito-mental diameter of the head, cor- 
 responds to the axis of the superior strait, and upper 
 part of the cavity of the pelvis, (see fig. 59.) 
 
 Fig. 59. 
 
 What is the second position ? The occiput is to- 
 wards the right acetabulum ; the sinciput toward the 
 
PREGNANCY — LABOR. 183 
 
 left sacro-iliac symphysis ; the occlpito-bregraatic dia- 
 meter, therefore, corresponds to this oblique diameter 
 of the pelvis, while the bi-parietal, also, corresponds to 
 the other oblique diameter. The occipito-mental dia- 
 meter corresponds to the axis of the pelvis. (Fig. 60.) 
 
 Fig. 60. 
 
 What is the third ? The occiput is directed to the 
 symphysis pubes, and the sinciput to the sacrum. The 
 occipito-bregmatic diameter of the head, therefore, 
 corresponds to the antero-posterior or sacro-pubal 
 diameter of the pelvis ; the bi-parietal diameter of 
 the head to the transverse diameter of the superior 
 strait of the pelvis ; the occipito-mental diameter cor- 
 responds to the axis of the pelvis. 
 
 What is the fourth ? The occiput is directed to the 
 right sacro-iliac junction ; the sinciput or the bregma- 
 tic, to the left acetabulum. Hence the occipito-breg- 
 matic diameter corresponds to this diameter, and the 
 bi-parietal diameter of the head to the other oblique 
 diameter of the pelvis. The occipito-mental diameter 
 corresponds nearly or quite to the axis of the pelvis. 
 (Fig. 61.) 
 
 What is the fifth ? The occiput is directed to the 
 
 left sacro-iliac symphysis ; the sinciput or bregma to 
 
 the right acetabulum. Hence the occipito-bregmatic 
 
 diameter corresponds to this oblique diameter of the 
 
 12 
 
134 PREGNANCY — LABOR. 
 
 pelvis, while the bi-parietal does to the other oblique 
 diameter. The occipito-mental diameter of the head 
 
 Fig. 61. 
 
 corresponds to the axis of the superior strait. (Fig. 
 62.) 
 
 Fig. C2. 
 
 What is the sixth ? The occiput is directed to the 
 sacrum, and the sinciput or bregma to the symphysis 
 pubes. The occipito-bregmatic diameter corresponds 
 to the sacro-pubal or antero-posterior diameter of the 
 superior strait of the pelvis ; the bi-parietal diameter 
 corresponds to the transverse diameter of the pelvis, 
 and the occipito-mental diameter corresponds nearly 
 or entirely with the axis of tlie superior strait. 
 
TREGNANCY — LABOR. 
 
 135 
 
 FLEXION. 
 
 • What technical term is used to describe that move- 
 ment executed upon the child by the contractions of 
 the uterus, by which the thorax and chin are brought 
 into contact, and the occipito-mental diameter of the 
 head, is made part of the long diameter of the fetal 
 ovoid or ellipse ? Flexion. 
 
 ROTATION. 
 
 What influence do the inclined planes, the sacrum, 
 coccyx, and perinceum exert upon the head of the 
 child under the continued contractions of the uterus? 
 In the first position, the occiput is compelled to 
 respond to the inclination or spirality of the left ante- 
 rior plane till it appears under the arch of the pubis. 
 
 Fig. 63. 
 
 (Fig. 63.) In the second position, it is obliged to pass 
 on the right anterior plane till it reaches the same 
 
136 PREGNANCY — LABOR. 
 
 point. In the fourth position, the occiput is passed 
 on the right posterior plane to the middle line of the 
 sacrum, while in the fifth position, it passes on the 
 left posterior plane to the same point. 
 
 What is the movement just described called? Rota- 
 tion. 
 
 Does rotation take place in the third and sixth po- 
 sitions ? No ; in these positions the occiput passes 
 so nearly down upon the anterior or posterior median 
 line of the pelvis, that no rotation is perceptible. 
 
 EXTENSION. 
 
 What happens to the head when it has reached the 
 floor of the pelvis, during process of parturition ? 
 In the occipito anterior position, as soon as the sinciput 
 has been impinged upon the sacrum, it is driven for- 
 ward along the arc of the sacrum, coccyx and perinaeura, 
 and the occiput pressed against the legs, and some- 
 times the crown of the arch of the pubes. It thus 
 undergoes the movement of extension^ as shewn in fig. 64. 
 
 Fig. 64. 
 
 In occipito-posterior positions, when the occiput 
 comes to the floor of the pelvis, it is propelled along 
 the same parts of the sacrum, coccyx, and perinaeum, 
 and the sinciput, forehead, and face are forced against 
 
PREGNANCY — LABOR. 137 
 
 the anterior part of the pelvis, and thus the head 
 has to be subjected to increased flexion. See fig. Qb. 
 
 How does the child's head pass through the infe- 
 rior strait? The occipito-mental diameter corres- 
 ponds to the axis of the inferior strait ; the occipito- 
 bregraatic to the antero-posterior, or coccy-pubal 
 diameter; the transverse diameter of the head to the 
 transverse or bis-isqhiatic diameter of the mother. 
 
 When does expansion of the perinseum begin to 
 take place ? As soon as the bead fairly engages in 
 the inferior strait. 
 
 What is this expansion called ? The perinaeal 
 tumor. 
 
 To what degree does the perinseum become ex- 
 panded ? Sometimes till it is large enough to cover 
 the whole cranium. 
 
 When may extension of the child's head be con- 
 sidered as perfect ? Just as the face or occiput is 
 clearing the perinaeum. 
 
 When does the perinaeum offer the greatest resist- 
 ance to the escape of the child ? At the time in which 
 the parietal protuberances are about to escape. 
 
 RESTITUTION. 
 
 What takes place in regard to the position of the 
 12* 
 
138 PREGNANCY — LABOR. 
 
 head, after it clears the perinseum ? Restitution^ in 
 which the head of the child takes the oblique position 
 at right angles with the direction of the shoulders. 
 
 ROTATION OF THE SHOULDER. 
 
 What change of positions do the shoulders undergo ? 
 They rotate on the inclined planes. One shoulder to 
 get in front of the sacrum, and the other behind the 
 symphysis pubes. 
 
 What direction does the head assume as the shoul- 
 ders become engaged under the symphysis, and 
 in front of the sacrum ? The occiput presents to the 
 left tuberosity of the ischium, and the chin towards 
 the right, in the first and fifth positions, and the occi- 
 put towards the tuber of the right ischium, and the chin 
 towards the left, in the second and fourth positions. 
 
 Do the shoulders engage in the same inclined planes 
 in which the occiput did ? No ; always in the opposite 
 ones. 
 
 What change takes place in the axis of the body of 
 the child as the shoulders escape ? The body curves 
 upon its axis laterally to accommodate itself to the 
 curvature of the axis of the pelvis. 
 
 What part of the child offers the greatest resist- 
 ance to the delivery in cephalic presentations? The 
 head. 
 
 What other portion offers the next degree of diffi- 
 culty ? The shoulders. 
 
 Which shoulder is delivered first ? In cases of 
 easy labor the pubal shoulder first, but in cases of 
 great rigidity of the perinseum, the pubal shoulder is 
 frequently thrown back under or behind the symphy- 
 sis, and the sacral shoulder thrown out first. 
 
 Do the same diameters of the child's head present to 
 the same planes of the pelvis, in the second as in the 
 first position of cephalic presentation ? The measure- 
 ments are the same in both cases, but the occipital 
 and biparietal diameters are changed about one fourth 
 of a circle. 
 
PREGNANCY — LABOR. 139 
 
 What circumstance offers the only interference to 
 as ready a delivery in the second as in the first posi- 
 tion ? The presence of the rectum, sometimes im- 
 pacted with feces. 
 
 Which way does the occiput present after restitu- 
 tion has taken place in the second position ? To the 
 right side. 
 
 Does rotation occur quite as readily in the second 
 as in the first position ? When the rectum is dis- 
 tended with feces, rotation does not in some cases 
 take place so readily. 
 
 What difficulty does the third position present 
 which is not experienced in the first and second po- 
 sitions ? The fact that it has the occipito-bregmatic 
 and part of the time the occipito-frontal diameter, 
 presenting to the short or antero-posterior diameters 
 of the superior strait of the pelvis. 
 
 Does rotation of the head take place in the third 
 position ? It does not usually, if it enters the pelvis 
 in that direction. 
 
 Do the shoulders rotate ? They mostly do. 
 
 Does restitution of the child's head take place in 
 the third position ? No ; or at least only to a less 
 extent than in either of the others, or only so far as 
 the return of the chin towards the thorax may be 
 included in the meaning of the word restitution. 
 
 Why is the first position more frequent than the 
 second or others? It is not easily accounted for, 
 though some think it is dependent upon the position 
 of the upper portion of the rectum. 
 
 Is the second position any more unfavorable than 
 the first ? Yes ; owing to the slightly greater degree 
 of difficulty of rotation of the head, in consequence 
 of the situation of the rectum on the left side of the 
 sacrum. 
 
 Why are the third positions uncommon ? Because of 
 the difficulty of retaining two convex surfaces, the sinci- 
 put and the promontory of the sacrum in contact with 
 each other. 
 
140 PREGNANCY — LABOR. 
 
 "What peculiar difSculty is liable to present in cases 
 of the third position ? The pressure of the anterior 
 fontanelle against the promontory of the sacrum. 
 
 How do the shoulders rotate in cases of third posi- 
 tion ? Either right or left comes under each of the 
 pubes. 
 
 Why is the fourth position more frequent than 
 the fifth ? Probably for the same reason which 
 renders the first more frequent than the second posi- 
 tion. 
 
 What is the opinion of Naegele and some others, 
 respecting the relative frequency of the occipito-right 
 sacroiliac, or so called fourth position ? That it oc- 
 curred so oftQii, as to be entitled to the second place 
 of a proper enumeration of the positions of the oc- 
 ciput. 
 
 What is the mechanism of the labor in the fourth 
 position ? First, flexion takes place, though perhaps 
 to a less degree than in the anterior varieties ; — then 
 the occiput • rotates along the right posterior inclined 
 plane ; flexion is now increased, and the forehead is 
 thrown behind the arch of the pubis. No extension 
 can take place until the occiput has passed over the 
 whole length of the sacrum, and the forehead has 
 passed out under the arch of the pubes. 
 
 What other parts than the head and neck are in- 
 volved in flexion, as the child enters the cavity of the 
 pelvis ? The thorax and shoulders. 
 
 What conditions are necessary in this case for favor- 
 able delivery ? That the parts of the mother be very 
 much relaxed, or the child small. 
 
 What accident is liable to happen to the mother, as 
 the head passes from the inferior strait ? Rupture of 
 the perinseum. 
 
 Is the bladder more likely to suffer in these than in 
 occipito-anterior positions ? Towards the latter stages 
 of labor it is liable to great distension from the forci- 
 ble pressure of the anterior part of the head. 
 
 What change takes place in regard to the head 
 
PREGNANCY — LABOR. 141 
 
 after it has cleared the perin?eum in occipito poste- 
 rior positions ? Revolution backwards. 
 
 Which way does the face of the child turn when it 
 has cleared the inferior strait in the fourth position ? 
 Towards the left thigh of the mother. 
 
 Under what circumstances may the forehead, and 
 not the anterior fontanelle, come out under the arch 
 of the pubes ? When the child is small, or the peri- 
 nseum much relaxed, or the coccyx very moveable. 
 
 In what direction do the contractions of the uterus 
 carry the head of the child in the early period of the 
 second stage of labor ? Directly down into the hol- 
 low of the sacrum. 
 
 What inconvenience arises in reference to the body 
 A the child ? In the posterior varieties the child's 
 spine bends under the contractions of the uterus, and 
 therefore, the expulsive powers are less efficient than 
 in the anterior position. 
 
 What is the mechanism of the fifth position ? The 
 bi-parietal and occipito-bregmatic diameters, corres- 
 ponding to the oblique diameters of the superior 
 strait, the contractions of the uterus force the occi- 
 put down along the left posterior inclined plane, and 
 the bregma along the right anterior plane. 
 
 Which way does the face turn, after it has escaped 
 the vulva ? To the inside of the right thigh. 
 
 Does the forehead present any difficulty in its pas- 
 sage under the arch ? It is believed by some that it 
 escapes less readily than the occiput, though it pro- 
 bably does not, if the coccyx and perinaeum offer no 
 resistance. 
 
 Which is the most rare position of all the occipital 
 presentations? The sixth. 
 
 Why does it occur rarely? Because of the ex- 
 treme difficulty of having two rounded surfaces, like 
 the occiput and promontory of the sacrum kept in 
 contact with each other. 
 
 What is the mechanism of labor in the sixth posi- 
 tion ? The head is driven directly down the central 
 
142 PREGNANCY — LABOR. 
 
 line of the sacrum without any rotation. The shoul- 
 ders are rotated as in the third position, except that 
 they are reversed. 
 
 POINTS PARTICULARLY TO BE STUDIED. 
 Wliat are the two main points to be studied, in 
 reference to the mechanism of all the positions ? The 
 characteristics of the first and the fourth positions, 
 as containing the elements of the mechanism in all 
 the other varieties. 
 
 ADDITIONAL POSITIONS. 
 Are there no other positions of the occiput worthy 
 to be Tjmbraced in a systematic classification by au- 
 thors or teachers ? There are two others, viz. : — one, 
 in which the occiput is directed towards the left side 
 of the superior strait which terminates the transverse 
 diameter, and the other, in which the occiput is di- 
 rected exactly towards the other or right extremity 
 of that diameter — in other words, they might be des- 
 cribed as occipito-left iliac or seventh position, and oc- 
 cipito-right iliac or eighth position. They are some- 
 times called transverse positions. 
 
 CONVERTIBILITY OF THE POSITIONS. 
 
 Why are the two transverse positions of the head 
 at the superior strait easily convertible into the first 
 or second, fourth or fifth ? Owing to the facility of 
 the rotation of the head upon the inclined planes. 
 
 Why may the fifth position become converted into 
 the first, and the fourth into the second ? Owing to 
 the fact that the anterior inclined planes are larger 
 than the posterior inclined planes. 
 
 MOVEMENTS EXECUTED ON THE SHOULDERS. 
 What changes do the shoulders undergo as they are 
 forced through the pelvis in a first position of the ce- 
 phalic extremity ? The right shoulder being already 
 at the commencement of the labor in the right side 
 of the pelvis, in advance of the transverse diameter, is 
 
PREGNANCY — LABOR. 143 
 
 under the influence of the contractions of the uterus 
 and the spiral form of the pelvis, forced to slide along 
 the right anterior or ischio pubic plane till it is ap- 
 plied behind the symphysis or under the arch of the 
 pubes. The left shoulder being behind the transverse 
 diameter on the left side of the pelvis, is likewise car- 
 ried down by the uterine forces acting on the body of 
 the fetus, and partly by the spirality of the materials 
 filling up the ischio-sacral notch, but especially, per- 
 haps, by the influence of the right anterior inclined 
 plane upon the opposite shoulder, it is obliged to ap- 
 pear upon the median line of the sacrum and coccyx, 
 over which it is made to pass by the continued uterine 
 and abdominal forces. 
 
 How do the shoulders rotate in the second position 
 of the occiput ? The left shoulder is carried down on 
 the left anterior inclined plane, and becomes, at the 
 inferior strait, the pubal shoulder, while the right one 
 is carried along the right posterior inclined plane and 
 becomes the sacral shoulder. 
 
 How are the shoulders disposed of in the third or 
 occipito-pubal position ? Either shoulder may engage 
 on the right or left anterior inclined plane, and so 
 be made to appear under the arch of the pubes. 
 
 What becomes of the shoulders in the fourth cepha- 
 lic position ? The left one being upon the right an- 
 terior inclined plane is carried downward and forward 
 by the uterine and abdominal forces till it is brought 
 behind or under the symphysis of the pubes, while 
 the right shoulder is necessarily moved downward 
 and backward on the left posterior inclined plane 
 to appear at length at the posterior commissure of the 
 vulva. 
 
 What may be said of the rotation of the shoulders in 
 the fifth position of the cephalic presentation ? That 
 here of course the right shoulder is compelled to de- 
 scend along the left anterior, and the left on the right 
 posterior inclined plane, till they each appear at the 
 vulva. 
 
144 LABOE— ARRANGEMENT OF THE BEl). 
 
 Is there any known law by which to determine 
 which of the two shoulders shall descend on the right 
 or left anterior plane, and the sixth or occipito-sacral 
 position of the head ? As in the third position, we 
 have here no reason why one shoulder in preference 
 to the other should descend upon the one or the other 
 of the anterior, or on the opposite posterior inclined 
 plane of the pelvis, consequently, we cannot in either the 
 third or the sixth position, anticipate to which tuber 
 ischii the occiput will necessarily be directed, nor how 
 the shoulders will descend. 
 
 Are the rules which have been stated as to the man- 
 ner in which rotation of the shoulders usually takes 
 place in the oblique positions of the head uniform 
 and without exceptions ? No — for it has been observed 
 that in some instances in which the process of the la- 
 bor has not been interfered with, the shoulders have 
 been found not to rotate at all, or the right shoulder 
 has passed down on the plane different from that on 
 which it would have been expected to rotate, and even 
 in a few instances in which the occiput of the child 
 had appeared at the arch of the pubes, the centre of 
 the fetal dorsum has been forced to slide along the 
 median line of the coccyx and perinseum. 
 
 How are the hips arnd the lower extremities usually 
 disposed of in their descent through the pelvis ? In some 
 cases the hips obey the same law of rotation, as the 
 slioulders, though this is not uniformly observed. The 
 lower extremities are almost always unfolded, and 
 extended before they pass through the canal and ap- 
 pear at the vulva. 
 
 ARRANGEMENTS OF THE CHAMBER AND BED OF THE 
 ACCOUCHEE. 
 
 What kind of room should the patient select for 
 her nursery during her parturient and puerperal state ? 
 It should be spacious and well ventilated, so circum- 
 stanced that light and noise can be excluded when 
 necessary. 
 
LABOR — ARRANGEMEXT OF THE BED. 145 
 
 What arrangement should be made in reference to 
 the bed ? It should be so situated as to be accessible 
 if possible at each side and the foot. It should have 
 posts sufficiently high to enable her to place her feet 
 against either one as may be desired, and if there be 
 curtains, these should be kept so drawn up that the bed 
 may be well ventilated. 
 
 What objection to her being delivered on one bed, 
 and after labor transferred to another ? There is 
 often much inconvenience as well as hazard in making 
 the transfer, as hemorrhage, &c. might be thus brought 
 on. 
 
 How should you have the bed prepared for de- 
 livery ? First, have the bed, if of feathers, properly 
 flattened down, then place upon the middle portion 
 of it upon which the hips will rest after delivery, a 
 folded sheet, blanket, or any soft material to protect 
 the bed below from the lochia, which may escape from 
 beyond its immediate recipients. Then place on the 
 lower sheet or blanket, fold the lower end of this in 
 sever'al short folds so near the middle of the bed, that 
 "when the patient is placed in her proper situation 
 after delivery, this fold will be below her hips. Put 
 on the top of this sheet, directly over the doublings 
 beneath it, a few folds of soft, CMiifortable material, 
 on which the hips will rest when the patient is placed 
 up in bed after delivery, and w^hich being more easily 
 removed than the expanded sheet, may serve well to 
 receive any discharges which may escape beyond the 
 perin?eal napkin. Place upon the lower portion of the 
 bed, first an oil-cloth, or some other impervious mate- 
 rial, and over this, several folds of clothing, as blan- 
 kets, sheets, or something of this kind, so arranged as 
 to cover principally, or entirely, the portion of the 
 bed thus left bare by the folding up of the lower 
 sheet. Bring the lower edge of these folds a little 
 over the foot or edge of the bed, at which the accou- 
 cheur is to sit. Then place the pillows diagonally 
 across the bed, that they will be comfortablv under 
 18 
 
146 LABOR — ARRANGEMENT OF PATIENT. 
 
 the patient's head when she is sufficiently flexed. 
 Replace the bed-covers,as sheet, blanket and spread, 
 comfortable, or quilt, as the case may be, as though 
 the bed had been made up as ordinarily ; then fold 
 the upper cover back to the farther side of the bed 
 from which the patient will lay while in labor, back 
 over this fold the free edge of the next cover, and so 
 on till the last free sheet is disposed of in the same 
 way. To that bed post against which her feet are to 
 be fixed when she is placed on the bed, attach a towel 
 or strong band, in such manner that her hand may 
 embrace the loop of it when she is properly flexed. 
 It is even better to pass a short round stick through 
 the loop so made, that the patient may make equal 
 draughts with both her hands during a strong bear- 
 ing down pain. 
 
 What principal object should the physician have in 
 view in giving directions for the preparations of the 
 bed ? That the patient may lie upon her left side so 
 curved forward as to throw the axis of the body into 
 nearly the same line with that of the uterus. 
 
 How should the patient be prepared to be placed on 
 the bed ? Her body clothing should be so adjusted 
 that she need not have it all soiled. For this reason 
 her skirts should be laid aside ; her linen so folded up 
 around her waist that it will be beyond the risk of 
 discharges, a bandage suitable for encircling her ab- 
 domen after delivery, should be placed around her 
 waist, and so pinned as to retain her linen as folded 
 up ; and next a sheet or blanket should be folded in 
 double in the direction of its length, the thin edges of 
 this fold should be placed in front of the abdomen, 
 and carried round on each side to the middle of the 
 back, or better still, one portion should be carried 
 round the left side over the back, to meet the other 
 portion on the right side, where it should be carefully 
 pinned with a large pin, taking care to have the por- 
 tion of the sheet or blanket carried round the body, 
 so adjusted that the portion which is carried round the 
 
LABOR— ARRANGEMENT OF PATIENT. 147 
 
 riglit side will extend at least twice as far backward as 
 that on the left. The night or bed gown, which should 
 be a short one, can then be allowed to drop down from 
 the shoulders to the waist. The patient should have 
 stockings on, without any garters to retard the circula- 
 tion, her feet should mostly also be protected by slippers. 
 She should then, if the stage of her labor require, be 
 placed upon her left side, with her hips within a foot 
 of the lower end of the bed, her body flexed forward, 
 her lower extremities drawn up, that her feet may be 
 placed against the right foot post of the bed ; the 
 lower side of the sheet or blanket is then to be 
 drawn out smoothly under her, while the upper por- 
 tion is to be carried out also smoothly behind her ; it 
 will thus protect her completely from any exposure 
 of her person ; next over this may be drawn a suit- 
 able amount of bed clothes. 
 
 Is it important what kind of bandage the patient 
 should have prepared for her use immediately after 
 parturition ? Notwithstanding the diversity of opinion 
 and practice amongst physicians on this point, and 
 the great variety of form and mode of application of 
 this essential article by women, it is unquestionably 
 important, that the principle to be kept in view in the 
 use of the bandage,* is that it gives support to the up- 
 per portion of the thighs, the entire pelvic, and the 
 greater portion if not the whole of the lumbar, and 
 abdominal regions of the body. 
 
 What form of bandage is best, to fulfil this indica- 
 tion ? It should be made to fit exactly the curve or 
 hollow of the back, spread out neatly over the nates, 
 then be so contracted below as to be exactly adapted 
 to the back part of the upper portion of the thighs, 
 with the extremities long enough to overlap each other 
 a few inches in front of the person, where it may be 
 smoothly secured by strong pins or laced by a large 
 needle armed by thread of sufficient size and strength 
 to make the requisite compression upon the several 
 
148 LABOR — ARRANGEMENT FOR THE CHILD. 
 
 points from just below the pubes to the scrobiculia 
 cordis, or the lower margin of the mammae. 
 
 How can a bandage so constructed be placed around 
 the waist of the patient, in such manner that it can be 
 gotten down to its place after delivery without incon- 
 venience to the patient, nurse, or accoucheur ? Let 
 the nurse or temporary attendant upon the patient ex- 
 tend this bandage upon a bed, fold it in three plaits 
 or folds, of which the lower edge shall be the first, the 
 middle of the bandage shall be the second, and the 
 upper margin shall be the last or uppermost plait ; 
 this will reduce the plaited bandage to about the width 
 of her hand and extended thumb. Let her then plait 
 it in short plaits in the opposite direction, crosswise, 
 or at right angles with the longitudinal folds ; the 
 whole bandage thus folded up she can now take in 
 one hand and carry it around the waist of the patient, 
 (so as to embrace the folds of the chemise previously 
 adjusted,) till it can be met by the opposite hand; the 
 two ends are next to be brought round upon the mass 
 of folds of the under garment, and when it is properly 
 secured by a single large pin it will be found to retain 
 this part of the under dress completely above all or- 
 dinary risk of becoming soiled by the fluids which may 
 escape from the uterus in the progress of the labor. 
 
 What is next to be done to cover the lower extrem- 
 ities of the patient while in labor ? Adjust the sheet 
 outside of this as explained in the answer to the ques- 
 tion about preparing the patient for placing her on 
 the bed. 
 
 What provision should be made in reference to the 
 management of the child at its birth ? There should 
 be provided a proper ligature for the umbilical cord, — 
 a pair of sharp-edged, but blunt ended scissors, should 
 be at hand ; also suitable clothing, in which to envelope 
 the child when born. There should also be the means 
 at command of raising the temperature if necessary — 
 as for example, an abundant supply of warm water, 
 and also some suitable stimulants, as spirits, aq. am- 
 
LABOR — ACCOMMODATION FOR ACCOUCHEUR. 149 
 
 monise, or something of the kind, to excite respiration 
 if necessary. 
 
 What accommodation should be furnished the ac- 
 coucheur ? A chair to sit upon, some unctuous mat- 
 ter with which to lubricate his hand, and the soft parts 
 of the mother ; and several napkins, properly plaited 
 or folded, for use as required. 
 
 What course of conduct should the accoucheur ex- 
 ercise while in attendance upon the parturient female ? 
 It should be such as would preserve her feelings free, 
 and inspire her with proper confidence in him — he 
 should remain calm under all circumstances, carefully 
 avoid, by any action or change of countenance, excit- 
 ing her apprehensions of an unfavorable termination 
 of her case ; he should offer candidly all reasonable 
 prospects of a happy and safe delivery, though he 
 should cautiously avoid any promise as to this or the 
 time of its occurrence. He should suppress all un- 
 necessary talking, or allusions to any other cases which 
 may have been knoAvn, or reported to be fatal or haz- 
 ardous ; he should advise his patient against straining, 
 or forcibly bearing down during the first stage, but 
 strongly urge the necessity of it, during the second 
 stage. He should carefully ascertain the state of the 
 bladder and bowels, and direct accordingly ; he should 
 recommend his patient to remain up considerably, 
 during the first stage, but to lie down, during the re- 
 maining period of labor. He should not remain con- 
 stantly with her during the first stage, but not be ab- 
 sent from her subsequently until the whole process is 
 completed. 
 
 What accommodation should be supplied to the ac- 
 coucheur, w^hen he is about to make an examination, 
 or is preparing to assist the patient by receiving her 
 child, &c. ? The nurse should adjust a napkin around 
 each fore arm, if he wish it, place a sheet, or folded 
 cloth upon his lap, put within his reach several nap- 
 kins, diapers or cloths, and a cup of lard or pure oil. 
 13* 
 
150 LABOR — MODE OF EXAMINATION. 
 
 She should do this quietly, and he should take his 
 seat with as little parade as possible. 
 
 Thus seated, and otherwise accommodated, what 
 should he proceed to do ? To make a proper examin- 
 ation, to determine the exact state of the case if 
 possible. 
 
 PHYSICAL ENQUIRY INTO THE FACT OR PROGRESS OF 
 LABOR— PATIENT RECLINING. 
 
 How should he make this examination ? He should 
 be seated with his right side to the bed ; the nurse, or he 
 with his left hand, should slightly and cautiously elevate 
 the double fold of the sheet, which had been placed 
 around the patient before she was laid on the bed ; 
 when a pain occurs, he should lubricate the index 
 finger of the right hand, and keeping this finger flexed 
 towards the hollow of the hand, at the same time that 
 the thumb is strongly extended, (thus guarding the 
 finger, from the risk of having the ointment on it 
 rubbed off on the clothes, and subsequently perhaps, 
 smeared upon his coat sleeve,) he should pass his right 
 hand under the folds of the sheet, the double of which 
 had been slightly raised by his left hand, or by the 
 nurse. The left hand is then to be carried, exterior 
 to all the covers, to the region of the right trochanter ; 
 at the same time, the right hand glided along, under 
 the folds" of the sheet in the manner directed, is to be 
 passed a little posterior to the spot upon which the 
 left hand slightly rests, viz. : upon the right trochanter; 
 in this way the knuckle of the examining finger may 
 with considerable certainty be brought to the sulcus 
 between nates, or to the raphe of the perinBeum, and 
 then glided forwards, until it slips into the genital fis- 
 sure over the posterior commissure, without bringing 
 it in contact with the sensitive apparatus at the ante- 
 rior commissure ; when once the finger has gained this 
 aperture, it may be extended along the vagina, with 
 its ulnar edge towards the arch of the pubes, and thus 
 cautiously applied to the orifice of the uterus, &c. 
 
LABOR — MODE OF EXAMINATION. 
 
 151 
 
 Although it is mostly greatly preferable that the 
 patient should be upon her left side for examination, 
 or for labor, is it not embarrassing to the accoucheur 
 to make the touch or rupture the membranes by the 
 finger applied to the orifice of the uterus as usually di- 
 rected? The usual mode of applying the finger to 
 the orifice of the womb, with its ulnar edge to the 
 pubes does not permit the finger readily either to re- 
 cognise the condition of the orifice of the uterus, the 
 character of the presentation, nor to rupture the mem- 
 branes, as may be seen in fig. 66, 
 
 Fig. 66. 
 
 How may this difliculty be obviated? By changing 
 the direction of the hand after the finger is inserted, 
 BO Hhat by forced supination, or better still, by forced 
 pronation, which is accommodated by a degree of cor- 
 responding motion in the arm and body of the accou- 
 
152 
 
 LABOR — MODE OF EXAMINATION. 
 
 cheur, the pulp of the right index finger can be 
 brought much more eifectivelj into relation with the 
 parts than when confined to the ulno-pubal position. 
 
 What is the importance of making this examination 
 at the time of a pain ? First, that he may determine 
 whether she is really in labor or not, and next to as- 
 certain the degree of dilatation of the os uteri, and if 
 possible the presentation of the child. 
 
 ADVANTAGES OF UPRIGHT POSITION. 
 
 Is it ever warrantable to make the examination of 
 the condition of the os uteri, in the supposed incipient 
 stage of labor, while the patient is in the erect position? 
 There are many instances in which an examination in 
 this manner would be less inconvenient to the patient 
 and attendants, and because of the greater facility of 
 
LABOR — MODE OF EXAMINATION. 153 
 
 reaching the os uteri by the proper curve of the index 
 finger, more accurate diagnosis of the condition of the 
 OS uteri and the impression of a contraction upon it 
 may be obtained, than when the patient is in the hor- 
 izontal position on her left side. 
 
 TIME AND MANNER— PATIENT STANDING. 
 
 What are the proper time and manner of making 
 the examination by touch in this way ? With a proper 
 understanding of the greater advantage and facility 
 of this method, provided the patient has not been al- 
 ready prepared to lay upon the bed for her delivery, 
 and under the impression also from the character of 
 the pains that the labor has not yet so far advanced 
 as not to admit of her remaining up for some time 
 longer, let the nurse or temporary female attendant 
 quietly provide the proper napkin and lard or oil, and 
 place them within easy reach of the physician. Let 
 her next take her position by the left side of the pa- 
 tient as she sits, and when a pain occurs let the patient 
 rise by the side of the nurse and repose slightly upon 
 her, w^hile the latter stooping forwards, gently collects 
 the lower margin of all the patient's skirts, carries 
 them forward and but very little upwards until 
 they can be deposited upon the flexure of the phy- 
 sician's arm as he is proceeding to make the 
 enquiry by examination. She will thus act in the 
 double capacity of companion and assistant to the pa- 
 tient. 
 
 What should be the movements of the accoucheur 
 in making the examination in this way ? Having pru- 
 dently seated himself near the right side of the patient, 
 and with his right hand nearest to her, let him, upon 
 the intimation that she has a pain and is about rising 
 by the side of the nurse, anoint his finger, cast the 
 napkin loosely over his wrist, carry his left hand over 
 the right hip to the sacrum or loins of the patient to 
 assist in giving her moderate support while the right 
 hand (the index finger of which is properly guarded 
 
154 LABOR — DUTIES OF PHYSICIAN AND NURSE. 
 
 against the risk of having the lubricating matter rubbed 
 off it) is carried upwards under the dress of the patient 
 to the raphe of the perinosum or posterior commissure 
 of the vulva, from which its introduction into the va- 
 gina can usually be easily effected without distress to 
 the patient or embarrassment to himself, the os uteri 
 easily reached, and its condition mostly made out with 
 much precision. 
 
 How much time is allowed for this examination in 
 the erect position ? Only so much as is occupied by a 
 pain or uterine contraction. 
 
 WHEN TO BE PUT TO BED FOR THE COMPLETION OF 
 LABOR. 
 
 When should she be put to led for the completion 
 of labor ? When you believe the os uteri is nearly or 
 entirely dilated, as shewn in fig. 68. 
 
 Fig. 68. 
 
 DUTIES OF PHYSICIAN, NURSE, AND PATIENT DURING 
 ^ THE SECOND STAGE OF LABOR. 
 
 Why should you have her flexed forward ? That 
 the axis of her uterus may be thrown into a line with 
 the axis of the superior strait. 
 
 Is it easy for you always to determine the Presen- 
 tation of the child, previous to the rupture of the mem- 
 
LABOR — DUTIES OF PHYSICTAX AND NURSE. 155 
 
 branes? It is mostly easy to do so, unless it be a 
 presentation of the face, side, or back, or breech of 
 the child. 
 
 Is the Position easy to be recognised through the 
 membranes ? In general it is not, until after they are 
 ruptured, and the presenting part fairly engaged in 
 the pelvis. 
 
 Does labor usually proceed more rapidly after the 
 rupture of membranes, if the os uteri be properly di- 
 lated ? It does, perhaps in consequence of the short- 
 ening of the muscular fibres of the uterus, and their 
 contact with the firmer and less regular surface of the 
 fetus. 
 
 How should you rupture the membranes ? By press- 
 ing the point of the finger into the fold of the mem- 
 branes, if the bag of water be large ; if not promi- 
 nent, the nail of the finger should be directed towards 
 the presenting part of the child, and then by a little 
 vibratory motion gradually wear them away. This 
 must be done with great caution, lest the scalp should 
 be torn in the process. 
 
 Should you use any precautions for your protection 
 from the sudden escape of the liquor amnii, when 
 you open the membranes ? The wrist should be en- 
 veloped in a napkin, and one should also be applied 
 to the perinceum and vulva, so that at the instant you 
 burst the membranes, you may withdraw the finger, 
 and apply the napkin to absorb the discharge. 
 
 Should you change the saturated napkins privately ? 
 They should be either handed quietly to the nurse, or 
 laid secretly at the bottom of the bed-post without 
 calling aloud to any one about them. 
 
 Should you after this time keep any thing applied 
 to the breech of the patient to absorb the discharges ? 
 This should be done by applying successively folds of a 
 sheet, or better still, by changing napkins as fast as 
 they become saturated. By this plan, the patient is 
 rendered less uncomfortable and the bed less soiled. 
 
 If the membranes require to be ruptured artificially 
 
156 LABOR — DUTIES OF PHYSICIAN AND NURSE. 
 
 at what period of the pain should it be done ? At the 
 commencement if possible. 
 
 Should the accoucheur interfere with the process of 
 labor, during the second stage ? He should let it 
 alone, if he have ascertained that the position is cor- 
 rect. 
 
 When should the patient be encouraged to assist the 
 expulsive effort ? As soon as the os uteri is dilated, 
 and the first stage complete. 
 
 If she do not know how, what instructions should 
 you give her ? To take in a full breath, and bear 
 down the whole time of a pain ; — to bend herself for- 
 Avard, &c. 
 
 How can she bring her accessory powers most ad- 
 vantageously to co-operate with the pains or relieve 
 contractions during the second stage of the labor ? In 
 by far the greatest number of cases the efficiency of 
 the accessory aid is increased by giving the patient a 
 firm purchase with her feet against the post of the 
 bed, or some other immoveable point, while her ex- 
 tended arms may reach the same point by means of 
 a well adjusted cord, napkin or any similar medium, 
 with a little round short stick passed through the loop 
 of it, so that she can flex the fingers of a hand on 
 each side of the tow^el or cord, without the risk of 
 contusing them by irregular pressure during her bear- 
 ing down effort. 
 
 Should she be careful to relax herself, as soon a a 
 the pain is off? This should be insisted upon in most 
 cases. 
 
 What kind of drink or other comforts should she 
 have to revive her during the second stage ? Cool 
 water, lemonade, toast water, carbonated or mineral 
 water, gentle fanning and such changes in the thick- 
 ness of her covers as her condition may require. 
 
 When should the nurse adjust a large cushion or 
 rolled up pillow between the limbs of the patient ? 
 
 When the accoucheur has observed that the present- 
 ing part of the child presses on the perinneum. 
 
LABOR — DUTIES OF PHYSICIAN AND NURSE. 157 
 
 In what direction should the pillow be placed ? 
 Prom ancle to knee, so as to be exactly longitudinally 
 above the left, and below the right leg. 
 
 What is the proportionate force of the uterine con- 
 tractions, during the labor ? Inversely as the size of 
 the organ, according to the calculations of some obstet- 
 ricians. ' 
 
 When is the force of the contractions of the uterus 
 at its acme ? When the presenting part is about to 
 pass through the genital fissure. 
 
 Is there any danger of rupture of the perinseum in 
 most cases of « labor ? It has been known to rupture 
 during the progress of natural labor. 
 
 How must the perinseum be supported ? It is best 
 done by the accoucheur, applying the palm of his hand 
 over the perinseum, and keeping his wrist directed to- 
 wards the child's head. 
 
 What should be interposed between the hand and 
 perinseum ? A napkin which will receive the feces if 
 any escape. 
 
 In what direction may the perinseum be ruptured or 
 lacerated ? From the fourchette backwards ; through 
 the centre ; or at the anus. 
 
 Is it ever necessary to resist the descent of the 
 child, when the perinseum is in danger ? It is, if the 
 perinseum is not relaxed. 
 
 When is the greatest danger of laceration ? At the 
 moment that the parietal protuberances are passing 
 through the vulva. 
 
 WHAT TO DO WHEN THE HEAD HAS PASSED THROUGH 
 THE VULVA. 
 
 When the head escapes, what attention should be 
 given in reference to the child ? To ascertain whether 
 the cord is around the child's neck, and if so, to at- 
 tempt to loosen it by drawing gently upon one ex- 
 tremity of it. 
 
 Suppose the cord to encircle the neck so closely as 
 to interfere with respiration or the quick descent of 
 14 
 
158 LABOii — DUTIES OF PHYSICIAN AND NURSE. 
 
 the child, what should you do then ? Carefully divide 
 it, and then expedite the delivery by traction by the 
 head and neck of the child. 
 
 Should the head of the child be supported after its 
 extrusion ? It should repose in an expanded hand of 
 the accoucheur. 
 
 What attention should be given to the shoulders, if 
 they do not readily rotate ? Assist the rotation by 
 pressing the proper one under the arch and lihe other 
 into the hollow of the sacrum. 
 
 Under what circumstances may the accoucheur 
 draw a little upon the head ? When the perinseum 
 offers a strong resistance to the exit of the shoulders. 
 
 In what direction should he draw upon the head ? 
 If a shoulder be thrown up behind the symphysis pu- 
 bes, the traction should be towards the sacrum, suffi- 
 cient to disengage the pubal shoulder ; but if this be 
 already free, the traction may be made in the direc- 
 tion of the axis of the vagina. 
 
 Having cleared the shoulders from the grasp of the 
 perinseum, should you hasten the delivery of the rest 
 of the child ? No ; its delivery should be rather re- 
 tarded, in order to allow the uterus to contract well 
 upon it and the placenta. 
 
 What should you do as soon as the body is ex- 
 truded ? Carry the child round and place it in such 
 a position as to be free from the discharges of the 
 mother. 
 
 What attention should you give the mother as soon 
 as the child is born ? Calm her excitement and ascer- 
 tain that the uterus is contracted. 
 
 How should you do this ? Speak kindly and sooth- 
 ingly to her ; then place your hand on the abdomen 
 and feel what the condition of the uterus is — if it do 
 not contain another ovum — make moderate compres- 
 sion upon it to insure its contraction upon the pla- 
 centa and membranes. 
 
LABOR—DUTIES OF PHYSICIAN AND NURSE. 159 
 
 TYING AND DIVIDING THE CORD. 
 
 Is it proper to put the ligature on, and to cut the 
 cord immediately after the child is extruded ? It is 
 better to wait until respiration, and the capillary cir- 
 culation are established, thus if the child cry, or re- 
 spire freely, and a red or arterial color may be seen 
 on the face and other parts of the skin, the ligation 
 and division of the cord may be made with propriety. 
 
 "What is the obiect of applying a ligature upon the 
 cord ? To arrest the circulation in the cord, and 
 prevent hemorrhage from its vessels when they are 
 divided. 
 
 How many ligatures should you place upon the 
 cord ? One ligature only is necessary in the great 
 majority of cases ; some practitioners think it proper 
 to apply two ligatures for the purpose of cleanliness, 
 and to avoid the possible risk of hemorrhage in case 
 of two placentas inosculating with each other. 
 
 At what distance from the abdomen should the lig- 
 ature be applied ? About two inches. 
 
 What precaution should you take in relation to the 
 possibility of the occurrence of umbilical hernia? 
 See that this does not exist, or if it does, apply the 
 ligature sufficiently far beyond it. 
 
 In case you adopt the better plan of putting only 
 one ligature upon the cord, what had you best do with 
 the extremity of the placental portion of it ? Wrap 
 it loosely in one end or corner of a napkin which 
 had been previously plaited transversely and laid upon 
 the right hip of the patient. 
 
 MODE OF RECEIVING AND DISPOSING OF THE CHILD. 
 
 In what manner should you take up the child to 
 give it to the nurse } The best plan is to have a nap- 
 kin so folded and applied near the breech of the 
 mother, that with one hand one of its extremities can 
 be placed under and support the head as soon as it is 
 extruded ; as the body passes out, these folds are gra- 
 
160 LABOR — DUTIES OF PHYSICIAN AND NURSE. 
 
 dually expanded until the whole child is extended 
 upon it. Then as soon as the cord is divided the 
 child is to be enveloped in this napkin, and thus easily 
 lifted to the receptacle held by the nurse, for as the 
 child is usually covered by a very slippery or pasty 
 matter, it is often difficult or disagreeable to handle it 
 properly. If, therefore, the napkin be not used, it 
 will be found perhaps most convenient to pass the 
 palm of one hand behind the thorax and nape of the 
 neck, while the other is passed under the thighs, and 
 the legs embraced with the index finger between 
 them. It has been suggested as an improvement upon 
 this method, to pass the palm of the hand under the 
 thorax, having its radial edge towards the chin of the 
 child, and thus raise it up from the bed to the receiver 
 held by the nurse. The child is thus easily held by 
 the hand, and is thus for a moment kept in a position 
 nearly as much flexed as when in utero. 
 
 How should the nurse receive and dispose of the 
 child ? She should be provided with a large piece of 
 flannel or soft warm cloth, which she should present at 
 the left side of the accoucheur : she should then en- 
 velop the child and retain it in her lap, or place it in 
 some safe situation, till she is prepared to wash and 
 dress it. 
 
 CONDITION OF THE UTERUS IMMEDIATELY AFTER COM- 
 PLETION OF THE SECOND STAGE OF LABOR. 
 
 Where may you expect to find the fundus uteri after 
 the extraction of the child ? Most frequently in the 
 umbilical or hypogastric region, though occasionally 
 it is met with in the left iliac fossa. 
 
 Suppose you find the uterus firm, should you feel un- 
 easy, however large it may be ? If it be very firm and 
 somewhere below the umbilicus, we perhaps should 
 not feel uneasy, but if larger than that, we should 
 suspect twins, or the presence of blood between the 
 uterus and placenta. 
 
LABOR — DUTIES OF PHYSICIAN AND NURSE. 161 
 
 MANAGEMENT OF THE PLACENTA. 
 
 Should the woman be expected to deliver herself 
 of the placenta ? In the majority of instances the 
 uterus spontaneously expels it into the vagina. 
 
 How many pains does it usually require ? Two, 
 three, or four. 
 
 WHAT TO DO TO PROMOTE THE DELIVERY OF THE PLA- 
 CENTA. 
 
 Is it ever necessary to stimulate the uterus to con- 
 tract, to expel the placenta ? It is sometimes neces- 
 sary to do so by friction. It is always proper, and 
 often indispensable that the hand of the accoucheur or 
 nurse should be carefully applied over the uterine 
 tumor till the placenta, membranes and the coagula, 
 if any, be clearly expelled. 
 
 Should you ever pull at the cord, unless you are 
 very sure the uterus is well contracted ? Never more 
 than to draw the cord into a right line. 
 
 What danger attends the practice of strong trac- 
 tion upon the cord ? Kupture of the cord, hemor- 
 rhage, inversion of the uterus, &c. 
 
 Under what circumstances may you assist by act- 
 ing on the placenta, through the medium of the cord ? 
 When the uterus has remained some time torpid and 
 will not contract. 
 
 Is any rule of time to be allowed for the sponta- 
 neous delivery of the placenta ? Opinions and prac- 
 tices appear to be very variable on this point, though 
 it is probably rarely necessary to wait beyond twenty 
 or thirty minutes after the birth of the child. 
 
 In what direction should 'you act upon the cord, or 
 the placenta ? Always in the axis of that part of 
 the uterus or pelvis in which the placenta is situated. 
 
 How is this to be done ? By passing up a finger 
 and allowing it to act as a pulley. 
 
 In what direction when the placenta is in the va- 
 gina ? In the axis of the vagina. In the axis of the 
 14* 
 
162 DELIVERY — DUTIES OF ATTENDANTS. 
 
 inferior strait, at first, and afterward along the plane 
 of the perinaeum. 
 
 Should you ever hook your finger into the pla- 
 centa, when it comes within reach ? It may be pro- 
 per to do so in case the mother does not expel it 
 The accoucheur should always carry it backward to- 
 ward the sacrum and the perinseum. 
 
 HOW TO RECEIVE AND DISPOSE OF THE PLACENTA. 
 
 When you get the placenta partially through the 
 vulva how should you act upon it to secure the deli- 
 very of the membranes ? Retard its expulsion from 
 the vulva ; then rotate it upon its axis to twist the 
 membranes into the form of a cord. 
 
 What is probably the neatest and most appropriate 
 mode of receiving and disposing of the placenta when 
 delivered ? As it comes down through the vulva let 
 the plaits of the napkin, which had been placed 
 upon the right hip, under the sheet, be frequently 
 drawn upon as the mass is expelled, so that by the 
 time the membranes and any coagula shall have es- 
 caped, the whole may be enveloped in the napkin, the 
 outer folds of which being almost entirely in a dry con- 
 dition, it can be handed to the nurse, or any other 
 attendant, or laid quietly away by the physician 
 himself. 
 
 CLEARING THE PATIENT AFTER COMPLETING THE DE- 
 LIVERY. 
 
 What is meant by the phrase of the lying-in cham 
 ber, '' clearing the w^oman ?" The complete removal 
 of the placenta with its membranes, and of all the 
 coagula and other discharges which are to be found 
 in the vagina and about the breech of the woman, 
 as well as the application of a soft dry napkin to the 
 vulva. 
 
 What cautions should be observed in reference to 
 the placing of the woman in her proper situation in 
 bed after delivery ? Every attention should first be 
 
DELIVERY — DUTIES OF ATTENDANTS. 163 
 
 paid to " clearing" the woman — a soft napkin should 
 be applied to her vulva — the bandage put properly over 
 the hypogastric and pubic regions — she should then be 
 carefully slided up in bed, in the completely horizontal 
 position, without being allowed to raise herself up. 
 
 APPLYING THE PERINJEAL NAPKIN. 
 
 How can the napkin be so applied as to be kept in 
 gentle contact with the vulva to receive the dis- 
 charges as they escape from the vagina? Let one of 
 the soft napkins, at least one-third of a yard wide, 
 be plaited in small plaits, in the direction of its width, 
 and so adjusted that its middle portion will be ap- 
 plied to the vulva, while one extremity is carried for- 
 ward upon the pubic region, where it can be tem- 
 porarily retained, by withdrawing the pillow from 
 between the knees, and allowing the thighs to ap- 
 proach each other ; at the same time the other end 
 can be carried over the perinseum and the sulcus 
 between the nates to the sacrum, upon w^hich the ex- 
 tremity will be expended. 
 
 How can it be retained in this situation while the 
 patient is subject to any change of position, as that 
 required for adjusting the pelvic and abdominal band- 
 age and placing her up in bed? This perinseal nap- 
 kin may be supported with a temporary fold or two of 
 the dry clothing on which she was delivered, so long as 
 she remains on her left side. 
 
 ADJUSTMENT OF THE PELVIC AND ABDOMINAL BAN- 
 DAGE. 
 
 What is next to be done ? While the physician is en- 
 gaged in making the proper ablution of his hands, let 
 the nurse or some other dextrous attendant unpin the 
 sheet which had been placed around the patient, and 
 draw the upper portion so far forward on the pa- 
 tient's right side, that it may be quite loose ; — directly 
 after this has been done she should unpin the band- 
 age, and seizing the lower edge of the upper of the 
 
164 DELIVERY — DUTIES OF ATTENDANTS. 
 
 three folds in wliich it had been arranged, and carry 
 it down on the bed, considerably below the seat of the 
 patient. By this time the physician or some other 
 person whose care and prudence can be relied upon, 
 may take hold of the flexed knees and assist in turn- 
 ing the patient, first on her back, and next partially 
 on her right hip, so that the bandage can be un- 
 folded and brought smoothly dowm on the back and 
 left side, at the same time that the end of the peri- 
 naeal napkin is made smooth and strait upon the sa- 
 cral portion of the pelvis ; — dry cloths being neatly 
 placed over those which were soiled during the labor, 
 the patient may be returned upon her back, gently 
 extending the limbs, the two ends of the bandage, 
 which, by this plan, will be found to adapt themselves 
 to each other, can now be overlapped on compresses 
 of greater or less thickness, as required, and neatly 
 pinned, or better still, securely laced with a strong 
 needle and large thread, as before mentioned. 
 
 Should this bandage be applied very tightly ? If 
 the uterus has well contracted into a small globe in 
 the hypogastric region, the bandage is needed only to 
 give support from without to substitute the distension 
 to which it had been subjected from within : — but if 
 the uterus appear indisposed to contract firmly, or if 
 there be any signs of hemorrhage, it will be proper to 
 draw the bandage tightly over the patient's pelvis and 
 lower part of the abdomen. 
 
 Is it important whether the bandage is pinned or 
 laced from below, upward, or in the reverse direction ? 
 Opinions and practices differ in respect to this. Some 
 thinking it an object to make the intestines descend 
 quickly towards the pelvis to the position they occu- 
 pied previous to the latter periods of pregnancy com- 
 mence the closing of the bandage upon the epigastric 
 region, and thence descend as low as they deem expe- 
 dient. Others considering the faintness which the 
 patient often experiences after delivery depends par- 
 tially, at least, upon the sudden return of the bowels 
 
DELIVERY — DUTIES OF ATTENDANTS. 165 
 
 out of tlieir places of confinement hj the recent pres- 
 sure of the uterus, begin the process of closing the 
 bandage from below the pubes upwards to the lower 
 margins of the mammae, but leaving it rather less 
 tight above than below. Whatever theories may be 
 indulged in, in this matter, the general experience is, 
 that the patient appe.ars the soonest to begin to derive 
 comfort when the upper part of the thighs are band- 
 aged first, and it is probably true, that in most cases 
 it is best to begin the tightening of the bandage from 
 below upwards. 
 
 HOW TO PUT PATIENT UP IN THE BED. 
 
 How long should the patient remain in the flexed 
 position on this part of the bed after delivery ? Un- 
 less she has been greatly prostrated by long or violent 
 labor, or by hemorrhage, it is most humane, to have her 
 placed comfortably upon the dry part of the bed which 
 had been previously prepared for her as a resting 
 place. Unless, therefore, she be in the condition 
 mentioned, or there be a deficiency of proper assist- 
 ance to slide her without the least efibrt on her part, 
 she should certainly be placed up in the position ulti- 
 mately intended for her as soon as practicable. 
 
 How may this be done with the least possible fa- 
 tigue to herself and embarrassment to the attendants ? 
 Let her be covered by a sheet or blanket, from her 
 shoulders to her feet, thrown into longitudinal folds or 
 plaits, so that in width it will just cover her person : 
 if she be a small woman and on a low bed, it may be 
 possible for a strong woman or the physician himself 
 to convey her to her appropriate place, while the 
 nurse is attending to the removal of the soiled bed and 
 sheet which were under and about her ; but if, as is 
 perhaps most commonly the case, the bed is high, it 
 will be best that the physician or the husband should, 
 with one foot on each side of the patient, and a hand in 
 each axilla, be prepared to lift the greater part of her 
 weight, and by an adroit motion carry her half way 
 
166 DELIVERY — DUTIES OF ATTENDANTS. 
 
 to the spot intended for her to occupy during the 
 first hours of repose ; the nurse, meanwhile, should 
 have laid off from the hips and limbs of the patient, 
 the sheet or blanket which had surrounded her, (keep- 
 ing her of course carefully covered by the loose one 
 which had been just placed upon her,) she should take 
 the heels of the patient in the . palm of one hand^ 
 while with the other, she should seize upon the margin 
 of all the clothes which are to be removed from under 
 the patient. At a signal understood between the two 
 persons thus employed in removing the patient, the 
 nurse assisting to place her up, quickly draws out 
 from under the patient all the clothes upon which 
 she had laid across the bed, while the other hand is 
 also aiding in sliding her up. Having by this co-ope- 
 rative movement placed her half way, or perhaps 
 rather more, towards the place for her head and 
 her hips, and having all the soiled clothes removed, the 
 nurse can now extend her left arm under the cover, 
 up the spinal column of the patient, take hold of the 
 lower edge of the folded chemise, and, at the next 
 signal given, to complete the upward movement of the 
 mother, she will find it not difficult to bring down the 
 back and the lower portion of her under-dress. 
 
 Is it not often well to leave the under garments of 
 the patient folded up for some time after putting her 
 up in bed till after the first discharges have time to 
 escape from her body ? With the consent of the pa- 
 tient, it would usually be well to allow the chemise to 
 remain for a few hours above all risk of being soiled, 
 should the napkins applied be not quite suflicient to 
 collect all which might escape. By this arrangement 
 it will also be more easy for the nurse to have access 
 to the hips of the mother to ascertain the condition of 
 the napkin, and to change it if necessary without 
 much if any disturbance to the weary woman. 
 
 What dangers may arise from close compression of 
 the vulva by the napkin ? It may arrest the discharge 
 of the blood from the vagina, plug it up by a coagu- 
 
DELIVERY — DUTIES OF ATTENDANTS. 1G7 
 
 lum, and thus obscure hemorrhage in some cases. 
 The cloth should therefore be applied loosely but 
 closely to the vulva. 
 
 What position is most comfortable for the patient 
 when she is carried up into the place intended for her 
 to lay in after delivery ? She mostly prefers to lay 
 on the left side with her limbs partially flexed, and 
 her head on a pillow of moderate height ; and it will 
 contribute to her comfort to have a pillow placed along 
 her back so as to support her loins and shoulders. 
 
 What other attention should she next receive ? 
 The nurse having adjusted the body, bed and head- 
 dress comfortably, she should be supplied with some 
 cool drink or light nourishment. 
 
 May she rise up in bed to take it ? She should not 
 be allowed to rise up for any purpose for several days 
 after her delivery. Her drinks and fluid nourish- 
 ment should be given her from a spout-cup or a tube, 
 or by a spoon. 
 
 ATTENTIONS TO BE GIVEN TO THE CHILD. 
 
 Which should be attended to first after delivery, 
 the mother or child ? Circumstances will necessarily 
 determine, whether attention may not be given to 
 both simultaneously, if there be sufficient assistance 
 in the room, or whether mother or child shall have 
 the precedence of the care of those present — gene- 
 rally the child will suffer little or no inconvenience by 
 remaining wrapped warmly, until after the mother 
 shall have been fully attended to, while perhaps, in 
 most cases, it would be unsafe to withdraw all atten- 
 tion from the mother for the sake of washing and 
 dressing the child as soon as it is born. 
 
 WASHING THE CHILD. 
 
 Should the practitioner pay attention to the mode 
 of washing the child ? He should carefully superin- 
 tend this process. 
 
 How should" the nurse get rid of the sebaceous mnt- 
 
168 DELIVERY — DUTIES OF ATTENDANTS. 
 
 ter which raostlj covers it ? By the free application 
 of unctuous matter, the best of which is animal oil, 
 as lard, &c. 
 
 What kind of soap should be used ? It should be 
 mild, bland, and not strongly alkaline. 
 
 Should the nurse use brandy, &c., on all occasions? 
 It is by no means necessary on all occasions. It 
 need not be used unless the child is in a very feeble 
 or asthenic state. 
 
 Cannot the child's skin be made clean, in many 
 cases, without the use of water at the first washing ? 
 In many and perhaps in most instances, the free ap- 
 plication of lard upon every part of the surface of 
 the child will so completely detach all the matter 
 which was adhering to it, that it can be wiped per- 
 fectly clean afterwards, by a fine sponge, or soft flan- 
 nel cloth. It is probable that by the general adoption 
 of the plan of making the first ablution of the child 
 with lard simply, it would suffer less than it often 
 does by the use of water and soap, which evaporates 
 so rapidly as to chill the surface greatly, unless the 
 nurse be very careful in drying and wrapping it up, 
 as she performs the duty in this way. 
 
 DRESSING THE UMBILICAL CORD. 
 
 How should you dress the cord ? Take a piece of 
 linen about six inches square, cut it in a central hole, 
 through this draw the umbilical cord, then fold this 
 linen up in such a manner as to envelope the cord 
 completely, keeping its cut extremity directed toward 
 the child's chin. A more simple method, and one 
 which we prefer to this, is, to take a piece of linen 
 about four inches wide and ten long, and cut into the 
 middle of one of its extremities, a slit about an inch long. 
 Holding the cord at right angles with the body, this 
 slit is to be drawn from above downward, to fit closely 
 to the root of the cord. This is then to be turned 
 up toward the chin, one of the lateral portions of the 
 linen is to be turned over in front of it, and then the 
 
DELIVERY — DUTIES OF ATTENDANTS. 169 
 
 other in the same manner. Next raise the upper end 
 of the cord, and fold these three layers of linen un- 
 der it, until there will thus be seven thicknesses of the 
 linen interposed between the cord and the teguments 
 of the abdomen. The balance of the linen folds, if 
 any, may be brought down in front of the cord. It 
 will in this manner be sufficiently isolated from the 
 body of the child, and the dressing can be easily 
 renewed if necessary. Over this, as in the other case, 
 a roller of flannel, just wide enough to reach from the 
 axillae to the hips, is to be fastened. 
 
 What is the object in thus enveloping the cord ? 
 To prevent the contact of it, as a putrefying mass, 
 with the surface of the abdomen, and thus causing 
 great irritation of the skin. 
 
 USES OF THE BANDAGE UPON THE BODY OF THE CHILD. 
 
 What is the principal object of the belly-band or 
 roller ? Merely to support the cord in its proper situ- 
 ation, and retain the dressings upon it. 
 
 How long should this bandage, binder, or roller be ? 
 Merely sufficient to encircle the body once and over- 
 lap to be secured by pinning or stitching. 
 
 Should you allow the nurse to pin the roller tight ? 
 It should never be pinned so tight as to interfere 
 with muscular motion, whether respiratory or other- 
 
 DRESSING THE CHILD. 
 
 How, in other respects, may the child be dressed ? 
 According to the desire of the mother or friends, 
 provided the clothing be such as to keep the child 
 sufficiently warm, and allow it sufficient freedom of 
 motion. 
 
 Are any cautions necessary for the nurse to observe 
 
 in reference to the diaper or napkin for the child's 
 
 hips ? The nurse should be careful that the diaper 
 
 should not be so thick and so stiff as to keep the limbs 
 
 15 
 
170 DELIVERY — DUTIES OF ATTENDANTS. 
 
 too widely separated, or too much excluded, or that 
 the mass of it be too heavy for the newly born 
 child ; the napkin should therefore be made of soft 
 old materials, and as nearly as can be calculated, be 
 of size and thickness merely sufficient to receive the 
 small quantities of meconium and urine the child may 
 discharge in the course of only a few hours before it 
 may be convenient to change it. 
 
 PRESENTATION OF THE CHILD TO THE MOTHER. 
 
 If the mother have been put up carefully and com- 
 fortably in bed, as soon after delivery as could be 
 done after the proper adjustment of her napkin and 
 bandage, and have had time to repose while you were 
 superintending the cleaning and dressing the child, 
 what should be your next duty in the lying-in cham- 
 ber ? To receive the child from the lap of the nurse, 
 to hold it, until she shall have cautiously opened the 
 bosom of the mother and prepared the nipple of the 
 lower breast, for its application to it, — then allowing 
 the mother a few moments to embrace her offspring, 
 put it so closely to her side that its head may repose 
 upon her lower arm, and that its mouth may embrace 
 and suck the nipple. 
 
 Why not allow the nurse to give it some butter and 
 sugar, some molasses and oil, molasses and water, or 
 sugar and water, or a little of its mother's food, as a 
 table spoonful or two of gruel, panada, or cracker- 
 victuals ? Because none of these things are ever neces- 
 sary for a child just born, and in nearly every in- 
 stance in which improprieties should be indulged in, 
 the child would be subjected to great suffering, from 
 incapacity to assimilate such food. 
 
 How long should the child be permitted to remain 
 drawing the nipple ? If the mother be strong, if she 
 have a firm well developed nipple, no inconvenience 
 will probably result to her from allowing the child to 
 draw at it for several minutes, whether there be any 
 milk in the breast or not ; but if the nipple be ten- 
 
DELIVERY — DUTIES OF ATTENDANTS. 171 
 
 der, the mother nervous, irritable, and the efforts of 
 the child excite violent uterine contractions, it should 
 be taken from her and placed in a soft warm bed by 
 itself, that both it and the mother may be allowed to 
 have repose in sleep. 
 
 If the child cry much, and the mother has no milk 
 in her breasts, how should it be treated ? Under such 
 circumstances it may be proper to allow the nurse to 
 give it a few tea-spoonsful of simple water, or water 
 with a little sugar in it, or perhaps a little milk to 
 which an equal quantity of boiling water has been 
 added, and allowed to cool. 
 
 ADMISSION OF COMPANY INTO THE LYING-IN ROOM. 
 
 When would it be proper to admit company, as 
 members of the patient's family, relatives or intimate 
 friends into her room ? Certainly not until she shall 
 have recovered from the fatigue of her recent effort, 
 and the iihmediate dangers of her puerperal condition 
 — the first certainly requires several hours, and the 
 last mostly several days. 
 
 DUTIES OF PHYSICIAN AND NURSE TOWARDS THE 
 PATIENT'S HUSBAND. 
 
 What regard should be paid to the husband during 
 the labor and at the time of delivery of his wife, and 
 the birth of their child ? If he be a prudent man, 
 of good moral force, competent to comfort, encourage 
 and aid in sustaining his wife through the conflict of 
 parturition, and to calm and compose her in the ex- 
 citement or ecstacy to which she is often subject upon 
 delivery, it will in most cases be the duty of physi- 
 cian and nurse to make his presence acceptable during 
 the whole time it is expedient for the physician him- 
 self to remain with the patient, inasmuch as the con- 
 jugal relation, strictly interpreted, would enjoin the 
 parties mutually to assist each other, at this as well 
 as any other period of matrimonial life. Since, how- 
 ever, the accidents and dangers to which the woman 
 
172 DELIVERY— DUTIES OF ATTENDANTS. 
 
 is subject during this and its immediately succeeding 
 eventful epoch, are often of the most important charac- 
 ter, it is requisite to place the management of the 
 case in charge of some one, who, by proper training, 
 ought to possess capability for acting in emergencies 
 which may occur in this condition, manifold more 
 wisely than the ordinary citizen, wdiatever his general 
 intelligence. The husband, whether present or ab- 
 sent, must regard the physician and nurse as substi- 
 tutes, or attorneys to whom is deputed the entire con- 
 trol of the affairs of the chamber and nursery for the 
 time being — and his conduct should be regulated by a 
 high sentiment of propriety, or by the suggestions of 
 the physician. Doubtless every husband who pos- 
 sesses the proper attributes of a man, will desire to be 
 in or near his wife's apartments during the diversified 
 conflict of body and soul to which she will be subject, 
 during the hours of labor, and at the moment of child- 
 birth ; but whether he shall be actually present during 
 the whole of this period, may be a question of expe- 
 diency to be settled mutually by her, himself and the 
 physician. The latter to whom is, or ought to be de- 
 legated the responsibilities of the case, under such 
 circumstances, must have a scrupulous regard to the 
 introduction of a properly co-operative influence, or 
 the exclusion or removal of any which, in his opinion, 
 may prove detrimental to the safe conduct of the 
 affair. 
 
 Is it proper that the husband should be introduced 
 into the room, by the time the mother and the child 
 are placed together in the bed ? It is due to the hus- 
 band, first that he* should have the satisfaction of 
 realizing the happy termination of his anxieties, and 
 in the next place it is due to the nurse and to the pa- 
 tient that an opportunity should be aff'orded to her of 
 having the instructions of the physician respecting the 
 hygienic treatment of the mother and child made 
 in the presence of the husband and father that he may 
 fully understand, and co-operate in executing them. 
 
DELIVERY — DUTIES OF ATTENDANTS. 173 
 
 TREATMENT OF THE PATIENT IMMEDIATELY AFTER 
 DELIVERY. 
 
 Should you keep the patient in the horizontal posi- 
 tion for several days ? This should be done to avoid 
 the risk of hemorrhage or of prolapsus, &c. 
 
 What kind of diet may she be allowed ? Very 
 light — as gruel, panada, barley water, toast Avater, 
 crackers, &c. 
 
 What kind of drinks should she have, and at what 
 temperature should they be administered ? Cool, 
 simple drinks. If feverish, water with sweet spirits 
 of nitre. 
 
 AFTER-PAINS. 
 
 Is the woman subject to pains subsequent to de- 
 livery ? Most women recently delivered, except 
 some of those with their first children, have at- 
 tacks of spasmodic uterine pain, a short time after 
 delivery. 
 
 What is their character ? They are spasmodic, al- 
 ternate, and neuralgic. 
 
 What is the usual cause ? Some think they are 
 owing to the presence of coagula in the uterus. 
 
 Do they ever depend upon the particular condition 
 of other organs ? They sometimes no doubt depend 
 upon certain conditions of the stomach, bowels, and 
 even bladder. 
 
 Should you always inquire into the cause before 
 prescribing for them ? This should be done with 
 much care, as the indication of treatment differs 
 greatly. 
 
 How should you treat them, when they depend 
 upon the condition of the nervous system? They 
 should be allayed by anodynes, the best of which are 
 camphor, morphia, &c. 
 
 Should you ever direct warm injections for the re- 
 lief of after pain ? Whenever they appear to depend 
 upon the existence of any irritation in the bowels, as 
 tiatu'encc, faeces, &c. 
 
 15* 
 
174 DELIVERY— DUTIES OF ATTENDANTS. 
 
 Are there any cases in which vascular depletion be- 
 comes useful ? Whenever there is a plethoric or fev- 
 erish condition of the system. 
 
 Is it ever necessary to evacuate the bladder by the 
 catheter ? It is necessary to ascertain the condition 
 of the bladder, and if full, relieve it by the catheter. 
 
 Are there any cases of misplaced after pains ? 
 When pains attack the region of the coccyx, the 
 knee, other joints, they may be so considered. 
 
 How would you treat this variety ? By the free 
 use of anodynes. 
 
 Are after pains ever dependant upon the want of 
 tonic contraction of the uterus ? They probably 
 mostly depend upon inefficient contraction of the ute- 
 rus ; and are, therefore, to be obviated by procur- 
 ing the complete contraction of the organ. They are 
 often prevented, or if they occur, may be often re- 
 lieved by free, long continued friction over the uterus 
 soon after delivery. It is also strongly recommended 
 by some teachers to examine the vagina and os uteri, 
 and if there be coagula in them carefully to turn 
 them out. 
 
 USUxVL CHANGES IN THE CONDITION OF THE PUERPE- 
 RAL WOMAN. 
 
 What duties does the accoucheur owe to the puer- 
 peral woman during several consecutive days after her 
 parturient effort ? He should inform himself through 
 the medium of the nurse respecting the condition of 
 the uterus as evinced by the frequency or severity of 
 the after pains ; he should ascertain the condition of 
 the bladder, and if the patient has not been relieved, 
 within ten or fifteen hours after the delivery, he 
 should, if necessary, draw off the urine by a catheter. 
 
 URINE. 
 
 How long can a patient be left without passing her 
 water ? Some patients after delivery have retained 
 the urine for thirty-six or more hours without much 
 
DELIVERY — DUTIES OF ATTENDANTS. 175 
 
 pain or inconvenience, while some others feel occasion 
 to p.ass large amounts of fluid from the bladder shortly 
 after delivery. As the rule of conduct of the physi- 
 cian he should satisfy himself by enquiry whether or 
 not she suffers any inconvenience in this respect ; and 
 if she do, he should, if he think it safe, encourage 
 her to make the effort in the horizontal or partially 
 inclined position, while he is in another room. If she 
 fail to urinate, he should afford her aid by a catheter. 
 If, however, she feels neither inconvenience from re- 
 tention, nor desire for relief, it may be safe to delay 
 the use of instrumental means for a few hours longer. 
 
 LOCHIA. 
 
 What is the usual amount of lochia during the first 
 twenty-four hours after delivery ? While it is very 
 variable in different cases, and even in the same pa- 
 tient at different times after delivery, it may perhaps, 
 be taken for an average, that she will have an occasion 
 to employ the nurse to remove six napkins well filled 
 during the first six hours ; four during the second ; 
 two in the third, and one in the last six of the 
 twenty-four hours after delivery. 
 
 What diminution will probably take place during 
 the next twenty-four hours ? She will probably re- 
 quire upon an average one napkin every six hours. 
 
 MILK. 
 
 What is the usual condition of the lactiferous ap- 
 paratus of the woman recently delivered ? It is va- 
 riable — some women having the gland in an active 
 state, and secreting milk freely, while in many this 
 function remains dormant for two, three, four, or five 
 days after the birth of the child. 
 
 What changes of condition does the patient usually 
 experience upon_the effort of the glands to secrete 
 milk ? Diminution, or temporary suspension of the 
 lochia, more or less chilliness, with flushes of heat — 
 sometimes a real shivering fit, followed by violent fc- 
 
176 DELIVERY — DUTIES OF ATTENDANTS. 
 
 ver, with severe headache, pain in the back, &c., fol- 
 lowed by perspiration and fulness of the breasts, or 
 the free flow of milk from the nipples. 
 
 TORPOR OF THE BOWELS. 
 
 What IS the usual condition of the bowels of the 
 puerperal woman ? They are usually torpid for sev- 
 eral days, especially till after the milk is secreted. 
 Upon the establishment of this function they some- 
 times act spontaneously, but in many patients they 
 require to be aided by some means. 
 
 GETTING UP. 
 
 When may the patient get up from her bed after 
 parturition ? In relation to the precise time when a 
 patient may venture to resume the upright position 
 no settled rule can well be established, and the physi- 
 cian having charge of the case must determine after 
 due consideration, when he can instruct or allow the 
 nurse to take the patient from her recumbent to an 
 upright position. However urgent the patient, nurse 
 or friends, may be to withdraw all restraint to her 
 getting about soon, and however numerous the cases 
 they may cite in which such indulgences have been 
 tolerated with impunity, it is certain that too many 
 dangerous and even fatal consequences have ensued 
 upon premature rising from or even in the bed to ex- 
 cuse the physician in countenancing much latitude in 
 this respect. Women who have risen upon their el- 
 bows to embrace their husbands upon their introduc- 
 tion into the chamber after delivery — women, who 
 have been prompted by their attendants to rise while 
 the bed and personal clothing were changed — women, 
 who with a determination to sit upon a chamber-vessel 
 to urinate shortly after parturition, and women also 
 who have at the recommendation of nurses sat up in 
 bed for the purpose of evacuating something which 
 caused a nisus in the perinoeal region, have forfeited 
 their lives or their health, for this departure from ap- 
 
DELIVERY — DUTIES OF ATTENDANTS. 177 
 
 propriate conduct after their organs have undergone 
 the rapid changes incident to parturition. It ought, 
 therefore, to be a part of the physician's duty to keep 
 a vigilant eye to the condition of his patient, to deter- 
 mine as to the time when, as well as the manner in 
 which, she is to be gotten out of, or even lifted up in 
 bed. Whenever practicable it should be the rule of 
 duty to keep her in bed till her milk is fairly secreted, 
 and the free discharge of the lochia has somewhat 
 abated, and the soreness and stiffness have entirely 
 subsided and she is quite able to turn herself from one 
 side of the bed to the other. After this, which will 
 usually require from four to five days, she might be 
 allowed to sit upright in the bed, or possibly be lifted 
 from one bed to another till both the bed and her body 
 clothing have been thoroughly changed. From this 
 period, if no accident have happened, it will be proper 
 to allow, encourage, or direct her to sit up in bed, not 
 only to nurse her child, but to make her ablutions and 
 take her food not only for longer periods, but also more 
 frequently. By the eighth or ninth day, she mostly may 
 with safety be allowed to be seated in her arm chair, 
 and to recline backwards, or to sit quite upright, for 
 an hour or two at a time. After the lapse of one or 
 two days spent in this training and testing her condi- 
 tion, she may be assisted by some one to walk a little, 
 and shortly after having acquired sufficient strength 
 by these means, she may begin gradually to resume 
 her household duties. 
 
 USUAL CONDITION OF THE CHILD DURING THE FIRST 
 FEW DAYS AFTER ITS BIRTH. 
 
 What is the usual condition of the child during the 
 first few days of its birth ? In the early hours of its 
 extra-uterine life it is most inclined to remain flexed 
 upon one side nursing or sleeping, expressing no un- 
 easiness, except when its clothes bind it too tightly or 
 its diaper has become wetted or soiled. In a sufficient 
 number of cases, the child will be found to cry more or 
 
178 DELIVERY — DUTIES OF ATTENDANTS. 
 
 less, even when there are no apparent causes of dis- 
 turbance, and both mother and nurse become so an- 
 noyed or distressed by it as to be tempted to resort to 
 some artificial means of quieting it by giving it warm 
 teas, as those of catnip, aniseed, &c., or under an impres- 
 sion that it is hungry, will feed it with gruel, bread and 
 water, or boiled crackers, &c., neither of which can be 
 suitable food for it. 
 
 STATE OF BOWELS. 
 What changes do its alvine discharges undergo ? At 
 first they are dark, have the consistence of tar, or 
 thick molasses ; in the course of two or three days they 
 often become greener, thinner, and interspersed with 
 yellow specks, and shortly after it can get a full supply 
 of milk, they become almost uniformly yellow. The 
 child while these changes are taking place is usually less 
 disposed to sleep, often expresses much uneasiness, and 
 even sometimes sufiers greatly from colic, or tenesmus, 
 and diarrhoea. 
 
 CONDITION OF SKIN. 
 
 What changes does its skin undergo ? In a day or 
 two after birth the skin often presents a straw or or- 
 ange color, even the adnata become tinged, but com- 
 monly, when the intestinal secretions assume the pro- 
 per yellow and consistent appearance, this yellowness 
 of the skin subsides. Very frequently in the course 
 of a few days after birth the skin becomes covered in 
 places with a miliary eruption, but still more com- 
 monly the exanthem is in red or yellow patches, a va- 
 riety of cutaneous affection technically called strophu- 
 lus intertinctus, or in nursery language red gum or 
 red gown. 
 
 DECADENCE OF THE CORD. 
 
 When does the umbilical cord usually separate from 
 the umbihcus or navel? The period of the complete 
 decadence of the cord is variable, ranging from two 
 
LABOR — PELVIC PRESENTATIONS. 
 
 179 
 
 days to more than two weeks. Perhaps the average 
 time required for the sloughing away of this extran- 
 eous matter is about five days. 
 
 What is the usual condition of the umbilicus itself 
 at the time of the falling, off of the cord ? In most 
 cases which have been properly nursed, the umbilical 
 surface exhibits a moist slightly red appearance which 
 dries up, and is covered by a skin in a few more days. 
 
 SECOND CLASS OF PRESENTATIONS— PRESENTATIONS OP 
 THE PELVIC EXTREMITY OF THE FETAL ELLIPSE. 
 
 What may be regarded as the second class of pre- 
 sentations of the fetus in utero ? That in which the 
 pelvic pole of the fetal ellipse offers to the os uteri 
 while the cephalic pole is at or near the fundus of the 
 organ, as shewn in fig. 69. 
 
 Fig. 69. 
 
 Why are they unfavorable for the mother ? Because 
 of the usual delay in the first and second stages of 
 the labor, and the consequently greater amount of 
 physical exertion which is necessary for her to com- 
 plete it. 
 
 Are pelvic presentations to be regarded as danger- 
 
180 LABOH — PELVIC PRESENTATIONS. 
 
 ous for tlie child ? Thcj are to be so regarded, be- 
 cause of the liability of the head to be arrested in the 
 pelvis of the mother, after the body is extruded. 
 
 Why are they more dangerous for the child ? Be- 
 cause during the second stage, the child is far more 
 liable to be fatally compressed, both as regards the 
 cord, and the delay of respiration while the head is 
 within, and the body without the uterus. 
 
 DIAGNOSIS OF PELVIC PRESENTATIONS. 
 
 How are you to diagnosticate breech presentations? 
 The OS uteri and bag of waters are not quite so large 
 as in the cephalic presentations ; the finger can usually 
 detect a sulcus between the limbs ; sometimes, also, 
 the genital organs can be felt, but a still more con- 
 clusive evidence presents, when in passing up the fin- 
 ger, you can feel the crista of an ilium and the fold in 
 the groin. 
 
 Does the presence or the absence of the meconium 
 afford any value in the diagnosis ? Usually it does 
 not, because it is not always present in pelvic presen- 
 tations ; whereas it is sometimes found deposited with- 
 in the inferior portion of the ovum in some cases of 
 cephalic presentation. 
 
 What is the first change which the uterus effects 
 upon the form of the child in cases of breech presen- 
 tations ? Still greater flexion into the form of an el- 
 lipse. 
 
 DIFFERENT POSITIONS OF PELVIC PRESENTATIONS. 
 
 What are the different varieties or positions of the 
 pelvic presentations ? For all practical purposes four 
 are sufficient, but some teachers m"ake six, taking the 
 sacrum for the occiput, and the posterior part of the 
 thighs for the anterior fontanelle into comparison. 
 
 What then is the first position of the breech presen- 
 tations ? The sacrum to the left acetabulum, and the 
 posterior part of the thighs to the right sacro-iliac 
 symphysis. 
 
LABOR — PELVIC PRESENTATIONS. 
 
 181 
 
 What the second ? The sacrum to the right acetab- 
 ulum, and the posterior part of the thighs to the left 
 sacro-iliac symphysis. 
 
 What the third ? The sacrum to the symphysis, 
 and the posterior part of the thighs to the sacrum of 
 the mother. 
 
 What the fourth ? The sacrum to the right sacro- 
 iliac symphysis, and the posterior part of the thighs 
 to the left acetabulum. 
 
 What the fifth ? The sacrum to the left sacro-iliac 
 symphysis, and the posterior part of the thighs to the 
 right acetabulum. 
 
 What the sixth ? The sacrum to the sacrum, and the 
 posterior part of the thighs to the pubes of the mother. 
 
 MECHANISM OF THE LABOR IN PELVIC PRESENTATIONS. 
 
 What is the mechanism of labor in the first position 
 of breech presentation ? The uterine contractions 
 compress the ovum, complete the fetal ellipse, force 
 down the bag of water, and after rupturing them, they, 
 with the aid of the accessory powers, cause the child 
 to descend through the pelvis in the direction of Carus' 
 curve. 
 
 How does rotation take place 
 in this case ? The left hip is car- 
 ried along the right anterior in- 
 clined plane, and the right along 
 the left posterior to the median 
 line of the sacrum and coccyx. 
 
 In what direction does flexion 
 take place after the hips are de- 
 livered ? Laterally, to accommo- 
 date the body to the axis of the 
 pelvis. Fig. 70. 
 
 Does restitution of the hips take 
 place ? In many cases this does 
 occur to some extent. 
 
 Which hip comes under the symphysis pubes in the 
 first position ? The left hip. 
 16 
 
182 LABOR — DUTIES OF PHYSICIAN AND NURSE. 
 
 WHAT TO DO WITH THE CORD. 
 
 "When the body is delivered as far as the umbilicus, 
 what attention should you give to the cord ? Draw 
 out a fold of it to prevent it from being put too forci- 
 bly upon a stretch. 
 
 Fig. 71. 
 
 Suppose you find it compressed, how should you 
 manage it? Endeavor to raise up the part which com- 
 presses it, then carry the cord to a part of the pelvis 
 in which there will be more space. 
 
 HOW TO MANAGE THE BODY WHEN EXTRUDED. 
 
 In what direction should the body of the child be 
 carried, to favor the ready engagement of the head in 
 the inferior strait ? In all the anterior varieties of 
 pelvic presentation, the body should be properly 
 wrapped in a napkin, and carried towards the front 
 of the abdomen of the mother. In the posterior va- 
 
LABOR — DUTIES OF PHYSICIAN AND NURSE. 183 
 
 rietles, the body is in the same manner to be carried 
 towards the sacrum of the mother. 
 
 Do the shoulders rotate in the uterus at the same 
 time that the hips rotate in the pelvis ? They are be- 
 lieved to remain fixed in the uterus until forced down 
 into the pelvis, after which they obey the law which 
 compels them to rotate on the inclined planes. 
 
 How^ are the shoulders delivered ? One of them 
 passes on the anterior inclined plane, to appear under 
 the arch of the pubes, wdiile the other passes along the 
 posterior inclined plane, to appear in front of the 
 coccyx. 
 
 Which arm or shoulder is usually delivered first ? 
 That which passes over the sacrum ; though this rule 
 is not invariable. 
 
 What effect has the rotation of the shoulders upon 
 the neck of the child ? It twists the neck of the child 
 one-eighth of a circle. 
 
 • Does restitution of the shoulders take place after 
 they are delivered ? It does, unless some resistance 
 be applied to the body. 
 
 Is it important that the head should present in a 
 particular direction, for its safe delivery ? It is highly 
 important that the head present its mento-occipital 
 diameter, to the axis of the pelvis. 
 
 What hazard may result if the practitioner draw 
 forcibly on the body of the child, as soon as it is de- 
 livered ? The direction of the head may be so altered 
 that the mento-occipital diameter, instead of corre- 
 sponding with the axis of the pelvis, becomes thrown 
 across, to correspond with one of its diameters, and 
 thus its delivery would be impracticable. 
 
 In what direction would the unaided efforts of the 
 uterus and abdominal muscles, force down the head 
 after the body is expelled ? Generally with its mento- 
 frontal, or mento-occipital diameter to the axis of the 
 pelvis. 
 
 Is there any difference in the mechanism of the se- 
 cond position of the breech ? There is uo essential 
 
184 LABOR — DUTIES OF PHYSICIAN AND NURSE. 
 
 diflference except that the rotation takes place in an 
 order reversed from that in the first position ; that is, 
 the right hip and shoulder rotate on the left anterior, 
 and the left hip and shoulder on the right posterior 
 inclined plane, and the occiput on the right anterior 
 inclined plane. 
 
 What is the usual mechanism of the labor in the 
 third position of the breech ? Although the breech 
 may engage with the sacrum to the pubis at the supe- 
 rior strait, the hips and shoulders are mostly twisted 
 upon the inclined planes, and thus come down ob- 
 liquely, and finally present one to the coccyx, and the 
 other to the pubes at the inferior strait. 
 
 Is the head in any greater danger of being arrested 
 at the superior strait in the third, than in either the 
 first or second positions ? The mento-occipital diame- 
 ter may become wedged in the antero-posterior diame- 
 ter of the superior strait, and thus require manual or 
 instrumental assistance to disengage it. 
 
 What is the mechanism of the fourth position of the 
 breech ? Here the sacrum is to the right sacro-iliac 
 symphysis, the right hip toward the right acetabu- 
 lum, and the left one toward the left sacro-iliac sym- 
 physis ; as the child descends, the left hip is carried 
 down the left posterior inclined plane, and the right 
 hip down the right anterior inclined plane to the arch 
 of the pubes ; the shoulders follow the same route, the 
 occiput is driven down along the right posterior in- 
 clined plane to the middle line of the sacrum and 
 coccyx, to escape at the posterior commissure of the 
 vulva. 
 
 What is the principal difficulty in this case, and that 
 of the fifth and sixth positions ? The liability of the 
 head to become arrested at the superior strait in con- 
 sequence of the chin being carried up by the forced 
 curvature of the thorax. 
 
 SUBDIVISIONS OF PELVIC PRESENTATIONS. 
 How are pelvic presentations divided ? Into regu- 
 
LABOR — DUTIES OF PHYSICIAN AND NURSE. 185 
 
 lar and irregnlar presentations — or into breech, feet, 
 and knee presentations. 
 
 Which of these are regarded as irregular and unfa- 
 vorable ? Those of the feet and the knees. 
 
 Is there any essential diiference in the cases of 
 presentation of the feet and breech ? There is nothing 
 essential in the mechanism of the labor, except that as 
 the first stage is shorter, the second is usually more 
 protracted. 
 
 Is the child subjected to any greater risk of its life 
 in this than in breech presentationa ? It is so, in con- 
 sequence of the degree of compression of the body, tho- 
 rax, and neck, which are compressed by the soft parts 
 of the mother. 
 
 Why are the shoulders likely to be delivered with 
 greater difficulty in this than in breech cases ? Because 
 as the feet or knees make their exit through the os 
 uteri before it is much dilated, and then meet with 
 little resistance to their descent in the pelvis, the os 
 uteri is liable to embrace the arms and shoulders, and 
 thus prevent their ready descent. 
 
 How are knee presentations calculated ? 
 
 The anterior part of the legs compare with the oc- 
 ciput or the nape of the neck, and the anterior part 
 of the thighs with the anterior fontanelle in cephalic 
 presentations. 
 
 What is the best direction to be given to the patient 
 during the first stage of labor in reference to her 
 bearing down ? As it is desirable to prolong the first 
 stage of labor in all the pelvic presentations, espe- 
 cially in these cases, she should be urged not to bear 
 or force down. 
 
 Suppose you find her strongly disposed to do so, 
 what precautions should you take not to allow the 
 membranes to be ruptured too early ? Oblige her to 
 lie down ; if she have intestinal or vesical irritation, 
 calm them by anodyne enemata ; if she cough, tran- 
 quillize it by some suitable anodyne. 
 
 When you diagnosticate any of the pelvic prescn- 
 16* 
 
186 LABOK — DUTIES OF PHYSICIAN AND NURSE. 
 
 tations, should you make any effort to deliver the 
 child while it is yet in the uterus ? Never, unless 
 some accident should complicate the labor, as convul- 
 sions, hemorrhage, &c., and then, not unless the os 
 uteri be sufficiently dilated. 
 
 When the hip descends should you be careful to as- 
 certain whether it rotates ? Although rotation of the 
 hip is of less importance than that of the occiput, yet 
 it is proper that you should secure the rotation of the 
 hip as it passes through the pelvis. 
 
 Should you use any traction effort on the child at 
 this time ? None whatever ; it would be generally 
 safer for you to retard the descent of the child, that 
 the OS uteri may become freely dilated. 
 
 Should you support the perinseum at this period ? 
 You should ; not so much however to prevent its being 
 lacerated as by this means to delay the descent of the 
 child. 
 
 Should you do any thing more than to support the 
 child, and the perinaeum at this time ? Nothing more 
 than this ; no traction should be made on any part of 
 the child, unless it be to assist rotation. 
 
 What duty devolves upon the practitioner in con- 
 ducting a labor in which the feet or knees present ? 
 Those which are similar to what is required in the 
 management of breech presentations, taking care in 
 every variety of such presentations not to interfere 
 Avith any portion of the child which is in utero, unless 
 there be some mechanical embarrassment to its de- 
 livery. 
 
 What is an important rule, in reference to feet 
 cases ? Not to facilitate the descent of the feet until 
 the first stage is completed. 
 
 Suppose the heels of the child are situated in con- 
 tact with the breech, should you pull down the feet ? 
 No ; you should retard the delivery in the first stage, 
 keeping up the feet, to allow the breech, &c., to de- 
 scend and dilate all the soft parts. 
 
LABOR — DUTIES OF PHYSICIAN AND NURSE. 187 
 
 MEDICINE AND SURGERY OF THE LYING-IN-CHAMBER. 
 
 Of what principles of the healing art, is the prac- 
 titioner of midwifery to avail himself, in the manage- 
 ment of difficult labors ? Both medical and surgical 
 principles, viz. : those which are strictly medical, by 
 which he is to overcome difficulties by the use of 
 agents generally administered internally; and those 
 which are strictly surgical, i. e. manual or instrumental ; 
 in which the obstacle is overcome, or aid rendered 
 by the hand alone, or by the hand and appropriate 
 instruments. 
 
 What circumstances may complicate labor, and 
 render medical or surgical aid, or both, necessary ? 
 Rigidity of the os uteri, or of the external organs, or 
 of both; hemorrhage from some part of the body, 
 particularly from the uterus ; convulsive movements 
 of the nervous and muscular systems ; inertia 
 of the uterus, &c. ; mal-positions of the fetus ; de- 
 formities of the pelvis ; the existence of tumors withiu 
 it, &c. 
 
 What has the accoucheur to do in these cases ? To 
 temporize and use medical means in the cases of 
 rigidity, but he must use the hands or instruments, or 
 both, in the other varieties of complications. 
 
 What is the character of the medical means to be 
 used ? Such as overcome rigidity when it exists, and 
 such as stimulate the uterus when necessary. 
 
 What is the character of the surgical means to be 
 used ? That which modifies the position, or presenta- 
 tion of the child, or expedites the delivery of it and 
 the placenta, when necessary, and that which pre- 
 vents or corrects accidents to the woman and child. 
 
 What are the operations by the hand called ? Ma- 
 noeuvres or manipulations. 
 
 What complications of labor require the use of the 
 hand to aid in its termination ? Those in which there 
 are deviations of position: and those in which hemor- 
 rhage, or convulsions occur. 
 
188 MEDICINE AND SURGERY 
 
 What function docs the hand usually perform ? 
 The correction of the presentation or position; ver- 
 sion, &c. 
 
 HOW TO ASSIST FLEXION. 
 
 Under what circumstances may you facilitate the 
 progress of the head through the pelvis ? Provided 
 flexion is not complete, you may apply the finger 
 against the side of the forehead, (not on the fonta- 
 nelle,) and pushing it up, facilitate the flexion. 
 
 Which finger should be used ? The index of 
 the left hand, for the first and fifth positions, and 
 that of the right hand for the second and fourth 
 positions, especially if the patient be on her back. 
 
 Is this the only manner in which you can accom- 
 plish this flexion ? In some cases it may be even bet- 
 ter to apply one or two fingers to the occiput with 
 a view to bring it down. 
 
 Would you then employ the same fingers? It would 
 then be more convenient and eff"ective to use those of 
 the right hand in the first and fifth, and those of the 
 left hand in the second and fourth positions, while 
 the patient remains on her left side. 
 
 VECTIS OR LEVER. 
 
 Could any instrumental means be brought to aid 
 or substitute the hand for assisting flexion, and rota- 
 tion ? The vectis or lever has for many years been 
 employed to aid, or substitute the hand in changing 
 deviated positions of the head. 
 
 What kind of instrument is the obstetric lever, or 
 vectis ? It is intended mainly as a substitute for the 
 better action of a single hand, whenever that hand 
 cannot be well applied to the parts upon which the 
 change is to be effected. 
 
 What is the usual form of the vectis ? Although 
 since the days of Roonhuysen, the supposed inventor, 
 in the early part of the eighteenth century, the vec- 
 tis has undergone many modifications in form, and pro- 
 
OF THE LYING-IN CHAMBEIl. 
 
 189 
 
 bably also in the mode of use, that commonly pre- 
 ferred at present is represented in 
 
 Fig. 72. 
 
 The whole instrument is twelve inches long ; the 
 handle four and a half, the rounded part of the shank 
 is two and a half inches, while the expanded and 
 concavo-convex clam occupies the remaining five 
 inches. 
 
 There are still to be found in the hands of some 
 practitioners the vectis with a clam at each end, one 
 of these clams is usually smaller than the other, for 
 introduction, in some cases, in which the pelvis is 
 contracted, or for the purpose of disengaging a pes- 
 sary from the vagina. This form is shown in 
 
 Fig. 73. 
 
 The original frona which the drawing was made 
 measures ten inches. 
 
 MANNER OF USING THE VECTIS OR LEVER. 
 
 What is the correct method of using the vectis or 
 lever ? The first principle to be borne in mind is 
 that the concave surface of the instrument is to be 
 adapted to the convex surface of the child's head. 
 
 What is probably the simplest rule for the hand in 
 which it is to be held, for introducing it to its pro- 
 per place on the head of the child ? It will be most 
 expedient to hold it in that hand which according to tho 
 
190 MEDICINE AND SURGERY 
 
 rule for making version or rotation of the head, is not 
 employed in the vagina, that is, since in the first and 
 fifth positions of the occiput, when the woman is on 
 her back, it is expedient to pass the left hand into 
 the vagina for rectifying deviation, causing rotation, 
 or assisting flexion, so it will be proper in these 
 cases to hold the vectis in the right hand, while the 
 left is used as a guide for it to its place, and the op- 
 posite hand will be found best to be used in the 
 second and fourth positions. 
 
 HOW TO EFFECT ROTATION OR CONVERT ONE POSI- 
 TION INTO ANOTHER. 
 
 How should you assist rotation, if the fetus require 
 ti? If, in the first position, by passing the index 
 finger of the right hand over the left parietal protu- 
 berance, and press from behind forward ; or what may 
 be better, introduce the index finger of the left hand, 
 to the right temple of the child, and press it from 
 above downwards. If in the second position, the 
 left finger is to be used on the right parietal, or the 
 right on the left temporal bone. If in the fourth 
 position, with a view to facilitate rotation into the 
 hollow of the sacrum, the left index finger is to be 
 applied to the left parietal bone, or the right to the 
 right temporal bone. If in the fifth position, to 
 rotate to the sacrum, the right index to the right 
 parietal bone, or the left index ^o the left temporal 
 bone. 
 
 Suppose you are not certain of your diagnosis at 
 this stage of the labor ? Do nothing until you are 
 certain both of the diagnosis, and indications. 
 
 Should you attempt to convert a third, into a 
 first or second position of the vertex ? Yes ; when- 
 ever possible. 
 
 Suppose flexion does not take place, how could you 
 assist it ? By passing one or more fingers up under 
 the arch of the pubes and applying it over the occi- 
 put aad drawing it down, or by passing up two fingers, 
 
OF THE LYING-IN CnAMBER. 191 
 
 one oti each side of the frontal bones, and pressing 
 them backwards and upwards. 
 
 When you find some difficulty in converting the 
 third into the first or second, how should you pro- 
 ceed? Pass in the hand, and carry up the whole 
 head during the absence of pain and then convert it. 
 
 In reference to the first or second position, how 
 far back may the occiput be, to justify our consider- 
 ing it still a first or second position ? Yery far 
 back when still high in the pelvis. 
 
 Are transverse, or occipito-iliac positions rare? 
 They so rarely occur, as not to have a place in most 
 systems of midwifery. 
 
 Does the occiput or the vertex enter the superior 
 strait readily in the posterior varieties ? It usually 
 enters the superior strait, more readily than when it 
 is anterior. 
 
 What is the usual difficulty in the case in the course 
 of the labor ? That of getting the flexion to take 
 place, to a sufficient degree. 
 
 How should you assist the flexion ? By pressing 
 against the forehead, or by passing a finger into the 
 rectum, and drawing the occiput forward if it cannot 
 be reached through the vagina. 
 
 Why is the peringeum in greater danger in this than 
 in other cases ? The occiput is applied to it with 
 more force because of the increased size of the cir- 
 cumference of the head. 
 
 What do some scientific and experienced accou- 
 cheurs think a good rule in all cases of occipito-poste- 
 rior position, if diagnosticated early ? Always to 
 direct the occiput toward the anterior part of the pel- 
 vis, which must pass through it in such cases. 
 
 • How would you convert a fourth into a second posi- 
 tion ? By pressing against the pubal side of the face 
 with a finger of the right hand, or upon the sacral 
 side of the occipital and parietal bone with the fingers 
 of the left hand. 
 
 How would you convert a fifth into a first position ? 
 
192 MEDICINE AND SURGERY 
 
 By pressing against the face, temple, or cheek; or 
 against the sacral side of the occiput with the finger 
 of the left hand in the first, and of the right hand, in 
 the second instance. 
 
 What theoretical objection might be suggested 
 against this practice of artificial conversions ? That 
 the oblique position of the child originally, may make 
 it necessary that the neck be twisted more than one- 
 third of a circle. 
 
 What is the result of experience on the subject ? 
 That no injury does arise from the practice. 
 
 What conversions should you make of the sixth 
 position ? Into a fourth or fifth position ; this con- 
 version is sometimes spontaneous. 
 
 What should you do with the occipito-left, and 
 occipito-right iliac, or left and right transverse posi- 
 tions ? Always strive to favor the conversion of the 
 first into an occipito-left, and the second into an occi- 
 pito-right acetabular position. 
 
 VERSION BY THE HEAD. 
 
 What do you mean by version by the head ? That 
 movement by which the head is restored from a devi- 
 ated to a proper position. 
 
 What is meant by version by the vertex ? That 
 movement by which a deviation of a vertex presenta- 
 tion is corrected, or reconverted to a true and favor- 
 able vertex presentation. This term applies especially to 
 the correction of deviated positions of the head simply, 
 while version by the head, usually means the bringing 
 of the head to the axis of the pelvis when some other 
 part of the child has been presenting. 
 
 What is the rule in reference to the hand which 
 must be used ? That which corresponds in name to 
 the name of the side to which the occiput presents. 
 
 DIFFERENT STEPS OF THE PROCESS. 
 
 What are the different steps of the operation? 
 First, lubrication of the hand and soft parts ; next, 
 
OF THE LYING-IN CHAMBER. 193 
 
 the dilatation of the genital fissure and vagina; then 
 the passage of the hand into the os uteri ; next the 
 seizing of the head ; and lastly, its version. 
 
 How are you to dilate the vulva ? By the gradual 
 introduction of the hand in a conical shape, with the 
 point of the thumb bedded between the fingers. 
 
 What position should the hand be in ? In a state 
 of semi — supination. 
 
 What is this movement technically called ? Intro- 
 duction. 
 
 In what condition of the patient are you to make 
 this introduction ? During a pain. 
 
 In what position are you to carry the hand when 
 introduced ? In that of supination. 
 
 What general direction are the thumb and fingers 
 to assume ? Thumb towards the face, fingers towards 
 the occiput. 
 
 In what condition of the patient are you to make 
 the rest of the manoeuvre ? In the absence of a pain. 
 
 How do you seize the head ? First, place your 
 hand against the presenting part, push it up in the axis 
 of the superior strait, and slide your hand under it to 
 beyond the middle line of the occiput — then embrace 
 the head, extend the thumb on the sinciput, and carry 
 the chin over to the iliac fossa, opposite to that in 
 which the occiput is situated ; then let it descend. 
 
 How should the other hand be employed at this 
 time ? It should be applied over the fundus of the 
 uterus, to support it properly. 
 
 What are the objections to this version by the 
 head ? The difficulty of seizing the head. 
 
 PRESENTATIONS OF THE ANTERIOR FONTANELLE. 
 
 Do cases of presentations of the anterior fonta- 
 nelle, to the centre of the pelvis, ever occur in prac- 
 tice ? They are sometimes met with. 
 
 How does this happen ? In consequence of the 
 head being carried down in a state of extension in- 
 stead of flexion. 
 
 17 
 
194 MEDrCINE AND SIRGERT 
 
 What diameters present to the pelvis in this case ? 
 The occipito-frontal, and bi-parietal diameters. 
 
 What diameter corresponds with the axis of the 
 superior strait ? The trachelo-bregmatic diameter. 
 
 Does this deviation ever become spontaneously cor- 
 rected as it descends ? It is believed that it might be 
 hazardous to rely upon spontaneous correction of this 
 deviation, though this may possibly occur. 
 
 Suppose, however, the occiput becomes arrested at 
 the linea-ilio pectinea, what is the consequence ? The 
 head becomes locked in the superior strait, cavity, or 
 inferior strait of pelvis. 
 
 Would such a state of things render delivery im- 
 practicable ? It would, unless the pelvis be very large, 
 or the head very small. 
 
 What practice should you adopt to prevent the oc- 
 currence of this difficulty, if you see the patient 
 early ? If the os uteri be sufficiently dilated, to en- 
 able you to carry up one or two fingers sufficiently 
 fiir, you may push up the forehead and let the occiput 
 descend. 
 
 Does the head, when so deviated, engage less readily 
 in the superior strait, than those in which the vertex 
 presents ? There are two causes of delay in the de- 
 scent of the head in deviations of this kind ; first, 
 because this position of the head offers a larger sur- 
 face to the OS uteri, and therefore cannot pass through 
 it so readily ; secondly, the occipito-frontal diameter 
 cannot readily descend in the superior strait, while 
 the thickness of the walls of the neck of the uterus is 
 added to it. ^ 
 
 When are these deviations mostly recognized ? 
 When the head has come down into the cavity or infe- 
 rior strait of the pelvis. 
 
 What indications have we to fulfill when the head 
 has descended into the inferior strait in either of these 
 positions ? The movements of flexion, and if necessary, 
 rotation. 
 
 How are you to make tlie restitution in this case ? 
 
Oi' THE LYING-IN CHAMBER. 195 
 
 Pass up your finger, and arrest the descent of 
 the head until the occiput comes down, or act on 
 the side of the forehead with the fingers of the ap- 
 propriate hand. 
 
 If the fingers do not succeed, what would be the 
 next best step of procedure ? If there be room, pass 
 up the entire hand into the pelvis, and then- seize the 
 head to carry its chin up to the thorax, and let the 
 occiput descend. 
 
 Is it indifferent which hand is used in these cases ? 
 By no means, since to provide against embarrassment 
 in this operation as much as possible, it will be found 
 best always to use the hand of which the palm would 
 always readily look toward the face of the child — 
 thus if the woman were lying on her back, and the 
 deviation was from the first, or occipito-left acetabular 
 position, the left hand should be used — also in similar 
 deviations from the fifth position — while in deviations 
 from the second and fourth positions, the right hand 
 should be used. 
 
 What is the manner of direction of either hand to 
 be used ? First, compress the fingers into a conical 
 form, then during a pain pass it entirely within the 
 vulva till the points of the fingers touch the child's 
 head ; next, as soon as the contraction subsides, pass 
 the fingers around the sacral side of the head, fairly 
 upon the occiput, spreading the thumb at the same 
 time upon the sinciput, as far as possible towards the 
 forehead, carry the head so embraced, a little way, if 
 possible, clear of the superior strait, and at the next 
 moment, by an adducting motion of the hand upon 
 the wrist carry up the mental and depress the occipi- 
 tal pole of the head — retain it in this position till a 
 contraction forces down the head with the occiput 
 fairly on one of the inclined planes. 
 
 What should the introduced hand perform at the 
 same time, if the occiput be posterior ? So rotate it 
 as to cause it to engage on one of the anterior inclined 
 planes. 
 
196 MEDICINE AND SUllGERY 
 
 How should the other hand he employed at the 
 same time ? In giving proper support to the uterus 
 by being expanded on the abdomen over the fundus 
 of the uterus, and assisting to correct a right or left 
 lateral obliquity if any exists. 
 
 TRY TO USE THE LEVER. 
 
 Suppose you cannot succeed with your fingers or 
 hand, what should you do ? Try to fix the lever upon 
 the occiput, and pressing up the forehead with the 
 finger, bring down the occiput. 
 
 Should you do this in the absence of a pain? 
 This is the only time in which you could expect to 
 succeed. 
 
 If the head descend into the cavity, how should you 
 manage it ? Pass in your lever under the sacral side 
 of the occiput, and effect flexion and rotation at the 
 same time. 
 
 Suppose the head has descended into the inferior 
 strait, how should you do ? It is desirable still to 
 make restitution if possible, and bring the occipito- 
 mental diameter into relation with the axis of the pel- 
 vis, and with this view it has been proposed to pass 
 one or two fingers into the anus, and press the head 
 through the recto-vaginal wall, into its proper relation 
 with the pelvis, and then let it come down. 
 
 OBLIQUITY OF THE UTERUS— PROBABLE CAUSE OF 
 DEVIATION. 
 
 Do the obliquities of the uterus probably ever con- 
 tribute to cause these deviations ? It is believed that 
 they do. 
 
 Is the head in these deviations more likely to be 
 arrested in the third, than in other anterior varie- 
 ties ? This opinion is entertained by some accoucheurs. 
 
 What practice should be resorted to, to correct the 
 deviation in these cases ? Push up the head, rotate 
 it partially, push up the forehead and allow the occiput 
 to descend. 
 
OF THE LYING-IN CHAMBER. 197 
 
 Can you use the lever to any advantage ? Yes, if 
 properly applied, you may effect both flexion and ro- 
 tation with it and the fingers. 
 
 Is this a proper case for the forceps ? No, not 
 while the deviation continues. 
 
 When the deviation takes place to a still greater 
 extent, what kind of presentation have we ? Presen- 
 tation of the face. 
 
 PRESENTATION OF THE FACE. 
 
 What diameters present to the pelvis in face presen- 
 tations ? The fronto-mental and bi-malar, apparently 
 — though really, the trachelo-bregmatic and bi -parie- 
 tal diameters, when the chin presents or rotates ante- 
 riorly. 
 
 What part presents to the centre of the pelvis ? 
 The root of the nose. 
 
 Fig. 74. 
 
 Does much embarrassment occur in all cases of face 
 presentation ? It does so when the sinciput is ante- 
 rior in consequence of the occiput being thrown back- 
 ^-ards upon the spine of the child. 
 17* 
 
198 
 
 MEDICINE AND SURGERY 
 
 Fig. 75. 
 
 Is delivery impracticable in that case ? It is 
 nearly always so, if the child has its usual proportions. 
 Suppose the chin presents to the anterior parts of 
 the pelvis, is delivery equally impracticable ? Spon- 
 taneous delivery is practicable, and the child may be 
 readily born alive. 
 
 What is the reason of this, 
 since in all other cases of dor- 
 sum of the child to the spine 
 of the mother is regarded 
 less favorable than when the 
 dorsum is anterior ? In this 
 case it is true, there are 
 many inconveniencies ; but 
 as the chin descends near- 
 ly in the axis of the pel- 
 vis, the sinciput is accom- 
 modated in the hollow of the 
 sacrum, the trachelo-bregma- 
 tic diameter nearly corres- 
 ponds to the occipito breg- 
 matic diameter as in cases of 
 original occipital presentation ; as the head descends, 
 the chin appears under the arch, while the front part 
 of the neck is forced strongly against the posterior 
 part of the p.ubes, and this part of the throat becomes 
 as it were, the centre of motion as the head is driven 
 forward ; to have first the chin, next the face, then 
 the forehead, and lastly the sinciput, pass successively 
 over the perinseum. In consequence of the small 
 depth of the pelvis at the symphysis, the back part 
 of the head and the top of the thorax, are less forci- 
 bly engaged in the superior strait at the same time 
 in this case, as must happen in the case of those po- 
 sitions in which the bregma comes under the arch of 
 the pubes, (fig. 77.) 
 
 Are the face presentations to be regarded as ren- 
 dering delivery impracticable ? Not when the chin 
 rotates under the arch of the pubes. 
 
or THE LYING-IN CHAMBER. 
 
 199 
 
 Fig. 76. 
 
 Can the face enter the superior strait when the 
 chin presents to the sacrum of the mother ? It 
 can enter the superior strait 
 without much, if any difl5- 
 cultj. 
 
 What obstacle offers to 
 the delivery of these cases? 
 When the chin is turned to- 
 wards the sacrum, it may 
 be said that we have the 
 occipito-bregmatic diameter 
 of the head, and the dor- 
 so-sternal diameter of the 
 upper part of the thorax, 
 attempting to pass down 
 into the space of the sacro- 
 pubal diameter of the pelvis. 
 Under such circumstances, it is impossible for the 
 occipito-mental diameter of the head to come into 
 correspondence with the axis of the pelvis ; the con- 
 vexity of the sinciput is constantly applied to that 
 
 Fig. 77, 
 
 of the inner side of the sjmiphysis pubes, while the 
 concavity of the mental, tracheal and thoracic surface ; 
 
200 
 
 MEDICINE AND SURGERY 
 
 SO to speak, is opposed to the cavity of the posterior 
 portion of the sacrum. Hence the capacity of the 
 pelvis is insufficient for the transmission of the head 
 and shoulders of the fetus in this direction, by the 
 uterine and voluntary powers of the mother alone, and 
 scarcely ever by the use of the forceps. 
 
 CLASSIFICATION OF FACE PRESENTATIONS. 
 
 How many varieties or positions of face presenta- 
 tions are recognized by systematic writers ? Usually 
 the same number as in occipital presentations. 
 
 What are the most common varieties of face pre- 
 sentations ? Presentations of the face are nearly al- 
 ways resolved into right mento-iliac and left mento- 
 iliac, by the time the face gets into the cavity of the 
 pelvis. 
 
 Can the labor in these cases be terminated spon- 
 taneously, or with slight assistance ? They can pro- 
 vided the chin comes under the arch of the pubes. 
 
 Fig. 78. 
 
 What is the mechanism of labor in these cases ? 
 First, the extension becomes as great as possible — 
 the face is then carried down, the chin rotates upon 
 
OF THE LYING-IN CHAMBER. 201 
 
 the anterior plane, until it gets under the arch of the 
 pubes : flexion then takes place until the head clears 
 the perin?eum, and the labor terminates as in an 
 occipito-posterior position. 
 
 Does flexion take place at any time during labor 
 with face presentation, chin forwards ? Not at all, 
 until the chin comes under the arch of the pubes. 
 
 Should you in all cases endeavor to assist the 
 rotation of the chin under the arch ? Always, if 
 possible. 
 
 What should you do if you find the child descend- 
 ing face foremost at the superior strait ? Ey the old 
 rule, we should make version by the feet, but under 
 the counsel of more scientific instruction, we should 
 perform version by the head, and bring down the 
 vertex, if the chin cannot be made to descend on an 
 anterior inclined plane to the symphysis pubes. 
 
 Suppose a manipulation of this kind to be admissi- 
 ble, that is, the head still high up and easily move- 
 able above the superior strait, in what direction 
 should you attempt to bring down the occiput ? Al- 
 ways at first into that opposite to that in which the 
 chin was situated, after which you must efiect rotation 
 if necessary, as already stated. 
 
 Suppose the second stage of labor be complete, and 
 the face have descended into the cavity of the pelvis^ 
 how should you act ? Endeavor to rotate the chin to- 
 wards the arch of the pubes. 
 
 Can much be done by the use of your fingers, if 
 you well understand the mechanism of labor? Much 
 may be done by these means at various degrees of the 
 progress of labor, if its mechanism be well under- 
 stood, and the accoucheur use his fingers dexterously 
 and cautiously. 
 
 Suppose you find the top of the head coming un- 
 der the arch of the pubes, and you cannot rotate it, 
 what instruments may you apply? The forceps, Avith 
 the hope of effecting delivery ultimately. 
 
 Does the introduction of these instruments require 
 
202 MEDICINE AND SURGERY 
 
 any particular care in these cases ? Great care is 
 necessary, as you are obliged to depress the handles, 
 and at the same time apply the ends of the blades 
 high above the pubes, and more or less against the 
 shoulders of the child. 
 
 What instruments are indicated in cases the forceps 
 cannot deliver ? Perforator and crotchet, &c., or 
 after the perforator and the collapse of the cranium, 
 the cranotomy forceps of Dr. Meigs. 
 
 CASES PROPER TO BE CONVERTED INTO FACE PRESEN- 
 TATION. 
 
 What deviations may we convert with advantage 
 into face presentations ? , Those in which the fore- 
 head presents, and cannot be rectified by restoration 
 to an occipital or vertex presentation. 
 
 What objections to this practice when the occiput 
 is anterior ? They would then be converted into a 
 case of impracticable labor with the face presenta- 
 tion, unless rotation could be effected by dexterous 
 manipulation. 
 
 Should you ever allow a forehead presentation to 
 continue as such when you discover it to exist ? 
 Never, if possible to correct it by reduction to an 
 occipital presentation, or an antero-mental presen- 
 tation. 
 
 What should be your rule of action in these cases ? 
 To convert the fronto-anterior position into the chin 
 presentation, and to attempt to bring down the occi- 
 put, when they are sincipito-anterior. 
 
 VERSION BY THE FEET. 
 
 What is meant by version by the feet ? That ope- 
 ration by which the hand is introduced into the ute- 
 rus, and the feet seized and brought down by it. 
 
 Which variety of version is most common in this 
 country ? Perhaps version by the feet. 
 
 Which is to be preferred, when either version by 
 the head, or by the feet, is accomplishable ? That by 
 
OF THE LYIXG-IX CIIAMBETl. 203 
 
 the head by far, as the subsequent delivery is more 
 natural and safe. 
 
 What inconveniences does the mother usually suffer 
 from an effort by the accoucheur to make version 
 by the feet ? Pain, risk of hemorrhage and the rup- 
 ture of the uterus, or other injury to it. 
 
 To what risks is the child subject, in version by the 
 feet ? It may suffer from being too severely twisted 
 upon its spine ; and also, all the inconvenience of 
 original feet or breech presentations. 
 
 Is version by the head or feet, to be resorted to 
 with a great deal of care ? It must so, and with 
 calculation of the capability of the mother to bear it. 
 
 Should you obtain a consultation on the propriety 
 of it, if possible ? You should, w^henever it is prac- 
 ticable without hazardous delay. 
 
 CONDITION OF THE MOTHER F^iVORABLE TO VERSION. 
 
 What condition of the os uteri must exist before it 
 will be admissible to perform version ? That of dila- 
 tion, or facility of dilation. 
 
 What are you to do until this state of the os uteri 
 is obtained ? Temporize by using proper medical 
 treatment if any be indicated. 
 
 ONLY WHILE THE HEAD IS WITHIN THE OS UTERL 
 
 Is it admissible to make version after the head has 
 passed the os uteri ? Never ; you should operate as 
 soon as possible after the first stage is completed. 
 
 What dangers attend any attempt at this opera- 
 tion under such circumstances, that is, when the 
 head has been driven out of the uterus ? The ute- 
 rus may be ruptured, and the soft parts within the 
 pelvis may be injured ; the child's head may also be 
 wounded. 
 
 OPERATION. 
 
 At what moment can you proceed to this opera- 
 tion with the best effect ? Directly that the first 
 
204 MEDICINE AND SURCERY 
 
 stage of labor is complete, or the os uteri suffi- 
 ciently dilated to admit the passage of the hand and 
 arm. 
 
 POSITION OF PATIENT PROPER FOR IT. 
 
 What position should the patient be placed in for 
 the purpose of making version by the feet ? On her 
 back, with her hips over the edge of the bed, and 
 her feet properly supported. 
 
 Why would you have her brought to the edge of 
 the bed ? To allow room for the ready move- 
 ments of the accoucheur in introducing his hand and 
 part of his arm and completing the manoeuvre. 
 
 How should the patient's feet be disposed of? 
 They should be placed out on chairs or any conve- 
 nient staging which may enable her to keep them on 
 a level with her hips. 
 
 POSITION OF THE ACCOUCHEUR. 
 
 What position is the accoucheur to assume for the 
 purpose of passing the hand ? One in front of the 
 patient and which is most easy to himself. 
 
 What attention should be given to the dress of his 
 person, to prepare for this purpose ? He should lay 
 off his tight coat, roll up his shirt-sleeves, then put on 
 a wrapper, or some other loose cover, with as little 
 display as possible. 
 
 How are the parts of the patient to be prepared ? 
 They should be well lubricated with some mucilage, 
 oil, or lard. 
 
 What calculation has the operator to make previ- 
 ously to passing the hand ? That by which he de- 
 termines what is the position of the different parts 
 of the child, what alteration he has to make, and 
 which hand he must use to eifect this object. 
 
 RULE FOR THE USE OF THE PARTICULAR HAND. 
 
 What is the rule for the use of the particular hand 
 in version of the feet ? Use that hand, the palm of 
 
OF THE LYING-IN CHAMBER. 205 
 
 which would correspond to the abdomen of the child, 
 and which in withdrawing it, having hold of the feet, 
 will keep the body in a state of flexion during the 
 whole process of the version, or till the limbs and 
 body are withdrawn from the uterus. 
 
 How are you to proceed to make the version by 
 the feet ? First, introduce the hand properly during 
 a pain ; next, press up the head, and pass the palm 
 of the hand along the front and on one side of the 
 child, over the whole body to the breech, then cause 
 it to descend upon the thighs and legs, and next em- 
 brace the feet, retain these in the hollow of the hand 
 until they are brought down into one iliac fossa, or 
 into the cavity of the pelvis ; then slip the index 
 finger between them, retaining the heels in the palm 
 of the hand, until they are completely beyond the 
 vulva. Fig. 79. 
 
 Fig. 79. 
 
 Can you always seize both feet in this case ? 
 Though a skilful operator can mostly do so, it is not 
 always practicable. 
 
 How must you act if you have but one foot ? Draw 
 
 18 
 
206 MEDICINE AND SURGERY 
 
 it carefully downward, in the direction of the axis of 
 the pelvis, at the same time adducting it towards the 
 other as much as possible. 
 
 Fig. 80. 
 
 How can you secure the foot drawn out, while you 
 search for the other ? Pass a noose of a soft band 
 or fillet upon it, and let the loose extremities of the 
 fillet remain out of the vulva. 
 
 Is it always necessary to reach the second foot ? 
 It is neither always necessary nor proper to search 
 for this, if it is not easily found. 
 
 What rule should be observed in reference to bring- 
 ing the back part of the feet to the anterior part of 
 the pelvis ? Always to do this, because of the much 
 greatej facility of subsequent delivery of the head. 
 
 How is this to be effected ? By acting upon the 
 pubal leg more than on the other. 
 
 Into what position of the feet do you change a first 
 cephalic position ? To the second, and not to the 
 fourth position of the feet. 
 
 How are you to do this ? By acting most on the 
 pubal leg, and abducting it from the other. 
 
 Into which position should you bring the feet, 
 when you use your right hand for version ? First 
 position. 
 
OF THE LYING-IN CHAMBER. 
 
 207 
 
 In which position does the left hand bring down 
 the feet ? Into the second position of the feet, as 
 seen in fig. 81. 
 
 Fig. 81. 
 
 WHEN TO ACT ON THE BREECH ONLY. 
 
 Suppose you were to find when you had decided 
 that version of the child was necessary, that the 
 ovisac had been ruptured, the waters drained off, and 
 the uterus was pressing on the fetus, by powerful 
 tonic contractions, would you deem it expedient to 
 overcome this resistance by a forcible attempt to un- 
 fold the feet, at the risk of increasing the transverse 
 diameter of the excited organ, at least three inches ? 
 The propriety of such a proceeding would be at least 
 doubtful, and it would probably be more appropriate 
 
208 MEDICINE AND SURGERY 
 
 to attempt the version by causing the hand employed 
 within to act upon the breech only, while the hand 
 without should by a well-directed movement aid in 
 causing the pelvic pole of the fetus to descend to- 
 wards the pelvis of the mother. 
 
 WHAT TO DO WITH THE CORD. 
 
 What should you do when you have delivered the 
 body as far as the umbilicus ? Draw out a fold of the 
 cord of sufficient length, to prevent it from being 
 ruptured, as shown in 
 
 Fig. 82. 
 
 Is it necessary for you to continue to aid the deli- 
 very of the child, after you have made version or 
 mutation ? It is usually necessary, at least to such 
 an extent as enables you to assist the proper rotation 
 of the hips, shoulders, and head. 
 
 If you find the arms do not descend with the body 
 
OP THE LYING-IN CHAMBER. 
 
 209 
 
 Fig. 83. 
 
 of the child, can you do any thing to encourage their 
 descent ? Suspend the tractive effort, resist for a few 
 moments, the descent of the body, and let the uterus 
 force down the arms if possible. 
 
 Suppose however this does not occur, how are you 
 to act to get down the arms ? Carry the body side- 
 wise, so as to admit of the introduction of the fingers 
 up to the elbow, and bring down first the sacral, and 
 next the pubal arm, in the proper direction for flexion 
 at the elbow. 
 
 Is there any rule as to 
 the hand, which should be 
 used in bringing down the 
 shoulders ? It will be found 
 more convenient, and is 
 certainly more appropriate 
 to use the right hand for 
 bringing down the right 
 shoulder, and vice versa. 
 
 In what way can you 
 best adapt the hand to 
 cause it to occupy the 
 least possible space, while 
 performing this part of 
 the operation? Spread the 
 palm upon the scapular 
 and the axillary space of 
 the thorax, so that the 
 thumb will be directed to- 
 wards the vertebral co- 
 lumn, while one or two fingers are spread upon the 
 humerus, to be flexed as soon as their points reach 
 the middle joint of the arm. 
 
 Which way are you to direct the movements of the 
 arm ? Always over the anterior portions of the child's 
 head, thorax, and abdomen. 
 
 Suppose the arms are locked behind the occiput of 
 the child, how would you disengage them ? . Press up 
 the head during the absence of a pain, and with the 
 18* 
 
210 
 
 MEDICINE AND SURGERY 
 
 points of your finger, carry the elbow over the side 
 of the head and face, and then over the thorax. If 
 you cannot succeed with your fingers, use the blunt 
 hook, as a lever for this purpose. 
 
 If the trunk and arms be thus delivered, and 
 the head is found to be arrested in the pelvis, 
 what steps should be taken to secure its speedy de- 
 livery ? Reposing the body of the child on an arm, 
 quickly but dexterously, insert one or more fingers, 
 over the chin of the child to its mouth, upon this 
 draw till the head is disengaged, or till the chin de- 
 scends as far as possible upon the neck or thorax ; if 
 this does not succeed in a very short time, pass two 
 fingers upon the zygomatic processes of the malar 
 bones, and draw down forcibly, while with one or 
 more fingers of the other hand push up the occiput 
 with a view to get the mento-occipital diameter of 
 the head to correspond as nearly as possible with the 
 axis of the pelvis, as seen in fig. 84. 
 
 Fig. 84. 
 
 What other benefit might accrue to the child if the 
 fingers of 4he accoucheur were skilfully applied upon 
 its face in case the delivery of the head could not be 
 
OF THE LYING-IN CHAMBER. 211 
 
 instantaneously effected ? By such attentions the 
 child is often enabled to respire freely, and its con- 
 dition rendered safe, though it, the mother, and the 
 attendants are still compelled to be in a very uncom- 
 fortable situation. 
 
 What instrumental aid would be indicated in case 
 of failure of success in attempts to deliver the head 
 by the hands alone ? The vectis or lever, might pos- 
 sibly be of service to assist in getting the head into 
 proper relations with the maternal pelvis, but the for- 
 ceps, and possibly the perforator also, should be most 
 relied upon if the extraction could not afterwards be 
 effected by the manual exertions. 
 
 SHOULDER PRESENTATIONS. 
 
 What do we mean by shoulder presentations ? They 
 are presentations of the upper parts of the sides of 
 the body, and are probably originally deviations 
 from cephalic presentations. 
 
 Fig. 85. 
 
 CLASSIFICATION OF SHOULDER PRESENTATIONS. 
 
 What number of presentations of the shoulders 
 are there? Two of the right and left shoulders, 
 each. 
 
 What points of the mother and child, do we take in 
 
212 MEDICINE AND SURGEEY 
 
 our diagnosis? The pubis and the sacrum of the 
 mother, and the dorsum of the child. 
 
 How do you diagnosticate the shoulder presenta- 
 tions ? By the presence of a tumor, on one side of 
 which is a smooth elastic surface, the side of the neck ; 
 on another a slender bone, the clavicle ; on the oppo- 
 site side a broad plate of bone, the scapula ; between 
 these a number of small ridges, the ribs ; mostly, and 
 more important, a small cylindrical body, an arm, ly- 
 ing parallel to a larger one. 
 
 What is the value of the hand of the fetus in the 
 diagnosis of shoulder presentations ? It may assist 
 considerably in making up the diagnosis. By some 
 practitioners it has been advised to bring down the arm 
 to determine the position. We are persuaded, how- 
 ever, that this practice is rarely if ever necessary. 
 
 Should we be very precise in our calculation of the 
 exact relative position of the back and the pelvis ? 
 As it probably rarely happens, that the dorsum of the 
 child is applied to the pubes with as much accuracy as 
 the occiput is to the left acetabulum, &c., we have to 
 take, as a general statement, the nearest approxima- 
 tion to it in our practice. 
 
 POSITIONS OF THE SHOULDERS. 
 
 What are the positions of the shoulders ? Dorso- 
 pubic, and dorso-sacral, of the right and of the left 
 shoulders. 
 
 Can spontaneous delivery ever take place in cases 
 of shoulder presentations ? Never while they con- 
 tinue as shoulder presentations, provided the child be 
 at or near the term of its development. In some very 
 rare instances, the uterine and voluntary contractions 
 have effected such mutations in the position of the 
 child as to expel it with one of the extremities, usually 
 the pelvic, presenting. 
 
OF THE LYING-IN CHAMBER. 
 
 213 
 
 SPONTANEOUS VERSION. 
 
 What is this mutation called ? Spontaneous evolu- 
 tion, or spontaneous version. 
 
 What is to be understood by spontaneous version ? 
 That movement by which the body of the child, origi- 
 nally unfavourably situated, becomes changed in such 
 a manner as to present one of the extremities (espe- 
 cially the pelvic) of the ellipse, that it can enter and 
 pass through the pelvis, aided by the powers of the 
 mother alone. 
 
 How do you explain the law 
 by which this change is ef- 
 fected ? As already mentioned, 
 it depends probably upon the 
 flexibility of the fetus, and 
 upon the direction of the ute- 
 rine forces aided by the con- 
 tractions of the abdominal 
 muscles. 
 
 What is the probable pro- 
 portion of cases of spontane- 
 ous version, in shoulder pre- 
 sentations ? It has been 
 rated at one case of sponta- 
 neous version, to one thousand 
 cases of shoulder presenta- 
 tions. 
 
 ALWAYS RECTIFY DEVIATED PRESENTATIONS IF 
 POSSIBLE. 
 
 Should you ever wait for spontaneous version, in 
 any cases of shoulder presentations, or of those of the 
 lower or upper part of the body ? It would not be 
 proper to wait, if it be possible to act judiciously for 
 correcting the deviation. 
 
 Suppose you find the lower part of the body pre- 
 sent ; what is the rule of practice ? To pass in the 
 hand, and bring down the breech or feet. 
 
214 
 
 MEDICINE AND SURGERY 
 
 Suppose some portion of the upper part of the body 
 present, what should you do ? Pass in the hand, and 
 make version by the feet. 
 
 What should be the condition of the soft parts, be- 
 fore you proceed to an attempt at version? They 
 should be relaxed or dilated, to an extent sufficient to 
 avoid contusion or laceration. 
 
 When you have diagnosticated such a deviation, 
 should you endeavor to preserve the membranes till all 
 the parts are dilated ? This is proper in all cases 
 of real, or supposed deviation, until the parts are well 
 dilated. 
 
 RULE FOR THE USE OF THE HAND. 
 
 What is the rule for the use of the particular hand, 
 and its mode # introduction ? 1. That rule which 
 applies to version by the knees or feet, in all cases, 
 viz. : the hand, the palm of which, looks towards 
 the abdomen of the child, except in dorso-sacral posi- 
 
 Fig. 87. 
 
 tion of the shoulders. 2. When it is ascertained that 
 the dorsum of the child is towards the pubes of the 
 mother, the hand is to be introduced, which can be 
 
OF THE LYING-IN CHAMBER. 215 
 
 readily flexed into the iliac fossa in which the breech 
 is situated ; this will be the right hand for the breech 
 in the right iliac fossa, and the left hand in the left 
 iliac fossa. 
 
 In either of these cases, the hand is to be carried up 
 supine beyond the child or between it and the sacrum 
 along one of its sides to the breech, then along the 
 thighs to the knees or feet, which of course are to be 
 brought down, by the left hand in the second, and by 
 the right hand, in the first position of the feet or knees. 
 
 Will the same rule apply to the case of dorso-sacral 
 positions ? No : here the reverse obtains, that is, 
 in the dorso-sacral position of the right shoulder, in 
 which the breech is in the left iliac fossa, the right 
 hand must be passed up in front of the child and in a 
 semi-prone condition : while in the dorso-sacral posi- 
 tion of the left side in Avhich the breech is in the right 
 iliac fossa the left hand must be passed up in a semi- 
 prone condition between the child and the lateral 
 part of the uterus. 
 
 Fig. 88. 
 
 In passing the hand for the purpose of reaching 
 the hams or feet for version, is it proper to persist in 
 
216 MEDICINE AND SURGERY 
 
 carrying it up where there is a uterine contraction ? 
 All attempts at acting with the hand in the uterus, 
 must be suspended as soon as the contraction takes 
 place, and moreover, the hand must be expanded upon 
 the part of the child with which it is in contact at 
 that time, lest the knuckles should cause rupture of 
 the uterus or other injury. 
 
 Is it sometimes necessary to rotate the body of the 
 child on its own axis, in some of the shoulder presen- 
 tations for the purpose of getting down the feet ? This 
 is unavoidable, particularly in dorso-sacral positions 
 of either side. 
 
 Suppose the body has been under pressure of the 
 uterus, and the shoulder is wedged down in the pelvis, 
 must you act at once, or endeavor to allay the con- 
 tractions of the uterus ? It is a fundamental rule, 
 never, if possible to avoid it, to act, in attempting at 
 least the first steps of version, unless when the uterus 
 is in a state of relaxation. If therefore the tonic 
 contraction of the uterus upon the child, be such that 
 it is immoveable in the uterus, efforts must be made 
 by bleeding, warm bath, nauseants or opiates, to over- 
 come the constriction which this powerful organ exerts 
 upon its contents. 
 
 INSTRUMENTAL DELIVERY IN SHOULDER PRESEN- 
 TATIONS. 
 
 Suppose the child be dead, or you have reason to 
 believe that the mother will die if not speedily de- 
 livered, what would you do ? Deliver by the crotchet 
 or other appropriate instrument. 
 
 How would you proceed to do this ? Eviscerate the 
 .thorax by perforating it, and removing its contents; 
 then remove portion after portion of the child, as it 
 comes within reach. 
 
 Should you always favor the process of version by 
 the feet, even after eviscerating the child, rather than 
 to force the head down first ? This is preferred by 
 good authority. 
 
OF THE LYING-IN CHAMEER. 217 
 
 Suppose a hand should descend with the head, what 
 practice should you resort to ? Support it at the su- 
 perior strait while the head descends. 
 
 Should you ever make traction effort upon the arm 
 in case of its descending first under any circumstances ? 
 Never ; such a practice would always complicate the 
 difficulty of subsequent delivery. 
 
 FURTHER INQUIRIES ON THE DIAGNOSIS, AND MODE OF 
 ACTION IN CASES OF FALSE PAINS AND THE DEVI- 
 ATED POSITION OF THE CEPHALIC OR PELVIC POLE 
 OF THE FETUS. 
 
 What condition of the os uteri should be found in 
 regular labor ? It should usually be found somewhat 
 dilated ; and when a finger is applied to it during a 
 pain depending upon uterine contraction, it will be 
 found to be tightened up by being drawn as it were, 
 over the lower segment of the ovum. 
 
 Is it always easy to determine whether the patient 
 is in labor or not ? To the young practitioner it is 
 often very difficult ; even experienced accoucheurs 
 cannot always decide positivel}^. 
 
 What are the usual means of discriminating true from 
 false pains by the history of the case ? By the character 
 of the pains : true labor pains are mostly alternate, show- 
 ing a distinct interval of ease between them, while in 
 colic, or neuralgic pains, they are more irregular, and in 
 the pains attendant upon inflammation, they are more 
 constant and accompanied by more febrile action. 
 
 Suppose you had reason to conclude that the pa- 
 tient was afflicted with false pains, how should you 
 attempt to relieve them ? By recourse to efforts to 
 remove the supposed causes ; if they depended upon 
 constipation, by cathartics, or enemata ; if upon in- 
 flammatory action, by bleeding, &c. ; if upon neu- 
 ralgia or spasms, by proper anodynes, or counter irri- 
 tants, &c. 
 
 Can you always positively assure a woman that she 
 is in labor, if you find her os uteri dilated to the size 
 of a ten cent piece ? Though this circumstance, ac- 
 19 
 
218 MEDICINE AND SURGEHY 
 
 companled by pains of a more or less regular cliarac- 
 ter, may be considered as sufficient data for diagnos- 
 ticating the actual existence of labor, yet it- has hap- 
 pened to some practitioners to observe this state of 
 things in women who have subsequelitly gone from 
 one to four weeks after this, before they were delivered. 
 
 CHANGES OF POSITION OF FETUS IN THE EARLY PART 
 OF LABOR. 
 
 Is any change effected in the position of the child 
 during the early stage of labor? Great changes are 
 sometimes effected in deviated positions, even before 
 the OS uteri is well dilated, or the child driven down 
 into the lower pelvis. 
 
 How are we to account for such changes ? First, in 
 the peculiar form of the abdominal and super-pelvic 
 cavity ; and secondly, in the flexibility of the child, 
 its form is adapted to the shape of the uterus, in such 
 manner as to make its long diameter correspond to 
 that of the long diameter of the uterus, whatever this 
 may be. 
 
 Some persons have compared the fetus in utero, to 
 a cork inside of a bottle, which can pass through the 
 neck only in a certain direction, is this comparison 
 correct ? Not exactly so, as the child is more pliable, 
 yet it must finally escape only in the direction of its 
 long diameter. 
 
 When deviations of presentations of the body occur, 
 is it proper for you to wait until spontaneous version 
 takes place ? It would not be best : we should always 
 endeavor, if under favorable circumstances, to intro- 
 duce the hand, and deliver by the feet, 
 
 PRESENTATION OF THE SIDES OF THE HEAD. 
 Are you liable to meet with presentations of the side 
 of the child's head ? They may occur when there is 
 great obliquity of the uterus, or the top of- the head 
 should be arrested in a certain direction at one side 
 of the superior strait. 
 
OF THE LYING-IN CHAMBER. 219 
 
 How are you to recognize them ? By the pre- 
 sence of an ear and a portion of the coronal, or of 
 the lambdoid suture, a mastoid, or a zygomatic pro- 
 cess, &c. 
 
 How are you to correct this kind of deviation ? If 
 possible, push up the head of the child by the hand, 
 and bring it to its proper relations with the pelvis. 
 
 OTHER DEVIATIONS. 
 
 When the nape of the neck presents to the centre 
 of the pelvis, what is the indication ? To correct the 
 deviation according to the general rules already pro- 
 posed. 
 
 May it happen in practice that various parts of the 
 body, as the hip, the back, one side, &c., may present 
 to the centre of the pelvis ? However rare, they are 
 stated to have occurred. 
 
 How do these generally result in practice ? Mostly 
 in the presentation of a shoulder, or hip, or of the 
 breech or feet, &c. 
 
 Should you be much disturbed by the occurrence 
 of the third position of the breech ? Inasmuch as we 
 can have considerable command over the rotation of 
 the child's shoulders by proper manipulations upon 
 the breech, we should apprehend little inconvenience 
 from this position. 
 
 Should you interfere with it before the breech has 
 descended into the cavity of the mother's pelvis? 
 No ; it is quite unnecessary to interfere at all until 
 the breech has fairly entered the cavity of the 
 pelvis. 
 
 What should you then do ? Assist or compel rota- 
 tion on to one of the anterior planes to convert it into 
 the first position. 
 
 Is it probable that the direction of the head is mo- 
 dified by the rotation of the shoulders as it descends 
 into the strait ? This idea is entertained by some 
 who believe that in rotations of the head in cephalic 
 
220 MEDICINE AND SURGERY 
 
 presentations the shoulders are not modified by such 
 rotation. 
 
 What is the mechanism of breech presentations in 
 the posterior positions ? The contractions of the ute- 
 rus impel the right hip, (if we take the fourth posi- 
 tion as the type of these posterior varieties,) along 
 the right anterior inclined plane towards the arch of 
 the pubes, while the left hip is driven along the left 
 posterior inclined plane to the middle line of the sa- 
 crum to become the sacral hip and usually to be de- 
 livered first. The body is then carried down in a state 
 of lateral flexion, until the right shoulder is carried 
 down on the right anterior, and the left on the left 
 posterior inclined plane, to be delivered at the vulva. 
 There is then a disposition for restitution to the ob- 
 lique position which the head occupies ; that is, with 
 the spine towards the posterior part of the right 
 thigh, and the umbilicus towards the anterior portion 
 of the left thigh ; but the occurrence, or non-occur- 
 rence of this will depend upon the manner in which 
 the body is supported on the hand of the accoucheur, 
 or on the bed of the mother. As the fetus is now 
 chiefly or entirely beyond the reach of uterine action, 
 the voluntary powers of the mother mainly drive down 
 the head of the child with its occiput on the right pos- 
 terior inclined plane to pass on the perinseum, while 
 the chin, mouth, nose, eyes, forehead, and bregma 
 successively escape under the arch of the pubes. 
 
 Is it safe for you to attempt rotation in a direction 
 opposite to that which it would spontaneously take, 
 and thus convert it into an anterior position ? Some 
 practical accoucheurs think it safe and easy after the 
 shoulders are delivered. 
 
 At what part of the pelvis can this forced rotation 
 be efl'ected ? While in the cavity and not in either 
 of the straits of the pelvis. 
 
 What should you do with a sixth position of the 
 pelvis ? Endeavor first to convert it into a fourth 
 or fifth, and when the shoulders are delivered, by 
 
OF THE LYING-IN CHAMBER. 221 
 
 the aid of the finger convert the head into a first or 
 second position. 
 
 Why can we do this with greater safety than in 
 cases of original cephalic presentations ? Because we 
 are in these cases able to modify the direction of the 
 body to that in which we force the head. 
 
 DEVIATED BREECH PRESENTATIONS. 
 
 Are breech presentations liable to any deviations 
 of position ? They are : hence we may have presen- 
 tations of the loins, or either one of the ilia, &c. 
 
 Do deviations of the breech usually become recti- 
 fied spontaneously ? Usually they do. 
 
 Suppose, however, there should be great delay in 
 the" descent of the breech, should any attempts be 
 made to rectify them ? It would be proper to facili- 
 tate the delivery, by rectifying the position. 
 
 HOW TO RECTIFY THEM. 
 
 What is the rule, in reference to the use of the 
 hand in these deviated positions of the breech ? Pass 
 up that hand the palm of which will look towards the 
 abdomen of the child. 
 
 BRINGING DOWN THE FEET IN BREECH TRESEN- 
 TATIONS. 
 
 Can you ever bring down the feet to any advan- 
 tage? The advantages of this manipulation would 
 rarely be commensurate with the risk of attempting 
 it, unless the breech is high up and the child easily 
 moveable in the uterus. 
 
 Suppose it becomes necessary to bring down the 
 feet in original breech presentations, how would you 
 proceed to do it ? The soft parts being sufiiciently 
 dilated, introduce the proper hand, push up the breech 
 if necessary, then pass it along the thighs to the 
 knees, to descend upon the legs and seize the feet. 
 
 W^hich hand should you use ? That, the palm of 
 w^hich looks to the abdomen, or the back part of the 
 thighs of the child. 
 
 19* 
 
222 MEDICINE AND SURGERY 
 
 Do jou bring down the feet in the same position 
 at which the breech was situated ? This would always 
 be right, as forced rotation can in such cases, if ne- 
 cessary, be effected by acting upon the legs, when 
 they are brought down. 
 
 Suppose the labor be far advanced, and the breech 
 becomes arrested in the cavity of the pelvis, or infe- 
 rior strait, what then would you do ? Attempt to 
 bring down the breech by passing up the hand and 
 fixing a thumb in one groin and a finger in the other. 
 
 FILLET. 
 
 Suppose there was not a space sufficient for the 
 passage of the hand and breech together, what in- 
 strumental means have you? The fillet, which if 
 it can be applied, would be well adapted for this 
 purpose. 
 
 What is the fillet ? A thin strong silk ribbon, or 
 a thin linen tape of such width as to admit its being 
 passed along a fold in the ham or groin. 
 
 How is this to be efi*ected, while this fold is still 
 within the pelvis ? This instrument properly lubri- 
 cated, is to have one of its extremities doubled up in 
 numerous plaits or folds, which are to be carried upon 
 the point of the, index finger of the proper hand and 
 applied to the fold in the groin or ham ; the fillet is 
 then to be passed on the point of the finger till it is 
 found on the opposite side of the limb ; the plaits are 
 then to be drawn out at the vulva, and thus the fold 
 of the groin or ham, will be secured in it. With this 
 tape or ribbon, a very considerable degree of force can 
 be exerted and very efficient aid often rendered. 
 
 What resources have you for the application of the 
 fillet, if the fold of the ham or groin is beyond the 
 reach of the finger ? A slightly curved silver canula, 
 containing a watch-spring, with an eyelet mounted upon 
 it ; this eyelet having a small loop of strong thread 
 in it is to be carried up to the fold in the ham or 
 groin, upon the end of the canula, it is then thrust 
 
OF THE LYING-IN CHAMBER. 223 
 
 forward along the fold to appear at the opposite side 
 of the limb, the end of the fillet is to be passed 
 through this loop, the steel-spring stillet is then to 
 be retracted, and the fillet thus drawn over the groin 
 or ham, and its extremity brought within reach of 
 the hand of the accoucheur, who is thus enabled to 
 act with it. 
 
 BLUNT HOOK. 
 
 What other instrument have we for the delivery of 
 the hips ? The blunt hook. 
 
 Fig. 89. 
 
 r= 
 
 Where are you to fix it ? In the groin if you need 
 to aid descent of the breech, or in the ham if you 
 have to use instrumental assistance, in cases of pre- 
 sentation of the knees. 
 
 How is it to be prepared for use ? Properly warmed 
 and lubricated. 
 
 Is it proper to apprise the patiei^ or her friends, 
 of the necessity of its use ? With few if any ex- 
 ceptions, the necessity for all such instruments should 
 be explicitly stated, and consent obtained. 
 
 Does the introduction and use of this instrument 
 give pain to the mother ? None, if properly man- 
 aged. 
 
 Into which groin or ham, is it to be passed ? Into 
 the sacral groin or ham if possible, though it is usu- 
 ally most convenient and even better to fix it in the 
 pubal limb, while in the upper part of the pelvis. 
 
 How are you to guide the instrument to its point 
 of application? Upon the end of one or more fin- 
 gers, to the body or thigh of the child, and when 
 passed sufficiently far onward the end of the hook 
 
224 
 
 MEDICINE AND SURGERY 
 
 should be made to slide around on one of these parts 
 to the fold into which it is to be fixed. 
 
 Fig. 90. 
 
 To whom is due the credit of having, placed a 
 guard upon the blunt hook, to render traction with 
 it less hazardous to the groin or ham of the child 
 when either is too large to allow the end of the hook 
 to pass securely behind it, or to protect the mother 
 from injury when the groin or ham has to be seized 
 so high up that the point cannot be easily reached by 
 the finger? Dr. John Livingston Ludlow, of Phila- 
 delphia. 
 
 How is this guard to be applied ? First put the 
 hook on the part on which the traction force is to be 
 exerted, then carry the point of the guard to that of 
 the hook, when if the notch will w^ell adapt itself to 
 
OF THE LYING-IN CHAMBER. 225 
 
 the pivot on the shaft of the hook, it will form a loop, 
 less injurious, and more reliable than that of a fillet. 
 
 Can jou use the blunt hook to any advantage in 
 cases in which it is difficult to bring down the arms 
 of the child with the fingers ? Its use is sometimes 
 indispensable, when the finger of thei accoucheur fails 
 to accomplish the object. 
 
 In what particular case, can the blunt hook be re- 
 sorted to, for the delivery of the head, in breech pre- 
 sentations ? When it is impossible to produce flexion 
 by the hand or vectis. 
 
 How are you to use it, and where are you to fix 
 it ? First, try it in the mouth carefully, next, it may 
 be fixed upon the lower edge of the orbit. 
 
 PROLArSE OF THE UMBILICAL CORD. 
 
 Does the descent of the umbilical* cord ever com- 
 plicate labor ? It does very materially, so far as the 
 life of the child is concerned, unless the labor is very 
 rapid and speedily terminates. 
 
 How does it do this ? By the risk of pressure 
 upon the cord, and arresting the circulation through 
 it, and speedily destroying the child by suspending 
 the process of hematosis. 
 
 What is the indication in prolapsus of the umbi- 
 lical cord ? To carry it above the superior strait, 
 and let the head descend first. 
 
 How are we to retain it there ? Some attach it 
 to loops at the ends of flexible catheters, but the bet- 
 ter plan is to carry it up in a pocket, on a piece of 
 whale bone, above the superior strait, and retain it 
 
226 MEDICINE AND SURGERY 
 
 till the head fairly engages, then withdraw the whale 
 bone and leave the cord and the pocket to be deli- 
 vered after the child. 
 
 Should you expect to gain any benefit by bringing 
 down the feet, in such cases ? We think this rarely, 
 if ever advisable, as the cord would still be in dan- 
 ger. If reduction of the cord be impracticable, we 
 would employ the forceps if the head were within 
 reach. 
 
 TOO SHORT A CORD. 
 
 Can a very short cord complicate the labor very se- 
 riously ? It may slightly retard delivery in some 
 cases, but the chief inconvenience it produces is from 
 the sudden dragging out of the placenta, and some- 
 times also the uterus with it, and causing inversion 
 of that organ. 
 
 TOO LARGE A HExVD FROM HYDROCEPHALUS OR ANY 
 OTHER CAUSE. 
 
 Do preternatural enlargements of the child or of 
 its head, ever complicate the labor ? Enlargements 
 of this kind may not only complicate the labor, but 
 render it impracticable without the aid of proper in- 
 struments. 
 
 What practice is indicated under such circum- 
 stances ? Tap the child's head, evacuate the water, 
 or open the head and evacuate the brain ; complete 
 the delivery by the forceps or the crotchet, if either 
 be necessary. 
 
 Does the base of the cranium ever offer any special 
 obstacle to delivery? Rarely, if ever, provided it be 
 brought down in the proper direction. 
 
 In what direction is the base of the cranium to 
 be brought down, after the vault has been removed? 
 Always, if possible, with its facial extremity fore- 
 most. In cases in which the pelvis is of normal size 
 and this direction is easily followed, such change in 
 the position of the face is less necessary, as in many, 
 
OF THE LYING-IN CHAMBER. 227 
 
 peihaps in most, such instances, the head can pass 
 in almost any direction after the vault of the crani- 
 um has coHapsed, after the escape of the brain, or 
 even the serum from a hydrocephalic enlargement. 
 
 DOUBLETS OR TRIPLETS. 
 
 Do you consider labor with twins, as more hazard- 
 ous to the mother than single pregnancies? Not 
 often so. 
 
 Fig. 92. 
 
 Are evidences of two or more fetuses in utero con- 
 spicuous, usually? There are few, if any rational 
 signs to be depended upon as evidences of compound, 
 or twin, or triplet pregnancy. 
 
 What is the most certain means of diagnosis of 
 compound pregnancies ? Auscultation. 
 
 What must you hear to convince you of the ex- 
 istence of twins or triplets ? The sound of two or 
 more hearts, each at different parts of the uterus. 
 
 What are the principal causes which render twin 
 or triplet cases of labor more tedious ? The great 
 
228 METCDINE AND SURGERY 
 
 distension of the uterus, and the unfavorable direc- 
 tion in which the contractions fall upon either of 
 the fetuses. 
 
 Is the second stage rapid ? It is usually so, when 
 once one fetus is fairly engaged, because it is usually 
 really smaller than when it is simple pregnancy. 
 
 Is there any more danger in the third stage of 
 labor in compound, than in simple pregnancies ? In 
 consequence of the. great distension of the uterus 
 during the latter periods of pregnancy in such cases, 
 it is more liable to acquire an atonic state, and hence 
 the greater risk of hemorrhage, &c. 
 
 Are labors in twin cases, liable to become compli- 
 cated by the descent of any portion of the other child 
 when one has originally presented ? This accident 
 has been known to occur, and it is easy to suppose 
 that this complication is often liable to happen. 
 
 Suppose the head of one child, and the feet of the 
 other should engage in the pelvis at the same time, 
 how should you manage the case ? If possible, push 
 up the feet, and let the head descend ; but if not, 
 apply the forceps with a view to deliver the head by 
 the side of the feet ; if this expedient should fail, 
 it has been advised to resort to craniotomy, and em- 
 bryulcia. 
 
 What other complications may take place ? A 
 great variety ; one of the most difficult and interest- 
 ing, perhaps, is that in which as one descends, with 
 the pelvic extremity first, its chin becomes locked un- 
 der the chin of the other, which was presenting the 
 cephalic extremity, and which had gotten down into 
 the cavity of the pelvis. 
 
 How should you proceed with a view to save the 
 life of one child ? Eviscerate the child which has 
 descended, detruncate it, leave the head in the cavity 
 of the uterus, push it up above the superior strait ; 
 then deliver the second child, and afterwards remove 
 the head of the first. 
 
OF THE LYING-IN OIIAMBER. 229 
 
 OBLIQUITIES OF THE UTERUS. 
 
 Do any complications of labor occur from obliqui- 
 ties of the uterus? It is believed that many cases 
 of complication or deviation, depend upon obliqui- 
 ties of the uterus, by which its axis is thrown out of 
 a line with that of the pelvis. 
 
 In what direction do these obliquities usually occur ? 
 Laterally and anteriorly* 
 
 Do obliquities of the uterus usually correct them- 
 selves ? They mostly do by the aid of the contrac- 
 tions of the abdominal muscles ; not always how- 
 ever, until after they have caused serious deviation 
 in the direction of the presentation of the fetus. 
 
 How should you correct those deviations which 
 interfere with ready delivery ? Generally by placing 
 the patient on the part of her body opposite to that 
 to which the uterus is inclined. 
 
 Are you justifiable in making any attempt at cor- 
 rection within the pelvis ? This may sometimes be 
 done advantageously by acting on the orifice of the 
 uterus steadily, but moderately in the absence of a 
 pain, and retaining it in the acquired position during 
 the next pain, &c. 
 
 SOMETIMES DIFFICULT TO FIND THE OS UTERI. 
 
 Are there any cases in which the os uteri cannot 
 be reached by the finger at the commencement of 
 labor ? Cases of this kind have been met with, and 
 the ignorant accoucheur has been persuaded that there 
 was no OS uteri at all, and from the apparent neces- 
 sity of the case, has proceeded to make one with his 
 bistoury. 
 
 How is this occurrence to be explained ? Either 
 by the very considerable anterior obliquity of the 
 uterus, or by the very great development of the an- 
 terior portion of the neck of the uterus, or both of 
 these together. 
 
 By what plan of practice is it to be corrected ? Bv 
 20 
 
230 
 
 MEDICINE AND SURGERY 
 
 passing a bandage around the abdomen of the patient, 
 and thus compressing the fundus and body of the 
 uterus backward ; then wait until the first stage pf 
 labor is nearly completed, by which time you can reach 
 the anterior lip, which you can draw gently forward. 
 
 CAUSES ARRESTING THE HEAD ABOVE THE SUPERIOR 
 STRAIT. 
 
 How are you to account for the occurrence of cases 
 in which the head of the child, instead of engaging in 
 the centre of the pelvis, becomes arrested upon the top 
 of the pubes ? They most probably depend upon 
 great relaxation of the muscles at the lower part of 
 the abdomen, impacted feces, or pelvic tumors. 
 
 How are you to manage cases of this kind ? Make 
 pressure upon the hypogastric, or rather upon the 
 pubic region. If the case offered any unusual diffi- 
 culty, we would propose the application of a firm 
 bandage around tlie pelvis, and then urge the patient 
 to take several successive pains in a sitting or stand- 
 ing position strongly inclined forwards. In all cases 
 of impaction of feces the rectum must be cleared by in- 
 jections or instruments. 
 
 LABOR COMPLICATED WITH PROLAPSION OF THE 
 BLADDER, VAGINA, &C. 
 
 92. Do not prolapsions of the 
 
 bladder, or of the vagina or the 
 bowels, sometimes complicate 
 labor ? The progress of labor 
 may be much retarded by a 
 vaginal vesicle as shown in 
 fig. 92, by prolapsion of the 
 vagina as well as in some cases 
 by the spreading out of the an- 
 terior lip of the uterus itself 
 over the head of the child, and 
 between it and the pubcs. 
 
 How is the difficulty aris- 
 ing from either of these 
 
 Fig. 
 
OF THE LYING-IN CHAMBER. 231 
 
 causes to be overcome ? If it arise from a prolapsed 
 bladder, the urine should be drawn from it bj a ca- 
 theter if possible — afterwards it, or the vagina, or the 
 lip of the uterus must be carried upon the tip of 
 one or more fingers above the top of the pubes, and 
 there retained till a pain forces the presenting part of 
 the child below it. 
 
 DR. B'S. CASE OF HERNIA OF THE INTESTINES INTO THE 
 PERITONiEL CUL-DE-SAC. 
 
 What is Dr. Meig's description and treatment in 
 his excellent work on obstetrics, of a case of labor 
 complicated by a prolapsion or hernia of the bowels? 
 Mrs. R. was in violent labor, which had continued long, 
 but without any effect. Dr. B. requested me to visit 
 her with him. The vagina was pressed forwards to- 
 wards the symphysis pubes, by a tumor behind it, 
 filling up the excavation of the pelvis and preventing 
 the descent of the head. I learned by examination 
 that this tumor consisted of a great mass of intestinal 
 convolutions that had fallen down below the strait 
 and that was kept there by the violent tenesmus, as 
 well as by the gravid womb above it. Indeed the 
 mass was to a certain extent, incarcerated within the 
 excavation of the pelvis. The efforts of the patient 
 to bear down upon her pains were most violent, and 
 the distress accompanying them apparently intense. 
 I introduced my fingers into the lower part of the va- 
 gina, and thrusting the posteri'or wall of that tube 
 backwards, got the points of the fingers beneath the 
 tumor, which occupied the recto-vaginal cul-de-sac of 
 the peritonaeum. A little patient manipulation 
 caused portions of the gut to ascend into the abdo- 
 men, and in a short time the whole mass fled upwards 
 above the brim, whereupon the expulsive efforts of 
 the womb being no longer opposed by it, the child was 
 speedily and safely born. 
 
232 MEDICINE AND SURGERY 
 
 LABOR COMPLICATED BY LESIONS OF FUNCTION OF 
 THE NERVOUS, VASCULAR, OR MUSCULAR SYSTEM. 
 
 Are there any abnormal conditions of the patient 
 which may interfere with the function of parturition ? 
 There are many depending upon conditions of the 
 nervous, vascular, and muscular systems. 
 
 RIGIDITY. 
 
 What is the most common of these abnormal con- 
 ditions ? Rigidity of the os uteri, or perinneum, from 
 original tonicity, depending perhaps upon plethora, 
 and again in some instances the rigidity may be 
 caused by an alteration of structure, as adhesions, 
 cicatrices, &c. 
 
 What process most readily overcomes the rigidity ? 
 Increased secretion, promoted by bleeding, warm bath- 
 ing, fomentations, &c. 
 
 Does rigidity ever depend upon irritation, the cause 
 of which is direct or remote ? It may, and no doubt 
 does. 
 
 May the hand of the accoucheur ever be the cause 
 of this rigidity? By too frequent, or too roughly 
 touching the orifice of the uterus, it may become irri- 
 tated, rigid, and even inflamed. 
 
 May too early a rupture of the membranes give rise 
 to rigidity ? It is probable that in some cases the too 
 early drainage of the waters, and the pressure of the 
 presenting part upon the os uteri, may cause irritation 
 and consequent rigidity. 
 
 TREATMENT OF RIGIDITY. 
 
 By what means can the accoucheur properly expe- 
 dite the delivery under such circumstances ? By such 
 medical treatment as may diminish the vital tone. If 
 the stomach be loaded with impurities, gentle eme- 
 tics, washing out the stomach, &c. Much may be 
 done, by acting on the bowels by the warm enemata, 
 purgatives, with castor oil, &c. Bleeding is very use- 
 
OF THE LYING-IN CHAMBER. 233 
 
 ful, particularly if the patient is febrile. After bleeding, 
 nauseating diaphoretics, &c., warm injections, warm 
 fomentations to the vulva, favor relaxation. Advan- 
 tage will be derived from keeping the patient's mind 
 calm and confident. Anti-spasmodics, as assafoetida, 
 camphor, &c. ; even laudanum may be beneficially 
 employed in some cases. As local adjuvants, the 
 ointments of belladonna, stramonium, &c., may be ap- 
 plied to the OS uteri ; anodyne enemata, from sixty to 
 one hundred drops of laudanum, may be given at once, 
 after the bleeding, or purging, &c. 
 
 Is it often necessai-y to divide the bands or cica- 
 trices, to overcome the constriction? It is rarely ne- 
 cessary, in the cicatrices or adhesion of the vagina or 
 perinaeum, and scarcely ever in cases of rigidity of 
 the OS uteri, if proper medical or constitutional means 
 are resorted to. 
 
 What danger would be involved in the division of 
 the OS uteri, under such circumstances ? Extension 
 of the incisions to a degree equal to a dangerous lace- 
 ration of the uterus. 
 
 IRREGULAR CONTRACTIONS OF THE UTERUS. 
 
 May labor be complicated or retarded by irregular 
 contractions of the uterus ? It may to a greater or 
 less degree. 
 
 How are these irregular contractions diagnosticated ? 
 By the woman feeling the pain in one particular spot, 
 and by the want of expulsive effort. 
 
 Where may these spasmodic contractions occur ? In 
 various points, as the body, fundus, and orifice of the 
 uterus. 
 
 Why do we rarely have spasmodic contractions in 
 the OS uteri, in cases of regular presentation of the 
 vertex ? Owing to the fact, that the orifice does not 
 embrace the neck of the child, in consequence of the 
 manner in which its chin is applied to the thorax. 
 
 May the internal os uteri, become spasmodically con- 
 tracted ? It is believed by some accoucheurs that it may. 
 
234 MEDICINE AND SURGERY 
 
 What effect has this upon the advancement or re- 
 tardation of the child ? The child descends to the 
 superior strait, during an expulsory effort, and re- 
 cedes at once, when the voluntary powers become sus- 
 pended. 
 
 TREATMENT. 
 What is the proper practice in this case ? Vene- 
 section, anodyne injections, &c., to suspend the irregu- 
 lar actions of the uterus. Avoid turning and forcible 
 delivery merely because the delivery is delayed on this 
 account. 
 
 CONVULSIONS. 
 
 Are convulsions during parturition ever dependent 
 upon rigidity ? There is much reason to believe they 
 are sometimes dependent upon this cause, as in the un- 
 availing effort at delivery, the brain becomes the seat 
 of such degree of congestion, as determines irregular 
 or spasmodic contractions of the muscular system. 
 
 Why do you call them puerperal convulsions ? 
 Merely because the woman affected, is in a pregnant, 
 or puerperal state. 
 
 Do you consider them different from convulsions 
 which may occur in unimpregnated women ? They do 
 not differ essentially from those which may attack un- 
 impregnated women, or even nervous men. 
 
 CLASSIFICATION OF PUERPERAL CONVULSIONS. 
 
 How many varieties of these convulsions, do you 
 generally recognize ? Two ; hysterical and apoplectic. 
 
 Which is the most frequent variety? The apo- 
 plectic. 
 
 Which is the least dangerous ? The hysterical 
 variety. 
 
 Upon what does the latter variety most frequently 
 depend? Irritability of the nervous system. 
 
 . SYMPTOMS OF HYSTERIC PUERPERAL CONVULSIONS. 
 What are the general symptoms of this variety of the 
 
OF THE LYING-IN CHAMBER. 235 
 
 affection ? They are similar to the higher grades of 
 hysterical convulsions in unimpregnated women. 
 
 What effect have these convulsions upon the labor ? 
 They usually suspend it, inasmuch as there appears 
 to be a sort of metastasis of muscular contraction of 
 the uterus to that of the body generally. 
 
 SYMPTOMS OF THE APOPLECTIC PUERPERAL CON- 
 VULSIONS. 
 
 What are the symptoms of the apoplectic variety 
 of convulsions ? Those of congestion ; mostly pain 
 in the head, sometimes intense in some one spot ; there 
 is loss of vision, perversion of the hearing, &c., pulse 
 full, slow and apoplectic. Muscles of face much 
 affected ; sibilating noise ; frothing at the mouth ; 
 convulsion of the anterior muscles of the face and 
 body ; the patient sometimes falls into a comatose 
 state, and remains so, until another convulsion comes 
 on, though sometimes she promptly recovers. 
 
 What is the cause of these convulsions during 
 labor ? They are supposed to depend upon the vio- 
 lence of the uterine and general expulsive effort react- 
 ing on the brain. 
 
 What are the usual post mortem appearances in 
 cases of these convulsions ? Congestion of numerous 
 vessels in the brain and its coverings, with serous, or 
 sanguineous effusion. 
 
 Are there some cases in which death occurs, with- 
 out any effusion, or apparent lesions of the brain ? 
 There are ; and this fact is calculated to lead to the 
 conclusion, that the convulsions may depend upon 
 some other cause than determination of blood to the 
 nervous pulp within the cranium. 
 
 What effect have these convulsions upon gestation ? 
 Women who have these convulsive movements during 
 pregnancy are liable to have the fetus die in utero, 
 or to abort it before it is completely developed. 
 
 What effect has gestation upon the convulsions ? 
 Though pregnancy is not always directly a cause of 
 
286 MEDICINE AND SURGERY 
 
 these morbid movements, yet the woman, in some in- 
 stances, is subject to have them occasionally while 
 pregnant, or a repetition of them, until the child is 
 delivered either at term or prematurely. 
 
 Are the pains usually suspended upon the occur- 
 rence of convulsions ? When convulsions occur during 
 labor, the regular contractions of the uterus become 
 suspended — a mere fluttering kind of movement is 
 observed. 
 
 TREATMENT IN CASE OF CONVULSIONS. 
 
 What are you to do in reference to the condition 
 of the uterus ? Let it alone in niost cases, especially 
 during the first stage of labor. Attend to the nerv- 
 ous and vascular systems alone, and allow the uterus 
 to take care of itself. This it will usually do, if the 
 tranquillity of the nervous and general muscular sys- 
 tem can be restored. If the labor have advanced to 
 the second stage, you may sometimes deliver with the 
 forceps, if the head be low in the pelvis. 
 
 How should you treat the apoplectic variety of 
 these convulsions ? Bleed, twenty, thirty, forty or fifty 
 ounces, until you empty the blood vessels and relieve 
 the plethora ; then resort to the usual treatment for 
 apoplexy — cold to the head — mercurial cathartics, 
 &c., — active enemata — cups and leeches may some- 
 times be employed after one free bleeding. When 
 vascular depletion has been carried sufficiently far, 
 sinapisms, blisters, &c., may be used as revulsives or 
 counter-irritants. When the congestion is thus re- 
 lieved, opium or camphor may be given in combina- 
 tion with calomel and ipecacuanha, and after the system 
 shall have been properly reduced, and the disease 
 controlled, mild tonics, as valerian, &c., may be ad- 
 ministered. 
 
 Should you interfere with the process of gestation, 
 supposing it be not complete ? We think not, at least 
 not until after all the usual means of treatment have 
 been fully employed. Should the convulsions persist 
 
or THE LYINGIX CHAMBER. 287 
 
 under such. circumstances, we might consider the pro- 
 priety of premature delivery. 
 
 Are some patients incident to continued effects of 
 convulsions, or rather to a state approaching that 
 which results in convulsions ? Yes ; there often 
 remains a disposition, for congestion of the large 
 blood vessels, with great irritability of the nervous 
 system. 
 
 What is the treatment proper for such a state ? 
 Revulsion by moderate bleeding, and the use of sina- 
 pisms, &c. 
 
 INERTIA OF THE UTERUS. 
 
 What do you mean by the phrase inertia of the 
 uterus? That condition of the organ in which it 
 does not obey the instinct of contraction. 
 
 What are its general causes ? During the first 
 stage of labor, it may depend upon plethora in the 
 uterus. Sometimes it depends upon a transference 
 of the irritation from the uterus to the brain, heart, 
 lungs, &c. — sometimes upon some diseases of the 
 uterus, or general debility from phthisis, uterine he- 
 morrhages, &c. 
 
 May not inertia occur while the uterus possesses 
 a sufficient amount of power ? It may, and then it 
 merely requires to be stimulated into action. 
 
 TREATMENT OF INERTIA. 
 
 How are you to manage a case of inertia of the 
 uterus ? During the first stage of labor, but little 
 interference is necessary : we should endeavor to 
 ascertain the causes of the inertia — if plethora, 
 bleed — if constipation, purge — if from irregular dis- 
 tribution of the nervous influence, give those medi- 
 cines calculated to act upon and regulate the nervous 
 system. 
 
 How would you stimulate the uterine fibres mo- 
 derately ? By friction, by cathartics, by warm teas, 
 
238 MEDICINE AND SURdERY 
 
 How in the second stage? If the uterus be dis- 
 tended, rupture the membranes, provided the os uteri 
 be sufficiently dilated ; then act slightly upon the os 
 tincse with the finger, by a slight traction in differ- 
 ent directions. If this did not succeed we would 
 administer the ergot. 
 
 ERGOT. 
 
 Would you consider ergot as a dangerous remedy? 
 Highly so, if not very judiciously resorted to ; but 
 very important and useful in proper cases. 
 
 Why has it probably been productive of such fatal 
 effects in practice? Because it has been resorted to 
 in cases when the advancement of the child was op- 
 posed by vital resistances, as before the os uteri or 
 the perinseum was sufficiently relaxed to admit of 
 ready egress of the fetus, forcibly compressed by the 
 ergotic contraction of the uterus. Furthermore, it 
 has been productive of immense evil when adminis- 
 tered in cases of mal-position of the child, or when 
 there has been deformity or deficiency of amplitude 
 in the pelvis. 
 
 Under what circumstances can you administer it 
 with propriety ? Dilatation or relaxation of all the 
 soft parts, favorable positions, or presentations ; ab- 
 sence of any mechanical resistance at either of the 
 straits of the pelvis. It is rarely proper to administer 
 it in cases of first pregnancy, because of the tenacity 
 of the vital resistances in these cases. 
 
 What are the usual effects of the ergot upon the 
 uterine fibre ? It stimulates it to tonic contraction, 
 by which nearly every portion of it acts in the direc- 
 tion to diminish its capacity, and the whole organ, 
 therefore, acts with great and persistent force upon 
 the body within its cavity. 
 
 ERGOT SOMETIMES ITSELF INERT. 
 
 Does the ergot sometimes fail in producing such 
 effect? It does so sometimes, owing either to the 
 
OF THE LYIXG-IN CHAMBER. 239 
 
 idiosyncracy of the patient, or to the bad quality of 
 the article. 
 
 Should you ever give ergot in any cases of me- 
 chanical obstruction in labor ? There is, probably, 
 no case of this kind in which the use of ergot would 
 be proper. 
 
 HEMORRHAGE AT OR SHORTLY AFTER THE TERMINA- 
 TION OF LABOR. 
 
 To how many varieties of hemorrhage may the pa- 
 tient be incident in the latter stage of labor, from 
 inertia of the uterus ? Two, the open, and the con- 
 cealed hemorrhage. 
 
 What is the distinction between these two varie- 
 ties ? In the first, the blood flows from the uterus 
 through the vagina, nearly as fast as it escapes from 
 the orifices of the uterine vessels, and is mostly 
 readily discerned and announced by the patient her- 
 self, or may without any difficulty be detected by the 
 nurse or personal attendant. In the other variety, 
 on the contrary, the patient may not evince the 
 slightest consciousness of the existence of the efi'usion 
 from the patulous orifices, nor can the nurse or phy- 
 sician become persuaded of its occurrence until the 
 patient has fainted, the pulse has failed, or become 
 enfeebled at the wrist, or her uterus has been found 
 to have reacquired, in part, or entirely, the size of the 
 recent gravidity. 
 
 Which of these two varieties is most alarming, and 
 dangerous ? The first, usually most alarms the pa- 
 tient, by the consciousness of its occurrence, and the 
 apprehension of dangerous consequence upon it — 
 while the latter or concealed variety most per- 
 turbs the physician, because it may have reached a 
 point of extreme danger before he has been apprised 
 of it, or had it in his power to control it. 
 
240 
 
 MEDICINE AND SURGERY 
 
 MANAGEMENT OF HEMORRHAGE. 
 
 What is the first object of the practitioner in cases 
 of hemorrhage from the uterus ; in the third stage of 
 labor ? To excite the tonic contractions of the or- 
 gan, and thus cause it to close up the open venous 
 orifices. 
 
 How should he eff'ect this ? By friction ; by knead- 
 ing, as it were, upon the uterus ; by the application of 
 a cold hand, cloth, or sponge, or plate of snow, or 
 ice upon the pubic region ; by powerful compression ; 
 by the passage of a hand into the cavity of the uterus ; 
 by introducing within it a sponge saturated with vine- 
 gar, or by passing up a peeled juicy lemon ; allow- 
 ing these acid vehicles to remain until expelled by 
 the contraction of the uterus, &c. 
 
 Would you give ergot in any of these cases ? It 
 might be given if at hand, particularly if in the form 
 of tincture, though it is the experience of some prac- 
 titioners that it rarely acts in cases of great prostra- 
 tion from hemorrhage. 
 
 HOW TO PREVENT IT BY ANTICIPATION. 
 
 Knowing your patient subject to atony and he- 
 morrhage in the last stage of labor, would you give 
 the ergot in anticipation ? We would give it just as 
 the child was about to be extruded. 
 
 Would you at once remove the placenta from the 
 vagina, or leave it in until the hemorrhage is arrested ? 
 Pass our hand beyond the placenta, remove the coa- 
 gula we may meet with, and as the uterus contracts 
 allow it to come away. 
 
 What general rule should you observe in reference 
 to the mode of preventing this accident? See that 
 the different stages of labor go on regularly. 
 
 Bhould you remain by your patient until she reacts 
 after her labor ? You should never leave her till you 
 have witnessed this state. 
 
 Suppose your patient arrives at the term of gesta- 
 
OF THE LYIXG-IX CHAMBER. 241 
 
 tion, and she becomes greatly prostrated by phthisis, 
 pulmonary hemorrhage, &c., would you think proper 
 to bring on labor and expedite her delivery ? If we 
 can arrest the cause of the exhaustion, we ought to 
 wait till term ; but if she be constantly sinking, it is 
 thought better to deliver promptly, but cautiously, 
 while the patient is yet capable of furnishing the 
 means of hematosis to the child. 
 
 Suppose your patient be affected by syncope during 
 labor or pregnancy, should you generally be alarmed? 
 Not generally ; we are rather to regard it as depend- 
 ing upon a want of regular distribution of the nervous 
 influence, but usually easily managed by the use of 
 cordials and aromatic stimuli, applied externally, or 
 administered internally as the case may require. 
 
 CONCEALED HEMORRHAGE. 
 
 What is the usual process by which occult hemorr- 
 hage occurs ? The blood which escapes from the pa- 
 tulous orifices of the vessels on the inner surface of 
 the uterus, becomes coagulated at the os tincse, which 
 it plugs up — the hemorrhage, thus prevented from 
 escaping externally, goes on, and the tonic contrac- 
 tion of the uterus being absent, it distends the uterus, 
 and the quantity thus abstracted from the system be- 
 comes so great that the patient dies at once, or falls 
 into a state of syncope, from which she can be revived 
 only by the most prompt measures. 
 
 What influence has the presence of coagula in the 
 vagina in this case ? It appears to paralyse the ute- 
 rus, and thus prevent it from closing up its venous 
 orifices by tonic contraction. 
 
 What should be done in such cases ? Promptly 
 and resolutely carry a hand through the vagina into 
 the orifice, neck or body of the uterus, break up the 
 coagulum, let the fragments pass by the palm, wrist 
 and arm, detaining these in the cavity into which they 
 had been introduced, until the contractions of the 
 uterus expel them. 
 
 21 
 
242 MEDICINE AND SURGERY 
 
 How should the opposite hand be employed during 
 this time ? Most assiduously in promoting the con- 
 traction of the uterus by pressure, or the application 
 of cold, or both, upon the abdomen. 
 
 What influence would galvanism probably have in 
 promoting the contraction, arresting hemorrhage and 
 preventing its recurrence. If a suitable battery were 
 at hand it would be worthy of a trial in cases of great 
 atony of the uterus. 
 
 LABOR COMPLICATED BY LESIONS OF STRUCTURE OF 
 THE UTERUS— RUPTURE OF THE UTERUS. 
 
 To what particular accident is the uterus liable, 
 during the parturient effort ? Lesion of its structure, 
 either partially or entirely, that is, there may be a 
 separation of some portion of its tissue, or the rupture 
 may extend through its entire substance involving the 
 peritonaeum. 
 
 What are the symptoms of rupture of the uterus ? 
 A sudden suspension of the alternate contractions, 
 great prostration of strength, hurried or gasping respi- 
 ration, rapid pulse, &c. 
 
 What are the consequences of this accident ? They 
 are dependent upon the extent of the accident : the 
 patient may recover from a partial rupture, but when 
 it is complete, the result is almost always fatal. 
 
 What are the indications of the treatment in this 
 case ? If the rupture take place in the first stage of 
 the labor, gastronomy should be resorted to imme- 
 diately, with a hope to sa-ve the child, but if in the 
 second stage, version by the feet, or delivery by the 
 forceps, should be promptly effected. 
 
 Suppose the child has escaped into the cavity of 
 the abdomen, what should you do ? Placing one hand 
 externally over the situation of the child, we should 
 pass the other into the pelvis, and through the rent in 
 the uterus endeavor to find the feet, and bring them 
 down. 
 
 What if the rupture should occur in the vagina, is 
 
OF THE LYING-IN CHAMBER. 243^ 
 
 your chance of delivery greater ? It is, inasmuch 
 as in such case the opening is not shut up by con- 
 traction. 
 
 Would you think you might resort promptly to the 
 operation of gastronomy, if you could not deliver the 
 child through the natural passages ? That would be 
 the only proper course. 
 
 Does this rupture ever arise from rigidity of the os 
 uteri or perinseum,- while other parts are subject to 
 ramollissement ? It is believed that it does. 
 
 Under what circumstances would you use the for- 
 ceps or crotchet in such an accident ? In case the 
 head was still in the cavity of> the pelvis, though the 
 body had passed into the cavity of the abdomen. 
 
 BLUNDELL'S INSTRUCTIONS. 
 What are Blundell's instructions to accoucheurs in 
 reference to their duties in this momentous accident ? 
 He tells them that the management of these cases, so 
 far as they admit of management, may be given in a 
 few words. If the child have been thrown into the 
 world, the accoucheur has nothing to do but to treat 
 the patient on the ordinary principles of medicine and 
 surgery. If disruption occurring it is incarcerated 
 amongst the bones, so as to remain fixed in the pelvis, 
 though the body lies forth through the rupture, you 
 may then, properly enough, apply a pair of forceps ; 
 in this way superseding the necessity of the operation 
 of turning. When lacerations of the womb occur, how- 
 ever, it will generally be .found that the child enters 
 the peritoneal sac, the placenta immediately following 
 it, the womb emptying itself as effectually as when,it 
 expels the ovum through the pelvis. Now, by exami- 
 nation, this ventral lodgement of the pelvis is easily 
 made out, and when ascertained, it then becomes your 
 office to remove the coat, raise the sleeve of your 
 shirt, to lubricate the hand, and to carry it resolutely, 
 but gently and steadily along the vagina and through 
 the ruptured opening, so as to enter the cavity of the 
 
244 MEDICINE AND SURGERY 
 
 perltonfPAim, lay hold of the feet and bring away the 
 child by the operation of turning. Beware of grasp- 
 ing the intestines and pulling them away with the feet. 
 Provided no injury be inflicted on the mother, the 
 sooner the operation of turning is commenced and 
 completed the better, because if the child is left long 
 in the peritonseal sac, it perishes in consequence of the 
 suspension of the function of the placenta, which lies 
 detached among the intestines ; but if the fetus is re- 
 moved promptly, there is a reasonable hope that it 
 may be abstracted alive, and if no violence be em- 
 ployed, promptitude of delivery may also facilitate 
 the recovery of the mother. The child taken away, 
 the placenta is to be extracted also ; the operator be- 
 ing careful not to leave any part of it behind, and in 
 this abstraction great care must be taken that you do 
 not draw down any other parts together with the 
 after-birth, and more especially the intestines. Let 
 the mind in these dreadful emergencies be kept tran- 
 quil and unshaken ; unless you are undisturbed and 
 settled steadily upon obstetric principles, you are unfit 
 to act. If you are unequal to the duty, give up the 
 management of the case altogether, and send for fur- 
 ther assistance. Do not mislead yourselves with the 
 notion, that these cases are desperate, and therefore 
 it matters little what is done by the patient. One re- 
 covery I have witnessed, and there are others on re- 
 cord. 
 
 What is the history and his mode of acting in the 
 case which he saw recover ? "A woman in the neigh- 
 borhood of Guy's Hospital, had a contraction of the 
 pelvis — I was called in, in consequence of a collapse 
 of the strength, and when I examined, I found the 
 child lying in the peritonreal sac, distinct from the 
 uterus, the aperture of which was contracted, and I 
 found further, a large transverse rent opposite the 
 bladder. Well, in this case, agreeably to the rule, I 
 determined to turn, and for this purpose introducing 
 my hand into the peritonaial sac, I perceived the intes- 
 
OF THE LYING-IN CHAMBER. 245 
 
 tines, felt the beat of the large abdominal arteries, 
 touched the edge of the liver, and ultimately reach- 
 ing the feet of the child, I withdrew it by the opera- 
 tion of turning, subsequently abstracting placenta 
 and membranes, the woman recovering in a few weeks 
 afterwards. About five years after the recovery, I 
 saw her not so vigorous as before the accident, but 
 nevertheless tolerably well. On very careful exami- 
 nation at this time, the os uteri was found to present 
 the natural character, and not a vestige of the cica- 
 trice was discoverable in the vagina any where above 
 or below ; the rupture therefore had been above in 
 the uterus itself. When, in this case, my hand was 
 introduced to turn the fetus, the womb, large as a 
 child's head, was felt lying upon the promontory of 
 the sacrum, above and behind the rent." 
 
 PROLAPSUS AND PROCIDENTIA OF THE UTERUS. 
 
 Are there any cases recorded in which the pro- 
 lapsus of the uterus has continued to \h.e end of ges- 
 tation ? In the late valuable edition of Professor 
 Meigs' work, *' Obstetrics, the Science and the Art," 
 is related a case under the care of Dr. W. S. Haines, 
 the present resident physician of the Blockley Hos- 
 pital, Philadelphia, in which the prolapse of the va- 
 gina was so great as to protrude some distance be- 
 yond the vulva, at the time of labor, at seven and a 
 half months of gestation. Dr, M., whose entire 
 work should be carefully read by every student and 
 practitioner of obstetrics, has given a drawing which 
 he considers a faithful representation of the condition 
 alluded to. Several instances are reported — one by 
 Dr. Ashwell, others by American physicians, in 
 which women afflicted with complete procidence of 
 the gestative organ, have continued in this distress- 
 ing condition till delivered at or near full time. 
 
 Does this condition of the uterus necessarily inter- 
 fere with easy delivery when the uterine contractions 
 are established ? Although it has been supposed that 
 21* 
 
246 MEDICINE AND SURGERY 
 
 the principal obstacle to the easy completion of the 
 second stage of labor was to be found in the curva- 
 tures of the pelvis and the resistance of the vagina 
 and perinoeum, yet Ashwell had recourse to the for- 
 ceps, and other gentlemen to embryulcia, for the com- 
 pletion of the delivery of the fetuses in their respec- 
 tive cases. It is not easy to conceive that instrumen- 
 tal deliveries must be necessary in all cases of proci- 
 dentia of the uterus. 
 
 INVERSION OF THE UTERUS AFTER DELIVERY. 
 
 What is another marked consequence of atony of 
 the uterus occurring during the second and third 
 stages of labor ? Inversion of the uterus. 
 
 What are the usual causes of this accident ? Firstly, 
 great weight of the placenta. Secondly, .too early 
 and too forcible expulsive efforts of the mother. 
 Thirdly, the continued and forcible bearing down of 
 the mother after extrusion of the child, &c. Fourthly, 
 Dewees and some others think it may depend upon 
 irregular contractions of the fundus, &c. 
 
 DEGREES OF INVERSION. 
 
 What are the degrees of inversion of the uterus ? 
 Three are generally recognized in this country, viz. ; 
 first, simple depression of the fundus — second, por- 
 tion of the fundus passed the orifice — third, com- 
 plete inversion, in which the whole organ is turned 
 inside out. 
 
 What degree of inversion causes the most serious 
 consequences, the complete or incomplete ? The in- 
 complete. 
 
 Why is this so ? Because in this case the portion with- 
 in the neck is strangulated, and the circulation is im- 
 peded through it, and hence venous hemorrhage is kept 
 up, inflammation and sloughing may also occur from 
 this cause, while in cases of complete inversion, all 
 contraction is obviated, and although more or less he- 
 
OF THE LYING-IN CHAMBER. 247 
 
 morrhage occurs frequently or constantly, yet there 
 are no consequences of strangulation in the part. 
 
 DIAGNOSIS OF INVEilSION. 
 
 What is the diagnosis of this accident ? The mo- 
 ment of its occurrence, the patient complains of a 
 sudden sinking about the pelvic region, shrieks out, 
 becomes faint, &c. Upon applying a hand at the va- 
 gina, a mass of greater or less size, depending upon 
 the degree of the inversion, will be perceived without 
 or wifliin the vulva, or perhaps even within the os 
 uteri itself, if it be merely in the first degree, (though 
 in this there is usually less sense of exhaustion.) If 
 it be external to the os uteri, the mass presents a 
 rather dense structure, with a soft, spongy, more 
 or less rugose surface, not necessarily sensitive to the 
 touch. 
 
 How can you distinguish this internal surface from 
 a polypus tumor ? This may be very difficult in some 
 cases, but generally perhaps the surface of the uterus 
 is more rugose than that of the polypus. 
 
 May the practitioner not mistake this for a coagu- 
 lum, a placenta, or a presentation of another fetus ? 
 This would require care in his physical examination, 
 but then with these the patient does not suffer in the 
 same manner. 
 
 TREATMENT OF THE INVERSION OF THE UTERUS. 
 
 Remembering that the fundus of the uterus, which 
 in the normal condition of things, is uppermost and 
 at the farther end of the axis of the organ, is now the 
 first thing to be seen or handled, it will be proper to 
 watch for the absence of contraction, and taking ad- 
 vantage of this moment, press upon its centre with 
 the points of the fingers of the hand brought into a 
 conical form, and steadily attempt to carry it up along 
 the direction of the axis of the uterus till the entire 
 hand, wrist, and part of the arm have passed through 
 the OS uteri — even though it should be necessary to 
 
248 MEDICINE AND SURGERY 
 
 carry the fundus by this process as high as the umbili- 
 cus of the patient : there retain it until a violent con- 
 traction of the organ expels it. Observing carefully 
 by the other hand now to be applied upon the hypo- 
 gastrium, that the contracting and diminishing organ 
 retains its proper rotundity ; but if this be not prac- 
 ticable, desist, and leave the case to the gradual phy- 
 siological changes which may be efiected in it, to adapt 
 it to its new situation. 
 
 How are cases of partial inversion to be managed ? 
 It has been proposed that the reposition of sucR cases 
 is more difficult than when the inversion is complete. 
 Still it is proper to attempt it by the means indicated 
 above, and if this fails, to seize the fundus and body, 
 bring them entirely down, and if reduction in the ab- 
 sence of contraction be not then easy, leave the case 
 to subsequent palliative treatment, till the hemorrhagic 
 tendencies are subjected to a healthy standard. 
 
 LABOR COMPLICATED WITH INCAPACITY OF THE NATU- 
 RAL POWERS TO COMPLETE EXPULSION OF THE CHILD. 
 
 May it occur that a woman may be well formed, 
 have her labor come on at time, her child present 
 either pole of its ellipse favorably, and yet be incom- 
 petent to complete its birth by her own unaided 
 power ? It may and does so occur, that some women 
 whose children present well, or whose deviated presen- 
 tation has been rectified, fail of ability to complete 
 the delivery at all, or not without the most exhausting 
 eiforts. 
 
 What is the duty of the accoucheur, patient, and 
 society under such circumstances ? It is the duty of 
 the accoucheur to exercise a prudent judgment, and 
 a high intelligence, as to the nature of the patient's 
 condition and her prospects of success, or otherwise 
 in the effort she is making, to give her the full benefit 
 of this judgment as to whether she will or will not be 
 able to complete the delivery safely to herself or infant 
 by her own unaided powers, frankly to inform her if 
 
OF THE LYING-IN CHAMBER. 249 
 
 he believes tins impracticable, itdvise her as to the 
 means of assistance which science and ^rt have placed 
 within his reach, and which he (if he have been pro- 
 perly trained) may make available for the benefit of 
 herself and child. It is the duty of the patient to 
 regard the counsel which a properly educated physi- 
 cian may communicate under such circumstances, to 
 ask him to be governed in his conduct towards her by 
 the dictates of his matured discretion ; to solicit of him 
 such interference as he believes her case to require, 
 and to submit with all possible calmness and confi- 
 dence to any manual or instrumental process w^hich 
 may be necessary for the safe conducfof herself and her 
 child through the perils to which either or both may be 
 unfortunately subjected ; and furthermore, it is the duty 
 of society, most earnestly, to place every reasonable fa- 
 cility in the way of those who, from promptings of hu- 
 manity, or even of self-interest, enter upon the study 
 of medicine with a view to practise the art upon the 
 afilicted of their fellow citizens; facilities for ac- 
 quiring a thoroilgh knowledge of the principles and 
 rules of the art, to hold in high appreciation those per- 
 sons who, at great personal sacrifice, devote them- 
 selves to such responsible and care-wearing services, 
 to encourage and sustain them by their kind regards, 
 and by substantial tokens to evince their gratitude to 
 them as ministers of a vocation the most important 
 which man can exercise towards the afilicted of his 
 race, and particularly to those cases in which the 
 lives of both mother and child are in jeopardy. 
 
 INSTRUMENTAL SURGERY.— CLASSIFICATION OF 
 OBSTETRIC INSTRUMENTS. 
 
 How^ are the instruments used in obstetricy classi- 
 fied ? 1. Those which do not injure mother or child : 
 2. Those which reduce the size of the child, for the 
 benefit of the mother : 3. Those which subject the hfe 
 of the mother to risk with a view to save the child alive. 
 
 Of what do these instruments consist ? The vectis ; 
 
250 
 
 MEDICINE AND SURGERY 
 
 the fillet; the Blunt hook; the forceps; the perforator; 
 the crotchet ; the craniotomy forceps ; and the cranial 
 compressors. 
 
 FORCEPS. 
 
 What obstetric instrument have we of much greater 
 value than the vectis or lever ? Forceps. 
 
 What do these forceps represent ? A pair of arti- 
 ficial hands. 
 
 What is the composition of the forceps ? Two blades 
 so arranged as to embrace the child's head, and so con- 
 structed that they can be introduced separately, and 
 then locked or united to each other, as shown at d, d, 
 and a, fisr. 94. 
 
 Fig. 94. 
 
 How do you distinguish the forceps by the length ? 
 Into English or short forceps, as shown in fig. 95, 
 measuring 12 inches, and into French, or long forceps. 
 
 Fig. 96. 
 
 as shown in fig. 96, measuring from sixteen to nine- 
 teen inches. 
 
OF THE LYING-m CHAMBER. ^51 
 
 I 
 
 What forceps are thought to be best, French or 
 English ? Upon the whole, the French forceps pro- 
 Fig. 96. 
 
 perly modified, are to be preferred ; though many ex- 
 cellent practitioners prefer the English or short for- 
 ceps for ordinary cases requiring the use of these 
 instruments. 
 
 What is the mode of locking in the English forceps ? 
 At the handle end of each shank is a deep notch into 
 which each handle of the instrument is neatly adjusted, 
 when properly locked, as seen at «, fig. 96, which re- 
 presents one blade of an English forceps, of the same 
 length, viz. twelve inches, as in fig. 97, but on a larger 
 scale. 
 
 Fig. 97. 
 
 What is the mode of locking the French or Gemjan 
 forceps ? There is a conical screw pivot near the 
 centre of one blade and a conical notch in the other, 
 into which the pivot is to be received. Their junction 
 is kept secure by the screw carrying down the cone of 
 the pivot into the conical notch, as seen at a, fig. 98, 
 which gives a profile view of the two blades as locked. 
 
 What mode of junction or locking, is the best ? 
 Perhaps the German, or French, is most preferred. 
 
 What is the use of the fenestra in the blades ? To 
 permit some portions of the scalp and cranium, as the 
 
252 MEDICINE AND SURGERY 
 
 parietal protuberances to pass tlirough them, and thus 
 enable them to occupy apparently less space in the 
 
 Fig. 98. 
 
 cavity of the pelvis, and at the same time to secure a 
 more firm grasp of the head. 
 
 To what part of the pelvis, is the use of the short 
 forceps restricted? Inferior strait, unless perhaps we 
 except those contrived by Professor D. D. Davis. 
 
 From what parts can you deliver the head with the 
 long forceps ? From every part of the pelvis, as a 
 general rule. 
 
 What rule have you for the application of force in 
 the use of forceps ? Sufficient to overcome the resis- 
 tance, if possible, without injury to the mother. 
 
 To what part of the child are the forceps to be ap- 
 plied ? Always to the head. 
 
 To what part of the head are they to be applied ? 
 To the sides, in all cases except perhaps one. 
 
 What is that one, if any ? In occipito-iliac positions, 
 in case rotation cannot be effected, nor the blades 
 carried up between the pubes and the sacrum. 
 
 To which diameter of the head, are the forceps to 
 be applied parallel ? The occipito-mental diameter. 
 
 Should you give the mother any pain in the intro- 
 duction of the forceps ? None other than to excite 
 the contraction of the uterus. 
 
 Is the child's head liable to receive some slight in- 
 jury by the use of the forceps ? This is in some cases 
 unavoidable, when the pelvis is small or deformed, or 
 the head badly situated^ or the forceps not well con- 
 structed. 
 
OF THE LYING-IN CHAMBER. 253 
 
 CASES FOR THEIR USE. 
 
 In what particular cases are the forceps indicated ? 
 When there is too much resistance to be overcome by 
 the natural powers, or when the powers of the mother 
 become enfeebled by hemorrhage, or the contractions 
 irregular by convulsions, &c. 
 
 What condition of the os uteri must exist, before 
 the forceps can be applied ? That of dilatation ; the 
 first stage of labor should be complete if possible. 
 
 Which practice is preferable for young practitioners, 
 forceps, or version by the feet, in cases in which the 
 head is still at the superior strait ? Version by the 
 feet, unless well trained to the use of -forceps. 
 
 Is it well for you to be provided with forceps in 
 cases of pelvic presentations ? It would be proper 
 always to have them at command in all cases of pelvic 
 presentations, whether original or rendered such by 
 version, that the delivery of the head may be effected 
 as rapidly and as safely as possible. 
 
 When the head is well situated, but some accident 
 has happened to the mother, should you resort to ver- 
 sion by the feet ? Remembering the dangers of ver- 
 sion, better use the forceps if practicable. 
 
 Suppose the head has passed out of the os uteri, 
 must you then use the forceps ; instead of resorting to 
 version ? Version would then be out of the question, 
 and the whole consideration would be upon the use of 
 the forceps. 
 
 Is it important you should diagnosticate very care- 
 fully before you attempt the application of the for- 
 ceps ? There would be hazard in using the forceps 
 without correct diagnosis. 
 
 POSITION OF PATIENT FOR USE OF FORCEPS. 
 IIpw Avould you have your patient placed for delivery 
 by the forceps ? She should be placed as for the op- 
 eration of version by the feet. 
 
 What preparation of the patient would vou have 
 2ii 
 
254 MEDICINE AND SURGERY 
 
 made before you operate with respect to the bladder 
 and bowels ? They should be carefully evacuated. 
 
 How do you designate the blades ? Male and fe- 
 male, or left hand and right hand blades. 
 
 Which is male, and which female ? The male blade 
 has the pivot, the female the notch. 
 
 What relations must the forceps hold to the pelvis 
 as they withdraw the child's head through the lower 
 strait ? Their concave edges must always look to the 
 pubes. 
 
 MODE OF APPLICATION. 
 
 What are the diiferent steps in the introduction of 
 these instruments ? In the first place the consent of 
 the patient or her friends should be obtained for the 
 purpose, after a due explanation of the necessity and 
 object of their use. The patient then being properly 
 placed, the instruments are to be brought to a suitable 
 temperature by dipping them for a few moments in 
 warm water ; the male blade or left hand blade, is to 
 have its fenestrated extremity properly lubricated, the 
 vulva is also to be lubricated as well as the right hand. 
 The accoucheur taking his station between the limbs 
 of the patient, holds the male or left hand blade in his 
 left hand, a little beyond the middle towards the fen- 
 estrated extremity, in the same manner that he would 
 hold a writing pen. The dorsum of the fingers of the 
 right hand is to be applied to the left labium and side 
 of the vagina, and the orifice of the uterus if within 
 reach. The handle of the blade being carried almost 
 perpendicular to the horizontal line on which the pa- 
 tient is placed, is now to have its point slided cau- 
 tiously along the palm of the hand and the fingers, 
 gradually approaching a parallel with the patient's 
 body, until the blade has been placed by the side of the 
 child's head in the direction of its occipito-mental 
 diameter. The handle of this blade is then to be 
 supported by an assistant, while the other blade is to 
 be taken in the right hand, and its fenestrated extrem- 
 
OF THE LYING-IN CIIAMBEE. 255 
 
 ity lubricated as the other; the left hand is now to be 
 properly prepared, and the dorsum of its fingers ap- 
 plied against the right labium, side of the vagina, and 
 mouth of the uterus if within reach. The handle of 
 this blade is then to be carried in a nearly perpendi- 
 cular direction towards tho left groin of the patient, 
 that its lower point may be slidod along the palm of 
 the left hand in the direction of the axis of the vagina, 
 of the inferior strait of the cavity of the pelvis, and if 
 necessary, the superior strait ; as this movement is 
 effected ; the handle is of course correspondingly de- 
 pressed, till it comes in contact with, and crosses ob- 
 liquely, the blade first introduced, and the points of 
 junction brought accurately together ; they are then 
 to be locked. 
 
 What is the general rule in reference to the con- 
 cave and convex edges of the blades ? The concave 
 edges are to look towards the pubes, and the convex 
 edges towards the hollow of the sacrum. 
 
 Should you always keep the point of the instru- 
 ment against the head of the child ? This should 
 always cautiously be done to prevent embracing any 
 of the soft parts of the mother between the instru- 
 ment and the child's head. 
 
 What dangers may result from want of care in this 
 matter ? The inclusion of some portion of the mouth 
 of the uterus, or even penetration into the abdomen, 
 with the instrument. 
 
 Is it warrantable, in any case, to introduce the 
 forceps before the head has cleared the os uteri? 
 Professor Meigs, who is high authority, says it is 
 not. 
 
 Is there any danger of entangling any of the soft 
 parts in the fenestra of the blades ? There is. 
 
 How are you to prevent this ? By carrying up the 
 hand as a guard in advance of the blades. 
 
 How are the blades to approach each other at the 
 lock ? In nearly parallel lines. 
 
 Should the blades always lock readily ? Unless 
 
256 MEDICINE AND SURGERY 
 
 they do, it is certain that the head is not accurately 
 embraced. 
 
 How are you to judge whether you have the for- 
 ceps properly applied to the child's head ? By their 
 locking readily, while the blades are applied in the 
 direction of the occipito-mental diameter of the child's 
 head, as indicated by the position of the occipital 
 fontanelle or by the chin. ^ 
 
 Is there any danger of passing up the forceps out- 
 side of the os uteri? There is great danger of this 
 accident without much care in some cases. 
 
 What test have you that this has occurred ? The 
 complaint of the patient that you hurt her. 
 
 When you have the blades locked, should you make 
 a little compression and traction effort ? This should 
 be done in order to bring the instruments to their 
 proper bearing, and to ascertain that no part of the 
 mother is included. 
 
 LIGATURE OR FILLET ON THE FORCEPS HANDLES. 
 
 Should you apply a fillet upon the forceps in all 
 cases ? In none except where it is important to keep 
 up long continued and firm pressure. 
 
 Under what circumstances is the fillet necessary ? 
 When there is some defect of size of pelvis, or too 
 great magnitude of the child's head. 
 
 PRINCIPLE OF ACTION WITH THE FORCEPS. 
 
 What is the modus operandi of the forceps ? Both 
 as levers and tractors. 
 
 Should the forceps be regarded as a double lever ? 
 They should. 
 
 Where is the common fulcrum ? The pivot. 
 
 What is the usual centre of motion of these levers 
 during the effort of delivery? The trachelo-bregma- 
 tic diameter of the child's head. 
 
 Should you be particularly careful to support the 
 perinaeum in delivery by the forceps ? This should 
 be regarded as an important object of attention. 
 
OF THE LYING-IN CHAMBER. 257 
 
 Is it proper for you to remove the forceps as soon 
 as the head escapes through the inferior strait ? This 
 is a good general rule. 
 
 FORCEPS IN FIRST POSITION. 
 
 In what direction are you to move the handles of 
 the blades ? Frfltai side to side of the head, and al- 
 ways from handle to handle. 
 
 Suppose the occiput situated obliquely to the left ace- 
 tabulum, how are you to apply the male blade ? Ele- 
 vate the handle, pass in the blade, sweep it under the 
 top of the head, then depress the handle rapidly to 
 'bring the blade to the side of the head, and the 
 pivot will look towards the left groin of the mo- 
 ther. 
 
 How should you pass in the female blade ? Pass 
 it firmly into the cavity of the pelvis along the top 
 of the child's head, then by insinuating the fingers 
 under the convex edge of the blade, depress the han- 
 dle of the blade to sweep it over the parietal protu- 
 berance, and allow the blade to lock with the pivot 
 to the left groin of the mother. 
 
 Suppose the shoulders become arrested, how w^ould 
 you assist their delivery ? Continue to act with the 
 forceps upon the head ; or lay them aside and apply 
 one hand behind, and the other in front of the neck, 
 make proper traction in this way ; or pass up the 
 blunt hook into one axilla, and thus make proper 
 traction till first one and then the other shoulder is 
 disengaged. 
 
 Suppose the head becomes arrested at the superior 
 strait, how should you proceed with the view to assist 
 the delivery ? Ascertain, if possible, if there be any 
 deviation; then correct it; and if there be none, or 
 if you cannot correct it, consider what further action 
 would be proper. 
 
 Would you turn, or apply the forceps ? Turning 
 would be safer, unless the practitioner have much ex- 
 perience in the use of forceps. 
 22* 
 
258 MEDICINE AND SURGERY 
 
 Can you apply them easily and safely at the supe- 
 rior strait ? They are neither easily or safely ap- 
 plied at the superior strait, and should not be applied 
 at that point under any circumstances, unless the 
 practitioner possess great dexterity in the use of for- 
 ceps. 
 
 What use should you make of th^ hand in the ap- 
 plication of the blades, admitting you attempt to use 
 them in this case ? Pass it into the cavity of the 
 pelvis till it comes in contact with the head suffi- 
 ciently completely to protect the mother from injury. 
 
 FORCJEPS IN SECOND POSITION 
 
 Are there any greater difficulties in applying the 
 forceps in the second position of the vertex than in 
 the first ? When the occiput is towards the right 
 acetabulum, the left side of the child's head to which 
 the male blade is to be applied, is so closely directed 
 to the anterior part of the pelvis, that when the first 
 or male blade is properly introduced, it occupies so 
 much of the anterior commissure of the vulva as to 
 leave insufficient space for the proper introduction of 
 the female blade. 
 
 How is this difficulty to be obviated ? First pass 
 in the male blade to its proper situation : having 
 then determined what this is by the actual introduc- 
 tion, retract the blade by reversing the motion by 
 which it was passed, till it is opposite the left ischium ; 
 then having it carefully supported by an assistant, 
 introduce the female blade to its proper situation 
 along the right sacro-iliac junction. This blade is 
 still in front of the male blade ; the male blade is 
 now to be passed up to its original situation under 
 the ramus of the left pubis ; when if all is right, it 
 will lock readily. 
 
 FORCEPS IN POSTERIOR POSITIONS. 
 
 What relation docs the child's head hold to the 
 forceps in the posterior positions of the occiput? 
 
OF THE LYING-IN CHAMBER. 259 
 
 The sinciput then corresponds to the concave edges 
 of the blades. 
 
 What rule have we for the direction of the handles 
 in the posterior varieties ? As the occipital extremity 
 of the occipito-mental diameter is directed strongly 
 backwards in these cases, it is necessary to depress the 
 handles on the perinseum to secure the proper portion 
 of the head within the blades. 
 
 FORCEPS IN TRANSVERSE POSITION OF THE HEAD. 
 
 Suppose the head present with the occiput to one 
 ischium, should you correct the deviation by the vectis 
 before you apply the forceps ? Yes^ if at all practi- 
 cable. 
 
 Is it a rule in obstetrics not to apply the forceps 
 with one blade under the arch of the pubes, and one 
 over the perinaeum or coccyx ? It should never be 
 done, if possible to avoid it. 
 
 Should we always attempt to correct the deviation 
 by the vectis, or a blade of the forceps used as a 
 single lever, before both blades are used for tractors 
 in this kind of presentation ? A persevering but 
 judicious effort should be made for this purpose, in 
 order, if possible, to prevent the necessity of applying 
 them over the occiput and face. 
 
 Suppose you fail in all reasonable attempts to rotate 
 the head into an oblique position ? It would then 
 seem necessary to apply the instruments either over 
 the sides *of the head in the sacro-pubal direction, or 
 over the sinciput and occiput in the bis-ischiatic 
 direction. 
 
 If you decide to attempt to apply the instrument 
 to the side of the child's head, what should be the 
 different steps of the process ? If the occiput be to- 
 wards the left ischium, although the left hand or male 
 blade can be so inserted into the pelvis as to embrace 
 the left side of the head from occiput to chin, yet the 
 shank of the instrument will necessarily be carried so 
 closely against the left tuber ischii, that it will be im- 
 
2G0 MEDICINE AND SURGERY 
 
 possible for the right hand or female blade to cross it 
 to lock properly. It therefore becomes necessary in 
 most instances to adopt a course differing from that 
 usually advised in regard to manipulation with the 
 forceps, viz. : to introduce the female first on the pubal 
 side of the head, and with the pubal curve of the blade 
 directed towards the occiput, then taking the sacral 
 edge of the male blade in the right hand^ leaving the 
 handle directed downwards, the tip of this blade is to 
 be carried upon the sinciput first, then under the left 
 parietal and temporal bones till it becomes placed 
 parallel with the clam of the other blade, and the pivot 
 comes accurately into the notch of the female blade 
 which had been first introduced. 
 
 In the occipito right-iliac position, the male blade, 
 if introduced first, usually presents its shank so strongly 
 on the median line behind the pubis, that it is impos- 
 sible to conduct the female blade in the right direc- 
 tion. It is therefore proper to withdraw the male 
 blade gradually and cause its point, and part of the 
 clam to rest upon the sinciput, and the left side of 
 the vulva and vagina, while attention is paid to car- 
 rying in the female blade with the right hand by con- 
 veying it to the right side of the head. When this is 
 satisfactorily accomplished, the handle may also be 
 held by an assistant while the left hand blade is slided 
 round to its proper position- on the head under the 
 arch, and the two branches brought into contact and 
 locked. 
 
 What forceps is probably best adapted to these 
 transverse or occipito-ischiatic positions ? The " eclec- 
 tic" forceps of Professor Hodge. 
 
 If you succeed in locking the forceps to your mind, 
 would you at once turn the occiput to the pubic arch ? 
 It is never proper to force the occiput across the in- 
 clined plane unless the head has descended sufficie«fttly 
 low in the pelvis for the forehead to get directly below 
 the promontory of the sacrum, after which the opera- 
 
OF THE LYING-IN CHAMBER. 261 
 
 tion with the instrument should be in the direction of 
 the curve of Carus. 
 
 FORCEPS IN MENTO-ANTERIOR CASES OF FACE PRE- 
 SENTATION. 
 
 How shouhl you operate with the forceps in cases 
 of mento-anterior positions of face presentations ? 
 Apply the blades as in cases of occipito-anterior po- 
 sitions, and as the chin clears the anterior commis- 
 sure, draw a little forward with the front part of the 
 neck against the under part of the arch, then carry 
 the handles rapidly over towards the abdomen of the 
 mother, with a view to move the trachelo-bregmatic 
 and the trachelo-occipital diameters, like radii, be- 
 tween the arch of the pubes, the sacrum, coccyx, and 
 the perinaeum. 
 
 FORCEPS IN BREECH PRESENTATION. 
 
 What other presentations of the fetus may require 
 the application of the forceps for the delivery of the 
 head? Presentations of the pelvic extremity, in 
 which after the delivery of the above, the head is 
 retained. 
 
 How are you to dispose of the body of the child in 
 such cases? In case the occiput is anterior the body 
 is to be carefully lifted up over the abdomen of the 
 mother and the forceps are to be introduced beloAv ; 
 while in posterior positions of the occiput, the body is 
 to be carried toward the sacrum of the mother, and 
 the forceps are to be introduced above the body of the 
 child. 
 
 Suppose the chin has departed from the axis of the 
 pelvis, can you introduce and apply the forceps with 
 benefit ? They would be ineffectual in deUvering the 
 child, and subject the woman to much risk of injury. 
 
 Can you hope to deliver the head from the superior 
 straits after the body has been delivered ? Scarcely 
 ever easily nor often safely. 
 
 What accident is liable to occur in cases of pelvic 
 
262 MEDICINE AND SURGERY 
 
 presentation with the body delivered but the head re- 
 tained, if you use great manual traction effort ? Se- 
 parating the body from the head. 
 
 Suppose you meet with a case in which the head is 
 retained after the body has been pulled off, what should 
 you do ? First try to get the head in a proper posi- 
 tion, then apply the forceps. 
 
 But suppose you cannot get it into the proper rela- 
 tion with the pelvis for the safe application of the 
 forceps, what means are you to employ ? Hooks, 
 vectis, &c., so applied to the head as to get it in such 
 position that the forceps can be applied, or that you 
 can introduce such instruments as to enable you to 
 diminish its capacity, and afterwards extract it. 
 
 DR. HODGE'S MODIFICATION OF FORCEPS. 
 
 What is Dr. Hodge's description and illustration 
 of his valuable modification of the obstetric forceps ? 
 He says : The great object of the forceps is to ex- 
 tract the head of the foetus from the mother's organs 
 in suitable cases, without injury to the mother or 
 child. It is notorious that injury to one or both par- 
 ties frequently results, exciting a too well-founded 
 dread of this instrument in the minds of females and 
 even of physicians. Many causes contribute to this 
 unfortunate result. No doubt much depends on the 
 size, weight, and especially on the form of the instru- 
 ment employed, a fact confirmed by the almost innu- 
 merable 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 modification 
 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, 
 
OF THE LYING-IX CHAMBER. 263 
 
 I think, many and decided, as 1st. by them, any ope- 
 ration pertaining to this instrument, can be performed. 
 There is no necessity to vary the form, structure, or 
 size of the instrument, whatever may be the presenta- 
 tion of the head, its position or location. 
 
 2d. By them, sufficient power can be applied in 
 cases of necessity, which cannot be done by the short 
 forceps. Their leverage is gr*eater. 
 
 3d. The narrowness of the blades which, without 
 detracting from the utility of this instrument, 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 cannot 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 tlie variety most in use in 
 this country, is not sufficiently great. Hence, when 
 the head is high in the pelvis, the perin^eum will be 
 too much pressed upon, or else the blades will not be ap- 
 plied in the direction of the occipito-mental or oblique 
 diameter. 
 
 3d. The divergence of the blades commencing at 
 the joint, must necessarily distend to the vulva (espe- 
 cially its posterior margin) prematurely, and when the 
 head is high up, gives pain, and endangers the lacera- 
 tion of the perinneum. 
 
264 MEDICINE AND SURGERY 
 
 4th. The small size and kite-like shape of the 
 fenestra prevents any portion of the cranium, even 
 of the parietal protuberances, projecting 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 sur- 
 faces 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. 
 
 The mode of junction of the French forceps is 
 decidedly inconvenient, when compared with the Eng- 
 lish, and especially with the German mode. 
 
 These disadvantages I have endeavored to obviate 
 without diminishing 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 inexpe- 
 rienced hands, the dangers of the forceps have been 
 materially lessened. 
 
 1st. The weight of the instrument has been di- 
 minished from twenty ounces avoirdupois, to seventeen 
 ounces. 
 
 2d. The pelvic curve has been slightly increased, 
 so that the peringeum 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 angu- 
 lar bend in the handles, in an opposite direction, that 
 the direct line of traction may be preserved, a sugges- 
 tion of our skilful and experienced instrument- maker, 
 Mr. Rorer. 
 
 3d. The shanks, or commencement of the blades, 
 are nearly parallel, diverging no more than is abso- 
 
OF THE LYING-IN CHAMBER. 265 
 
 lutely necessary, until they approximate the head of 
 the chihi, when a more rapid curvature than in the 
 Levret forceps occurs. 
 
 4th. 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 extre- 
 mity of the French forceps. 
 
 The advantages are a more secure hold of the 
 head, and especially allowing larger fenestras, so that 
 the parietal protuberances may project into the open- 
 ings and no space be occupied by the blades, when 
 properly applied. 
 
 6th. The cephalic surface of the blade is con- 
 cave, 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 compres- 
 sion is made. 
 
 7th. The very ingenious and scientific mode of 
 locking the blades, as in the German or Sieboid's for- 
 ceps, by means of a conical pivot, and the correspond- 
 ing 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 
 joints are maintained. 
 
 The eclectic forceps weigh one pound and one 
 ounce, being nine ounces lighter than the French for- 
 ceps, as usually manufactured by Rorer, of Philadel- 
 phia, and eleven ounces lighter than a specimen of Du- 
 bois' forceps in my possession, made in Paris. The 
 whole length of the instrument, (see fig. 99) in a di- 
 rect line from h to c is 16 inches ; from the joint a, 
 to the extremity b, the length of the handles, is 6.8 ; 
 from a to d, the parallel shanks is 3.5 ; from d to c, 
 the proper blades in a direct Hne, is 6 inches ; from 
 c, c, the extremities, to e, /, /, 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 ban- 
 
266 
 
 MEDICINE AND SURGERY 
 
 dies touch, is 2.5 ; when the separation at ef is 
 3.5, the points tftf are separated 2 inches; the breadth 
 of the blade is 1.8, slightly tapering to 1.7 near 
 6'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 joint above the 
 same horizontal line, is 1.3, (including the thickness 
 of the blades) which indicates the extent of the angu- 
 lar bend in the handles, (see fig. 99 and reference 
 letters.) 
 
 Fig. 99. 
 
 Which forceps does Professor Meigs prefer ? In his 
 valuable work on obstetrics, he says the most conve- 
 
OF THE LYING-IN CIIAMB2R. 267 
 
 nient instrument he has ever employed, and the one he 
 commonly makes use of, is that recommended by the 
 late Professor Davis, of the London University. 
 
 DR. BOND'S REMARKS ON OBSTETRICAL FORCEPS. 
 
 What very sensible observations respecting the con- 
 struction and mode of use of the forceps have been 
 made by Dr. Henry Bond, of Philadelphia, and com- 
 municated by him first to the American Journal of the 
 Medical Sciences in July, 1850 ? At an early period 
 of my professional life it occurred to me that obstet- 
 rical cases are sometimes, although not very frequently, 
 met with where the use of the forceps is clearly indi- 
 cated, but where the instrument is found defective. I 
 refer to those cases where, owing to the position or the 
 form of the fetal head, and its relation to the pelvis, 
 it is found impracticable to adapt the clams to the 
 head so as to lock the branches, or to do so without 
 violent injury to the mother or child. There is pro- 
 bably no obstetrician of large experience who could 
 not furnish ample illustrations of this opinion, if he 
 would give a full and faithful detail of his observations. 
 
 Systematic writers tell us that " we must feel the 
 ear," or otherwise determine the precise situation of 
 the head, and then the blades " must be placed exactly 
 upon the parallel sides of the head, so that they may 
 lock — if the handles do not readily join upon the in- 
 troduction of the second blade — then we must, by ju- 
 dicious management of the one in fault, make it join 
 its fellow." [This term parallel^ as employed by some 
 obstetrical writers, is not used correctly. There are 
 no parallel sides of the head, but there are symmetrical 
 sides or portions, using this term in its geometrical ac- 
 ceptation. The term opposite will not express their 
 idea in this case, because the frons and occiput are op- 
 posite, but they are neither parallel nor symmetrical. 
 The terms similar and correspondent may express the 
 idea, but their import is more vague — less precise and 
 
268 MEDICINE AND SUKGERY 
 
 technical than symmetrical.] We are directed to 
 withdraw the blade in fault and introduce it again, as 
 if that would certainly accomplish that exact adapta- 
 tion. When the head is above the brim of the pelvis, 
 where the use of the forceps is sometimes clearly indi- 
 cated and urgently demanded, it is an empty pretence 
 that we can always determine the exact position of the 
 head, and not less so, that "judicious management" 
 will always enable us to adapt the blades exactly to 
 symmetrical portions of the head so as to lock readily. 
 Dr. Blundell says, "they (the long forceps in such 
 cases) are more generally laid over the forehead and 
 occiput." See also Velpeau, sect. 1061. 
 
 I will here present, very briefly, a few illustrative 
 cases. 1. In the early part of my practice, I was 
 called to a patient who was attacked with very violent 
 puerperal convulsions. I requested a friend to come 
 to my aid, bringing a forceps with him. We made re- 
 peated attempts to apply the instrument, and with a 
 similar result — we could not lock the branches. We 
 then summoned to our aid a gentleman of much expe- 
 rience and repute as a teacher of obstetrics. He in- 
 troduced the blades, and he found them no nearer to 
 an apposition, that admitted of locking, than we had 
 done. But, as a professor must not be thwarted in 
 the exercise of his own art, and, moreover, as the case 
 was very urgent, with a strong hand he made them lock, 
 and soon delivered the child ; but the temporal artery 
 was wounded, the cranium was fractured, and the child 
 was not a long time dead. 
 
 2. In a case where the use of the forceps seemed 
 to be indicated, and where the head was above the up- 
 per strait, I called to my aid a gentleman of eminent 
 skill and great experience. We both attempted to 
 apply the instrument, and with equal want of success. 
 We could not adjust it so that the branches would lock, 
 or that we could obtain any command of the head. 
 The vectis was also tried without success. The case 
 
OF THE LYING-IN CHAMBER. 269 
 
 •was very urgent, and we were obliged to resort to em- 
 hryulcia. This is the only instance in which this 
 operation has been resorted to in a patient of mine, 
 in a practice of thirty-three years. Owing to the dis- 
 proportion between the dimensions of the head and the 
 pelvis, it is, indeed, problematicalwhether the delivery 
 could have been accomplished by means of the forceps, 
 if it could have been adapted to the head, so as to 
 lock ; but it was very desirable to try the problem. 
 
 3. A few years ago I had a case, where, in consul- 
 tation with a friend, it was deemed necessary to use 
 the forceps. The head was above the upper strait, 
 and I found it impossible to apply the instrument so 
 as to lock the branches. I then made the female 
 branch bear upon the pivot without locking^ allowing 
 the clams to be adapted to the head obliquely in their 
 relation to each other ; and using my hands as a lock, 
 with much care to prevent slipping, I succeeded in 
 safely delivering the child. If I had forced the branches 
 to lock in this case, some violence must have been in- 
 flicted on the mother or child. This case, apparently 
 so simple and devoid of striking incidents, was to me 
 a very instructive one. 
 
 4. A case occurred recently in this city, as I have 
 heard, where, owing to the difficulty or impossibility 
 of properly adapting the forceps, the superciliary ridge 
 was fractured and the eye destroyed. A similar case 
 is mentioned in Dewees' Midwifery. These belong to 
 that too numerous class of cases, the details of which 
 are seldom allowed to escape the confines of the darkly 
 shaded nursery. 
 
 Dr. Blundell very justly observes, "Unless the 
 blades be elastic, absolute adaptation can (I conceive) 
 never be obtained; for while the form of the instru- 
 ment remains unchanged, that of the head itself va- 
 ries. The lock should be loose, so as to admit of a 
 junction of the blades, although they may not be 
 brought into exact apposition with each other ; for, in 
 applying them to the head, this adaptation cannot al- 
 23* 
 
270 MEDICIN-E AND SURGERY 
 
 ways be obtained." For this reason, he says that 
 Smellie's lock (made loose) is decidedly the best. 
 
 Dr. Meigs says, "If we fail to adjust the branches 
 accurately in apposition, we either cannot make them 
 lock, or we lock them in such a way that the edge of 
 the instrument contuses, or even cuts the part of the 
 scalp or cheek on which it rests, leaving a scar, or ac- 
 tually breaking the tender bones of the cranium, while 
 the other edge cuts the womb or vagina by its free pro- 
 jecting edge. In fact, the forceps is designed for the 
 sides of the head ; and if, under the stress of circum- 
 stances, we are compelled to fix them in any other po- 
 sition, (an incident not very unfrequent,) we shall al- 
 ways feel reluctant to do so, and look forward with 
 painful anxiety to the birth, in order to learn whether 
 we have done the mischief we feared, but which we 
 could not avoid." 
 
 " The difficulty and the danger in such cases evi- 
 dently arise, to a great extent, from the want of an 
 accommodating, rocking motion of the branches of the 
 forceps upon each other, such as will allow the de- 
 pressed (" cutting and contusing") edge to rise, and the 
 elevated edge to sink and come in contact and apposi- 
 tion with the head ; that is, so that the blades may be 
 adapted to the head by varying from their usual rela- 
 tion to each other. 
 
 [See " Obetstrics," the science and the art, for ex- 
 cellent lessons and much information on the use of the 
 forceps. I commend attention to the author's em- 
 phatic inculcation of the idea, that the forceps is the 
 child's instrument,^ 
 
 None of the French forceps, or their numerous 
 modifications, so far as I know, are intended to admit 
 of such a motion. When locked, they are truly 
 locked ; and whatever be the form of the head, or 
 whatever the parts of the head to which the instrument 
 is applied, the head must conform to the forceps and 
 not the forceps to the head. Smellie's joint (which 
 can hardly be called a lock) will admit of some motion, 
 
OP THE LYING-IN CHAMBER. 271 
 
 if made loose, as recommended by Dr. Blundell ; but 
 this motion is very limited and unregulated. Dr. Da- 
 vis, of London, has adopted Smellie's joint, (fig. 100) but 
 without observing Dr. Blundell's precaution as to its 
 
 looseness. 
 
 Fig. 100. 
 
 The lock of Dr. Siebold's forceps, when the pivot is 
 partly unscrewed, will admit of the lateral motion of 
 on^ branch upon the other, to a very considerable ex- 
 tent. The branches of forceps are two levers of the 
 first kind, the pivot being the common fulcrum of 
 each. It is to be observed in Siebold's forceps, 
 that the branches are so much curved — make so 
 wide a sweep — that the fulcrum is far removed from 
 the direct line between the power (the hand) and the 
 weight (the head) ; and it will be seen on examination 
 that this circumstance will render their lateral or rock- 
 ing motion nearly useless, if not dangerous. Indeed, 
 I should infer, from the structure of the joint and the 
 form of the blades, that the use of this motion was 
 never contemplated by the inventor. 
 
 A forceps was exhibited to the profession in this 
 city, several years ago, devised with a view to supply 
 a rocking, accommodating motion. It was constructed 
 with a swivel joint in each shank, allowing motion to 
 a limited extent. The objections to it were, 1st. That 
 this joint rendered the blade very weak, and that it 
 would almost unavoidably become corroded with rust. 
 2d. That the operator had no control over the motion 
 of it J it would rock or wabble always, whereas the 
 
272 
 
 MEDICINE AND SURGERY 
 
 rocking motion is not commonly requisite. This un- 
 restricted motion, together with the form of the blades, 
 would render this instrument very liable to slipping or 
 displacement. I have forgotten the name of the in- 
 ventor, and I am not aware that there is a specimen 
 of the invention in this city. 
 
 In the instrument (from the manufactory of Messrs. 
 John Rorer & Sons, of Philadelphia, made of German 
 steel, and spring -tempered,) which is illustrated in fig. 
 101, I have attempted to supply what has seemed to 
 
 Fig. 101. 
 
 me an obvious desideratum, viz., to give the branches 
 of the forceps an accommodating rocking motion 
 upon each other, the extent of which can he regu- 
 lated at will, and which shall in 7io respect lessen 
 the power of the instrument. The mechanism devised 
 to obtain this motion is very simple, not liable to de- 
 rangement, and it may be adopted in the construction 
 of forceps of other forms than that here presented ; 
 provided that the pelvic curvature of the branches 
 does not take such a wide sweep, as to throw the pivot 
 far out of the direct line between the handle and the 
 centre of the fenestrje. [There being some vagueness 
 and discrepancy in the use of the terms employ.ed in 
 describing the obstetrical forceps. T i^^-e offer some ex- 
 
OF THE LYING-IN - CHAMBER. 273 
 
 planatory remarks. These may be entirely super- 
 fluous to many readers, but perhaps not so to all. A for- 
 ceps consists of two branches (brachia) and a pivot or 
 fulcrum (that is, in such forceps as have their branches 
 connected by a pivot). A branch consists of the han- 
 dle {manubrium)^ which extends to the joint (junctura), 
 and of the blade (^cochleare), which extends from the 
 joint to the remote point. The blade consists of the 
 clam {cochlea), which is that concave portion of it in- 
 tended to embrace the head, and the shank (femur), 
 that portion between the joint and the clam. This di- 
 vision of the blade into shank and clam is not recog- 
 nized by Mulder, but it has become very convenient if 
 not absolutely necessary. The two parts of the clam, 
 on the side of the opening or fenestra, are sometimes 
 called the limbs of the blade, viz., the upper limb, and 
 the under or outer limb. The pivot consists of the 
 thumb piece, the screw, and the intermediate beari7ig 
 point or fulcrum. When the branches are connected 
 by a pivot, they are usually designated as the male 
 and the female branches ; that which has the notch 
 for the reception of the pivot, being the female, and 
 the other the male branch. Dr. Velpeau designates 
 the two branches as the right and the left, from the 
 position of the handles as held in the hand of the 
 operator. It seems to me more appropriate to desig- 
 nate them from the position of the blades, these being 
 the more essential parts of the instrument, and the 
 attention, in an operation, being directed more to the 
 position of the blades than to that of the handles. 
 Otherwise the blades seem to be playing at cross-pur- 
 poses — the right blade being on the left, and the left 
 on the right. I am aware that it may be said, in sup- 
 port of that usage, that the branches are named right 
 and left, in reference to the pelvis of the patient. For 
 the same reason, when riding backwards in a coach, a 
 man's right hand becomes his left. As one curve of 
 the forceps is made in reference to the form of the 
 head, and the other to that of the pelvis, it seems to 
 
274 
 
 MEDICINE AND SURGERY 
 
 me more distinctive and suggestive to name them re- 
 spectively the cranial and the pelvic curvatures, than 
 the old and the new curvatures. This was new in the 
 time of Levret, but it has ceased to be so ; and we do 
 not derogate from the credit of the inventor of that 
 important improvement by giving it an expressive 
 term.] 
 
 The instrument will be seen to differ, as a whole, 
 from any now in use ; although no one of its modifica- 
 tions, except the lock, has any claim to novelty. The 
 handles are Dr. Siebold's, with unimportant modifica- 
 tions. The blades are a little modified, from Dr. 
 Davis's, shown in fig. 102 on a small scale. Its whole 
 
 Fig. 102. 
 
 length is about fifteen inches, and its weight about fif- 
 teen ounces. The length of the handle is six inches, and 
 that of the blade nine inches. It might be made 
 somewhat shorter and lighter without impairing its 
 power. 
 
 Of the Loch, — In fig. 103, the screw is of about 
 double the diameter and nearly double the length of 
 those in other instruments. This addi- 
 tional strength is necessary, because the 
 bearing point of the pivot is not imme- 
 diately above the blade in which it is in- 
 serted (as in other instruments), espe- 
 cially when this bearing point is elevated 
 so as to give the blades a free rocking mo- 
 tion. The additional length is required to 
 give the screw a firm lodgment, when it is partly with- 
 drawn from the blade. The thumb-piece is made to fit so 
 
 Fig. 103. 
 
, OF THE LYING-IN CHAMBER. 275 
 
 close upon the female blade, but without resting upon 
 it, and is so thick and rounded, that there may be no 
 risk of injury shodld it ever happen to be brought in- 
 to contact with the patient. The screw, when well 
 made, will turn so easily that the thumb-piece may be 
 made much less prominent than it is here represented. 
 When the forceps is used, the thumb-piece should be 
 placed parallel with the blades ; otherwise it may in- 
 terfere with the rocking motion. Between the thumb- 
 piece and the screw, the pivot is of the form of two 
 frusta of cones of equal dimensions, united together 
 at their smaller diameters, forming an obtuse angle or 
 groove at their junction. The base of that cone joined 
 to the screw projects a little, forming a shoulder, in- 
 tended to limit the motion of the screw into the blade. 
 The notch in the female blade, made to receive 
 the pivot, is so deep that the pivot, in relation to 
 the edges of the branch, is nearly in the middle ; 
 yet the width of this branch, opposite to it, is swelled 
 out, so as to give it adequate firmness. The width 
 and the form of the sides of the notch are accurately 
 adapted to those of the pivot, and the bottom of the 
 notch terminates in an edge, like the knife-edge of a 
 balance, which is intended to rest in, and bear upon, 
 the angle or groove in the pivot. On the under side 
 of the male blade is seen a protuberance, finished so 
 as to present no salient points. It is a shield for the 
 extra length of the screw. When the pivot is screwed 
 entirely down, the branches have no more lateral or 
 rocking motion than those of any other forceps, and, 
 in this condition, they will very generally be used. 
 But by turning the screw, so as to elevate the bear- 
 ing point, more or less freedom is given to the rock- 
 ing motion, according to its elevation ; and this mo- 
 tion is effectually restricted within any desired limits. 
 When, by means of this free motion, the operator has 
 been enabled to grasp the head, he may sometimes 
 change its position, so that the clams may be then 
 adapted to the head, without the obliquity at firbt 
 
276 MEDICINE AND SURGERY . 
 
 necessarily allowed to them liy the elevation of the 
 pivot; and then, if desirable, the pivot may be screwed 
 down, and the blades will become as fixed as those of 
 other forceps. 
 
 Two objects seem to have been kept more or less 
 in view by the various modelers of the obstetrical 
 forceps. One of these objects has been efficiency, 
 having reference chiefly to the certainty of accom- 
 plishing the delivery. Of this sort is the long heavy 
 French forceps, and to some extent its several modi- 
 fications. It is undoubtedly a powerful, but danger- 
 ous instrument. The narrowness of the blades allows 
 them to be introduced with comparative ease to the 
 operator, and then (with such powerful levers, as their 
 long handles) also to be locked with apparent ease, 
 without being adapted to the head. They must be 
 efficient in the hands of a bold operator in effecting 
 *' a triumph of the art," but, like other victories, too 
 often attended with havoc. [See Blundell's " Obste- 
 tric Medicine," part ii., chap, viii., sec. 3, last para- 
 graph.] The other of these objects has been safety, 
 especially for the child. Dr. Davis, of London, 
 seems to me to have had this object especially in 
 view in modeling his forceps, and to have been so 
 engrossed with it that he has not had a due regard 
 to efficiency. Such blades as his, in awkward, inex- 
 perienced hands, and, indeed, in any hands, are pro- 
 bably less easily introduced so as to be locked than 
 the French forceps ; because, for the purpose of lock- 
 ing, they require a more exact adaptation ; but when 
 applied they are much safer — there will be much 
 less p^^obability of injuring the child. The French 
 forceps have received several successive modifications 
 in this country, which add much to their safety and 
 convenience. Indeed, some accoucheurs extol some 
 of these modifications as the ne plus ultra and al- 
 most the sine qua non of obstetrical instrumentality. 
 
 It will be seen that the blades of those here 
 presented (fig. 104,) resemble nearly those of 
 
OF THE LYING-IN CHAMBER. 211 
 
 Dr. Davis. The shanks are considerably longer ; 
 the clams are not ^uite so long ; the radius of their 
 
 Fig. 104. 
 
 pelvic curvature is a little less, especially that of 
 the outer limbs, so that it will be less liable to be 
 obstructed by the promontory of the sacrum, in pass- 
 ing the instrument above the superior strait. The 
 fenestrns are wider in theii" middle and posterior pait 
 than those in most other forceps now in use. When 
 the pivot is elevated, so as to allow the blades their 
 rocking motion, this width becomes especially requi- 
 site in order to secure a firm hold on the head, and 
 to avoid the risk of their slipping sideways. The 
 space between the blades is such, that, when applied 
 to the head, the handles shall not be at a distance 
 from each other, awkward and inconvenient to the 
 operator. From the pivot, the upper line of the 
 shank continues forward, without any elevation or de- 
 pression to the beginning of the pelvic curvature ; 
 and the form and the relation of the shank to the 
 clam are intended to be such as to interfere the least 
 with the perinaium. 
 
 While a form has been selected, which, it is be- 
 lieved, will admit of application easy and safe for the 
 mother and child, and grasp the head above the su- 
 
 Fig. 105. 
 
278 MEDICINE AND SURGERY 
 
 perior strait, it will be seen (fig. 105,) that the pivot 
 is in a direct line between the handles and the centre 
 of the fenestrge. This is a point of importance in 
 those cases where the rocking motion of the blade 
 may be required, as it will cause each limb of the 
 clams to press with nearly equal force, thus avoiding 
 undue pressure upon any one part of the head, and 
 the liability to slipping or displacement. 
 
 The handles are made partly of ebony, and they 
 resemble those of Siebold, although considerably 
 lighter. The precise model, of those represented in 
 the illustration, is not important ; for it may be 
 varied to suit the grip or the taste of diiferent ope- 
 rators. The objects aimed at in their construction 
 should be, first, such a length, compared with that of 
 the whole instrument, as to give a sufficiently firm 
 hold and pressure upon the head, without inflicting a 
 dangerous compression ; and, secondly, such a form 
 as to allow them to be easily grasped in the hand of 
 the operator, with the full assurance that he has the 
 best command of the instrument, without the danger 
 of slipping, and without the necessity of a napkin 
 envelope. These qualities do not belong to the long 
 polished steel handles, which are heavy, upon which 
 the wet, oiled hand of the operator must slip, and which 
 even when encumbered with a napkin, must convey an 
 uncomfortable sensation of misgiving. Ask the litho- 
 tomist or amputator how he would like to have his in- 
 struments finished with such handles that he would be 
 obliged to grasp them wrapped in a napkin ? One 
 prominent objection, if not the chief one, to Dr. 
 Davis's forceps, is the shortness of the handles 
 and their uncomfortable grip, except in a hand in- 
 conveniently large for an accoucheur. They cannot, 
 however, slip in the hand, like those of polished 
 steel. 
 
 The attempts to combine several other instru- 
 ments in the handles of the forceps, I regard as, ge- 
 nerally, worse than useless. With the long polished 
 
OF THE LYING-IN CHAMBER. 279 
 
 steel handle may be combined an efficient blunt hook. 
 Bat with such a heavy, mis-shapen handle, the ope- 
 rator would be much more liable to injure the mother 
 or child than with a well-constructed blunt hook. I 
 refrain from any criticism upon such useless perfora- 
 tors and dangerous crotchets as I have seen com- 
 bined with forceps. It is sufficient for an instrument, 
 so important as the forceps, that it is exactly fitted for 
 the performance of its appropriate uses. In skilful 
 hands it will preclude the demand for the perforator 
 or the crotchet, except in very rare cases ; and in 
 these terrible cases, truly of life and death, the ope- 
 rator ought not to be satisfied with instruments which 
 are but ill-contrived suecedanea. 
 
 I am aware that the first impression of some per- 
 sons, upon looking at the illustrations, will be, that 
 the instrument is too strait, that the pelvic curvature 
 ought to be continued into the shanks. If the whole 
 operation, or the most difficult and important part of 
 it, consisted in passing the blades above the superior 
 strait, narrow blades, with a curve of a wider sweep, 
 like those of Professor Siebold, slipping in probably 
 with rather more facility, would be preferable. But 
 as those here represented can be passed above the 
 superior strait with facility, it seems to me that what 
 I have already said upon the importance, in many 
 cases, of having the pivot in nearly a direct line be- 
 tween the handles and the fenestra, furnishes a valid 
 reason for adopting a model not differing essentially 
 from that here presented. 
 
 Others may object, that unskilful and incautious 
 persons will be tempted to carelessness in applying 
 such a forceps, and to avail themselves of the free 
 motion of its lock unnecessarily. Professors of ob- 
 stetrics, if they deign to notice it, ought to give their 
 pupils the proper directions and precautions in the 
 use of this instrument, as they do in that of others. 
 Some persons are, indeed, so unhandy in the use of 
 any instrument or tool, that all the professors in the 
 
280 MEDICINE AND SURGEKY 
 
 land cannot give them such tact and dexterity, that 
 they ought to be allowed to approach the puerperal 
 bed. Should this instrument happen to fall into such 
 hands, the danger to either mother or child would 
 probably be much less than from the use of power- 
 ful, unaccommodating forceps, misapplied by such 
 hands. 
 
 Others may object that it is an innovation, a gim- 
 crack novelty — for they are the conservatives^ scrupu- 
 lously maintaining the ancient landmarks. It differs 
 from the one extolled by their venerated preceptor, 
 the one to which they have been accustomed, and in 
 the use of which experience has given them expert- 
 ness. Long companionship produces partiality, and 
 perhaps some little modification of their own may 
 have given them the feelings of paternity. It has 
 answered their purpose, for with it they have accom- 
 plished delivery safely ; and if, in some instances, 
 they have wounded the integuments or fractured the 
 cranium ; or if they have been compelled to resort 
 to the perforator, in cases where the forceps was in- 
 dicated, they will console themselves with the reflec- 
 tion that it was an inevitable destiny — a fault of 
 nature, and not a defect of art. 
 
 In conclusion, I must observe that I am by no 
 means pertinacious for the precise model of the in- 
 strument presented in the illustration ; for it is not 
 improbable that experience may suggest modifications 
 of it, which will improve its adaptability, and yet 
 retain its essential principles. All I ask is, a care- 
 ful and candid examination of those principles. 
 
 LABOR COMPLICATED BY DISTORTION OF THE PELVIS. 
 
 What diseases often result in distortion of the pel- 
 vis ? Rachitis, or mollitis osseum. 
 
 What varieties of form do pelves assume from rickets 
 or softening of the bones ? Nearly every conceivable 
 variety, as may be seen by diagrams taken from ac- 
 tual specimens collected both in Europe and this coun- 
 
OF THE LYING-IN CHAMBER.^ 281 
 
 try. Thus, while fig. 106 gives a faithful representation 
 Fig. 106. 
 
 of well arranged iliac fossae and a superior strait of 
 standard dimensions ; and fig. 107 exhibits the normal 
 
 Fig. 107. 
 
 proportions of the inferior strait of a well-formed 
 pelvis, the departures from this standard are very va- 
 riable, partly in consequence of the manner in which 
 the rickets or mollities have affected the different por- 
 tions of bone constituting the pelvic canal, and partly 
 also in consequence of the position in which the pa- 
 tient had been during the confinement necessary in 
 24* 
 
282 . MEDICINE AND SURGERY 
 
 some cases, Avhile the bones were in a merely gelati- 
 nous state, it may be observed, that the antero -poste- 
 rior diameter of the superior strait is sometimes elon- 
 gated, so as to give the inlet an oblong appearance as 
 in fig. 108 ; while on the contrary, the sacro-pubal dia- 
 
 Fig. 108. 
 
 meter is so much abbreviated as to give the entrance 
 to the canal the resemblance of the numeral 8, placed 
 transversely, as shown in fig. 109, in which, as will be 
 
 easily seen, the antero-posterior diameter, though 
 strictly on the median line of the body, is very much 
 shortened, while the ilia are so widely separated as to 
 make the transverse mensuration abnormally long, 
 the oblique diameters measuring nearly or quite the 
 usual length. Besides this a less regular form is 
 
OF THE LYING-IN CHAMBER. 283 
 
 shown in fig. 110, while a considerable lateral dis- 
 Fig. 110. 
 
 tortion is exhibited in fig. Ill, and a still greater 
 Fig. 111. 
 
 one is represented in fig. 112, in which it may be ob- 
 served, that the antero-posterior diameter, starting 
 from the middle of the promontory, will fall not on 
 the pubes but over the left acetabulum; and that 
 while the right oblique diameter is nearly or quite 
 normal, the left one is greatly abridged. At the 
 
284 MEDICINE AND SURGERY 
 
 Fig. 112. 
 
 same time can be seen in fig. 113, that variety of 
 Fig. 113. 
 
 distortion, dependent apparently upon equal soften- 
 ing of the pubic bones, and their approximation by 
 the resistance made by the femora to the superin- 
 cumbent "weight of the trunk. 
 
OF THE LYING-IN CHAMBER. 285 
 
 Why do the distortions usually take place in the 
 direction of the sacro-pubal diameter ? From the fact 
 that the pressure is made in that direction by the su- 
 perincumbent weight of the spine or body. 
 
 What is the smallest size in diameter through which 
 a living child can be delivered if arrived at term ? 
 Three inches. 
 
 If less than this, is it proper for the accoucheur to 
 wait for the effects of the natural powers ? It is not, 
 because all the efforts of the womb and the woman 
 would be ineffectual. 
 
 MODE OF MEASURING THE DISTORTIONS. 
 
 What methods have been proposed for ascertaining 
 deformity of the pelvis ? Very many modes of ascer- 
 taining the mensuration of the pelvis, by instruments 
 intended to be applied externally or internally, or 
 both. Hence we have the pelvimeter of Baudelocque, 
 of Coutouly, of Stein, of Stark, of Simeon, of Boivin, 
 and others, for ascertaining by various modes of appli- 
 cation, the dimensions of certain portions of the pelvis. 
 
 What is the pelvimeter, or calliper of Baude- 
 locque ? His compas d'^paisseur, or calliper is con- 
 trived with a bulb at the upper ends of the instrument 
 with a graduated scale near the middle of each limb, 
 and is so constructed, that when the limbs are sepa- 
 rated from each other, the scale will indicate the de- 
 gree of the expansion, and consequently indicate the 
 dimension of the body embraced within the points 
 when applied to the mensuration of it. 
 
 How is the instrument to be used ? One of the 
 bulbs is to be brought as nearly as possible in contact 
 with the symphysis pubes, and the other to the tip of 
 the first spinous process; observe the intervening space 
 upon the scale, and you thus obtain the external 
 measurement of the sacro-pubal diameter of the exte- 
 rior of the pelvis. By deducting two and a half inches 
 for the usual thickness of the base of the sacrum, and 
 half an inch for the thickness of the pubes, the 
 
286 
 
 MEDICINE AND SURGERY 
 
 remainder will indicate nearly or quite the sacro-pubal 
 interspace, (see fig. 114.) 
 
 Fig. 114. 
 
 Fig. 115. 
 
 What in practice has been found more convenient 
 and reliable than any of the various instrumental 
 pelvimeters ? The index finger 
 of the accoucheur, carried with 
 its radial edge against the curve 
 of the pelvic arch towards the 
 promontory of the sacrum, as 
 shown in fig. 115. 
 
 If he cannot reach the sacro- 
 vertebral angle by this means 
 short of carrying the entire hand 
 within the vulva, need he en- 
 tertain any apprehension of want 
 of space for the head to pass 
 in this direction ? Under such 
 circumstances he will have no- 
 thing to fear in this respect, 
 but if the point of his finger 
 
OF THE LYING -IN CHAMBER. 287 
 
 should reach the promontory, and the nail of the in- 
 dex finger of the other hand be applied upon it at the 
 point of contact with the pubic arch, and the finger 
 be withdrawn, the measurement of the inter-space 
 can be sufficiently accurately ascertained. 
 
 Is it expedient to carry the hand into the vulva 
 unless the woman be in labor, and indeed have at the 
 time a pain ? It must rarely if ever happen that there 
 will be occasion for doing more than to introduce the 
 index to the commissure, or perhaps the index asso- 
 ciated with the middle finger may be carried as far as 
 the commissure between it and the next, which should 
 be kept in a state of flexion in all cases of examina- 
 tion unless when the patient is in labor. 
 
 What are Dr. Meigs' remarks on this digital means 
 of measurement ? He says, as a general rule, the in- 
 dicator finger of the accoucheur w^ill scarcely be found 
 Capable of extending further than three and a quarter 
 or three and a half inches beyond the crown of the 
 pubal arch. It is true, that by the introduction of 
 half the hand, the palp of the indicator finger can 
 be made to explore a region of four and a half inches 
 distant from the crown of the arch ; but, as the intro- 
 duction of half the hand in the woman not in labor, 
 or aff"ected only with the earliest signs of labor, is so 
 painful as to excite the greatest repugnance and re- 
 sistance on the part of the patient, the vaginal taxis 
 is generally preferred with the indicator alone. 
 
 MODE OF DELIVERY IN CASES OF PELVIC DISTORTION. 
 
 What resources has the practitioner in such cases 
 of distortion of the pelvis as do not allow the child 
 of full size to pass through it ? Premature delivery, 
 artificially induced, or craniotomy, or the cesarean 
 section, i. e., gastro-hysterotoray. 
 
 What is afforded by the perforation of the cranium, 
 and the breaking up of the pulpy mass ? An oppor- 
 tunity for the vault *of the cranium to collapse, and 
 pass down more readily. 
 
288 
 
 MEDICINE AND SURGERY 
 
 What are tlie diameters of the base of the skull 
 after the vault has been removed ? The face measures 
 one and a half inches ; two inches with the lower jaw. 
 The transverse diameter of the base of the cranium is 
 two and a half inches. 
 
 What is the operation of diminishing the size of 
 the child's head called? Craniotomy, cephalotomy, 
 and embryotomy. 
 
 CRANIOTOMY. 
 What instruments are used for the purpose of open- 
 ing the head ? A simple trocar, which is capable of 
 making an orifice of capacity equal only to the circum- 
 ference of its cutting surface, as shown in fig. 116 ; 
 
 Fig. 116. 
 
 a scissors, as devised by Smellie with edges about 
 one inch long, cutting outwardly, which, when the two 
 blades are brought together resemble a trochar cleft in 
 the direction of its long axis ; a scissors with double 
 cutting edges, and slightly curved on one of its lat- 
 eral surfaces, as contrived by Dr. D. D. Davis; a 
 scissors curved on one of its edges, with one point 
 longer than the other, as modified by Dr. Hodge, and 
 specimen given in 
 
 Fig. 117. 
 
 What advantage are the scissors of Smellie sup- 
 posed to afford over the simple trocar, for perforating 
 
OP THE LYING-IN CHAMBER. 289 
 
 the cranium ? Their capahility furnished the oper- 
 ator in making a larger opening by sepai^ting the 
 blades of the scissors. 
 
 Is it always easy to open the blades of such scissors 
 by a single hand ? The scalp, inter-cranial mem- 
 branes, and the margins of the "bones, sometimes 
 oppose the expansion of the blades of these scissors 
 by the extensor muscles of one hand only, which there- 
 fore requires the combined force of two hands and 
 abducting muscles of both arms to accomplish this 
 object. The scissors devised by Dr. Hodge are an 
 exception to this objection, because after perforating 
 they cut in the opposite direction. 
 
 What are some of the contrivances which have been 
 proposed to obviate this difficulty in attempting to 
 increase the opening from a point to a long slit ? 
 There have been several modifications of the original 
 trocar, or perce-crane, divided like Smellie's scissors, 
 but so constructed as to be opened by the flexor mus- 
 cles of the hand, one by a German accoucheur, oru? 
 by Dr. J. L. Ludlow, of Philadelphia, and one by 
 Mr. Holmes, of England. Ludlow's instrument is 
 shown in 
 
 Fig. 118. 
 
 ^^ 
 
 What is the general description of Holmes' perfo- 
 rator ? When the two handles are most widely 
 separated, the two sections of the cutting blades 
 are in contact, and represent a v-o- nq 
 
 partially cleft perce-crane, as shown 
 by a section of the instrument 
 in fig. 119. In proportion as 
 the handles are made to approach 
 each other, (as shown in fig. 120,) these blades are 
 
290 MEDICINE AND SURGERY 
 
 Fig. 120. 
 
 separated as scissors "^ath their edges reversed for 
 cutting from williin outwards. The large section 
 (fig. 121) in which the blades 
 ^^* * have been partially separated 
 
 rirr^jt:::::-^^^^^ as if by compression upon the 
 
 / - — =^^^^^ handles, shows the manner in 
 ^-^^^^ fu— --^^^^^^ which the lateral section of one 
 -^^ of the blades has been arranged 
 
 to fortify the closed instrument when used as a 
 bocer to perforate a firm scull, and to prevent 
 the vibration of the two halves of the instrument 
 upon each other as occurs in Smellie's scissors while 
 used in that process ; in one side of this lateral sec- 
 tion is a conical groove into which a conical projec- 
 tion from the other blade is made to fit accurately 
 when the instrument is closed by the wide separation 
 of the handles, which are to be kept thus abducted 
 by the commissure of the thumb and fingers being 
 applied at the crossing of the stems of the handles, 
 while the point of the instrument is carried up, 
 guarded by the fingers of the other hand to the part 
 of the head to be perforated. The instant the per- 
 foration has been effected by such rotary motion of 
 the instrument as may be necessary, the hand is to 
 be slided from the stems to grasp the hanTiles, and 
 adducting them by the flexor muscles, the blades are 
 separated partially, or to the fullest extent as may be 
 desired or as may be practicable. It may be ob- 
 served that the point and blades of Dr. Ludlow's 
 modification of the German instrument operate in a 
 similar manner with that just described. 
 
 How is the uterus to be supported for the opera- 
 tion ? It must be supported by one or both hands of 
 an assistant. 
 
OF THE LYIXG-IN CHAMBER. 291 
 
 HOW TO USE THE INSTRUMENT. 
 
 Suppose the head, &c., be properly supported by 
 the hands of an assistant over the abdomen, how is 
 the operator to proceed to the introduction of the 
 instrument ? The point of the perforator, or scissors, 
 is to be well guarded by one hand which is to be 
 introduced to the proper part of the head. 
 
 How is he to operate with it ? Fix it, if possible, 
 in a suture or fontanelle, push it up to the shoulders 
 of the blades if he use the scissors ; then open the 
 handles and cut from within outwards, then turn the 
 edges in another direction, and cut again till he has 
 made a considerable opening. 
 
 When you have perforated to the cranium suffi- 
 ciently, how are you to break up the membranes and 
 the pulpy mass of the brain ? Pass the scissors, or 
 some other convenient instrument and rotate it freely 
 within the cranium, at the same time scoop out the 
 mass thus broken up hj it. 
 
 HOW TO AID THE COLLAPSE OF THE CRANIAL VAULT. 
 If the head do not readily collapse, what means of 
 assistance have you ? The application of the forceps 
 has been proposed, and in some cases used with suc- 
 cess, to assist in compressing the cranial bones when 
 they have not readily been moulded to the form of 
 the pelvic canal. 
 
 VECTIS IN THESE CASES. 
 
 Could you ever use the vectis to advantage in cases 
 in which the head has been perforated ? It may 
 sometimes be used with benefit to change the direction 
 of the head, or to assist in traction. 
 
 What modification of vectis did Dr. D. D. Davis 
 make for this purpose ? He caused a number of sharp 
 points or teeth to be set on the extremity of the con- 
 cave surface and nearly at right angles with it, for the 
 purpose of securing a firm hold on the part of the 
 
292 MEDICINE AND SURGERY 
 
 scalp or cranial bone to which it was applied, when 
 used either as a lever or tractor. 
 
 What is the value of this modification in practice ? 
 Such an instrument could rarely be useful, as it would 
 at least be attended with embarrassment should the 
 teeth become fastened in the scalp or bone while the 
 head was high up, or pressed against the wall of the 
 pelvis. 
 
 CROTCHET— HOW USED. 
 
 What other and common means have you to act as 
 a tractor ? An instrument called the crotchet, or 
 sharp hook. 
 
 How is this instrument to be apphed ? It is to be 
 passed through the artificial opening in the head, and 
 fixed upon some firm point within the cranium. It is 
 however a dangerous instrument, and never to be used 
 when it can be avoided. 
 
 How are you to guard it when introduced ? By 
 the finger applied against some other part of the 
 head to prevent any accident from slipping. 
 
 Are crotchets ever guarded by a blade opposed to 
 them ? They are ; and it is unsafe to use one without 
 a proper guard of this kind. See fig. 122. 
 
 Fig. 122. 
 
 HOW TO REMOVE THE CRANIAL BONES. 
 
 Suppose there is not room for the bones to pass 
 down even after the brain is evacuated, what then is 
 to be done ? Pick, or tear, or cut away the different 
 portions of the vault of the cranium. 
 
 In the use of instruments for this purpose, should 
 
OF THE LYING-IN CHAMBER. 
 
 293 
 
 you have regard to the scalp ? Yes ; it is important 
 not to cut it away with the bones, but preserve it as a 
 guard to the soft parts of the mother. 
 
 What instrument would you use for cutting up the 
 bones of the cranium ? The craniotomist of Professor 
 Davis of London, (fig. 123) of which the spring be- 
 tween the handles has been added by Dr. Warring- 
 
 ton ; or the curved scissors of Professor Hodge of 
 Philadelphia, (fig. 124). 
 
 Fig. 124. 
 
 Suppose the space is too small for you to operate 
 with the craniotomist, what could you substitute 
 for it ? The old-fashioned duck-bill forceps of the 
 German surgeon-accoucheurs, shown in fig. 125; or 
 
 Fi-. 125. 
 
294 
 
 MEDICINE AND SUrxGERY 
 
 the straiiQ^ht and curved craniotomy forceps, devised 
 by Dr. Meigs, in 1831, on the occasion of his be- 
 ing obliged to pick away the cranial bones of the 
 child of Mrs. R., whose case is amply detailed in 
 his work on obstetrics, (page 570, edition of 1852,) 
 and upon whom the cesarean section has since been 
 twice successfully performed. 
 
 Fig. 126. 
 
OF THE LYING-IN CHAMBER. 295 
 
 OPERATE DELIBEHATELY. 
 
 When tills difficult operation has been decided upon, 
 is it necessftry for you to complete it at once ? Gene- 
 rally the operator may take his time at it, work at it 
 till he is weary, then give his patient an anodyne, rest 
 her and himself, and afterwards resume the task. 
 
 Through what sized aperture can you bring down 
 the base of the cranium ? One that is from one and 
 a quarter to one and a half inches antero-posteriorly, 
 and from two and a half to three inches transversely. 
 
 Is the operation of cephalotomy dangerous to the 
 mother ? Not in common cases, if performed in time 
 and with proper care. 
 
 Is her situation hazarded by the necessity of break- 
 ing up the vault of the cranium ? It is, unless great 
 care is taken to adjust the instrument safely. 
 
 Suppose the body will not pass through the de- 
 formed canal ? It must then be mutilated. 
 
 Should you make up your mind in the early part 
 of labor, in what manner you will complete the de- 
 livery ? It is proper that you make a careful exami- 
 nation for that purpose. 
 
 TRY FORCEPS FIRST IF POSSIBLE. 
 
 Suppose the pelvis be rather smaller than the stand- 
 ard size, what should be done when labor takes place? 
 Clear the bowels and the bladder, promote relaxation 
 of the soft parts — make a careful examination of the 
 internal capacity of the pelvis — and if it be regular 
 and not very small, some hope may be entertained 
 that the child may be extracted without being previ- 
 ously mutilated. 
 
 If the blades of the forceps could be introduced, do 
 you think it prudent to try the use of them ? Yes — 
 in all cases in which the capacity of the pelvis will 
 admit of the application of forceps, it will be best to 
 make compression and traction by means of them. 
 
 Suppose you had applied the forceps, and found 
 
296 MEDICINE AND SURGERY 
 
 you could not deliver with them, how should you do ? 
 Open the head while the forceps are still on, then 
 compress the bones with these instruments, and renew 
 the attempt to deliver. 
 
 Suppose the size of the pelvis he so small that you 
 cannot introduce the forceps, what should you do? 
 Diminish the size of the child's head, and then apply 
 the crotchet or the craniotomy forceps. 
 
 What instrument have you to diminish the size of the 
 child's head in utero, besides that of the perforator 
 or ordinary forceps ? The crushing forceps, brise- 
 tete or cephalotribe of A. C. Baudelocque. 
 
 Would you be disposed to use this instrument ? It 
 is so large and cumbrous an instrument, that we think 
 it could not be used without great hazard to the pa- 
 tient, though it is said to have been successfully em- 
 ployed in some cases in Paris. 
 
 Is it probably not susceptible of some reduction of 
 its size, and thus be better adapted to use ? Under 
 direction of Professor Hodge, the instrument has been 
 much reduced in size, by Mr. John Rorer and Sons, 
 without material loss of power, and has several times 
 been used in Philadelphia in bringing heads through 
 the pelvis, after protracted attempts with well made 
 forceps had failed. 
 
 DR. HODGE'S COMPRESSORES CRANII. 
 
 What appears to be the reason which led Professor 
 Hodge to modify, improve, and render practical the 
 heavy and otherAvise inconvenient Brise tete of A. C. 
 Baudelocque ? He says, I was called in 18 — to as- 
 sist in consultation, at the delivery of a young wo- 
 man with her first child, who had been in labor for 
 five days. After three da3^s, the pains had entirely 
 subsided, and could not be re-excited even by large 
 doses of the secale cornutum. 
 
 The presentation was the head at the superior 
 strait, but what part could not be exactly recognized. 
 A strong pair of Baudelocque's forceps was applied 
 
OF THE LYING-IN CHAMBER. 297 
 
 at the sides of the pelvis, and moderate tractive efforts 
 soon convinced me that the head was too firmly 
 "locked " to be moved. I was unwilling to abandon 
 the firm hold on the head by the forceps, and deter- 
 mined therefore to puncture the head without remov- 
 ing the instrument. This being accomplished, strong 
 compression was made by the fillet to the handles of 
 the forceps, and in a short time the head descended, 
 and was delivered without difficulty — transversely, 
 the face to the right tuber ischii, the occiput to the 
 left, so great was the diminution of the occipito-fron- 
 tal diameter by the blades passed over the two extre- 
 mities of the head. The success of the operation, the 
 short time occupied, the comparative facility of exe- 
 cution compared with the usual operation by means of 
 crotchets and craniotomy forceps, determined me to 
 repeat the experiment. On several minor occasions it 
 answered. In 1842 a more serious case occurred in a 
 woman with a contracted pelvis, measuring three 
 inches in the antero-posterior diameter of the supe- 
 rior strait, to Dr. Warrington, who politely requested 
 my assistance. Dr. W. opened the head and applied 
 the forceps. The instrument was not sufficiently pow- 
 erful immediately to effect our purpose. Fortunately, 
 however, by continued pressure, the left parietal bone 
 collapsed, when delivery was safely and easily accom- 
 plished. 
 
 The superiority of this mode of delivery was to me 
 sufficiently evident, and having heard of the "brise- 
 t^te " of Baudelocque, Jun., I procured a specimen 
 from Paris, which proved to be so very large, heavy, 
 and awkward, that I did not venture to use it. Re- 
 flection on the dangers of the usual mode of delivery 
 by tractors, after craniotomy, and on those by com- 
 pression, so perfectly satisfied me, that the latter were 
 far less, in every respect, determined me to have a 
 strong pair of forceps made for effectually crushing 
 the head of the child, so as to relieve the tissues of 
 the mother as much as possible, from the effects of 
 
298 MEDICINE AND SURGER . 
 
 pressure, in these unfortunate cases, and yet small 
 enough to be readily and safely used by any one ac- 
 customed to the use of the common long forceps at 
 the superior strait. 
 
 Our excellent obstetric instrument-maker, Mr. 
 Rorer, No. 24 North Sixth street, has successfully 
 carried out my ideas in the manufacture of a pair of 
 strong forceps on the model of Baudelocque's " brise 
 t^te." Experiments on dead infants, first made after 
 delivery, and subsequently before delivery, evince the 
 facility and safety of its employment, and also, that 
 it has sufficient power. 
 
 Although much heavier than the common forceps 
 for the purpose of strength, yet the " compressores 
 cranii" are of much easier application, as their di- 
 mensions are smaller and the blades may be passed 
 up in any direction where there is most room — it be- 
 ing indifferent to what part of the head they are ap- 
 plied. The action of the instrument is two-fold — 
 first, to compress, and thus break up the cranium 
 and reduce its diameters, if needs be, to two 
 inches, which experience shows may be done without 
 any danger of the crushed fragments of the cranium 
 dividing the scalp of the child and penetrating the 
 soft parts of the mother. They fall inward. Second, 
 They operate as " tractors'' in the same manner as the 
 common forceps ; care being taken to deliver slowly, 
 that no undue or irregular pressure be made on the 
 perinaeum, rectum, vulva, &c. 
 
 The general appearance of the compressores cranii 
 resembles the French long forceps with the double 
 curve ; each curve being somewhat modified. The pel- 
 vic curve is less, allowing more strength to the instru- 
 ment. The cephalic curve is modified on the same 
 principle as that of the ^'eclectic forceps," (quod 
 vide) so that when the handles are in contact, an oval 
 space exists between the blades, six inches and five 
 tenths long, the greatest breadth being at a point 
 three inches and three quarters from the extremity 
 
OF THE LYING-IN CHAMBER. 299 
 
 and but two inches and three quarters from the com- 
 mencement of the cephalic curve nearest the joint of 
 the instrument, corresponding to the oval form of the 
 head, and having the mechanical effect of forcing the 
 head, as it is diminished in size, more and more into the 
 grasp of the blades. The blades are solid for strength ; 
 fenestra are not here wanted. They measure 6.5 inches 
 in length ; their greatest breadth is 1.5 inch, at an 
 inch from their termination, rery gradually dimin- 
 ishing towards the lower portion near the joint ; and 
 .25 of an inch in thickness. The external surface is 
 convex and perfectly smooth ; the internal concave. 
 When closed, the greatest breadth of the instrument 
 is 2 inches ; hence the closed instrument could be 
 drawn through an orifice two inches in diameter. The 
 shanks of the blades, from the termination of the cepha- 
 lic curve to the centre of the joint, measure 3.5 inches, 
 making the whole distance from the joint to the ter- 
 mination of the blades, 10 inches. The handles of 
 the instrument are strong, flat, generally .75 of an inch 
 wide and 9.5 inches in length : thus making the 
 whole instrument 19.5 inches long. The extremities 
 of the handles are enlarged slightly and perforated 
 so as to admit a moveable screw. This is fixed on the 
 left blade by means of a small pivot, while a burr or nut, 
 with lever-like handles, plays on the screw, being very 
 light, easily managed by the fingers, and very powerful. 
 In the most gradual, yet in the most efficient manner, 
 can the blades be brought together by this combined 
 action of the screw and lever. The force can be re- 
 gulated with the utmost precision. 
 
 The joint is similar to that of the German forceps, 
 with a conical, but fixed pivot. To strengthen the 
 instrument, at this point, where the force is most 
 concentrated, the instrument is here broader and 
 thicker, and to maintain the parallelism of the blades, 
 not only are the surfaces at the joints broad and flat, 
 but a very large button is affixed to the top of the 
 pivot, preventing tlie twisting of the blades on 
 
800 MEDICINE AND SURGERY 
 
 each other. The weight of the instrument is three lbs. 
 two ounces. 
 
 Fig. 127 gives a profile-view of the instrument, 
 slightly turned to show the upper edge of the clam 
 of the left-hand branch. The shanks, lock, and a 
 section of the handle, are also shown in this figure. 
 
 Fig. 128, exhibits the entire instrument, as seen 
 from above, completely closed. 
 
 Fig. 129, represents a section of the instrument as 
 seen from above, with the clams applied upon the 
 two sides of a firm fetal cranium. 
 
 Fig. 130, exhibits the burr or nut, intended to 
 work upon the screw for approximating the handles 
 when the instrument is in use ; / is the orifice of the 
 female screw, cut through the centre of the burr ; 
 g^ g^ g^ are the lever-like handles, about one inch 
 and three quarters long, having bulbs at their outer 
 extremities. 
 
 Fig. 131, represents a screw about five inches 
 long, intended to be joined to an oblong opening 
 in the extremity of the handles of the left hand 
 or male branch of the instrument, by its flattened 
 extremity, li, at which is seen also a hole through w^hich 
 a small thumb-screw (fig. 132) is to pass to secure it in 
 its place. The shaft of the screw represented in this 
 figure, is to be passed through, and have free play in 
 a still more oblong opening in the end of the handle 
 of the female, or right-hand branch of the instrument, 
 after it has been applied upon the part it is intended 
 to compress or crush. 
 
 Fig. 132, displays the thumb-screw to be passed 
 through a circular opening on the extremity of the male 
 blade, and also through the circular opening at the 
 end of the screw, shown in the immediately preceding 
 figure. 
 
 In the figs. 127, 128 and 129, a b show the clams; 
 h c, the shanks of the clams ; d d, the handles, in part 
 and entire ; and e, the broad flat button on the top of 
 the strong pivot fixed in the male blade, and ofl'ering 
 
OP THE LYI>^G-IN CHAMBER. 
 
 301 
 
 its neck to be embraced bj the notch of the female 
 blade or branch of the instrument. 
 
 Fig. 127. Fig. 128. 
 
 Fig. 129. 
 
 Fig. 131. 
 26 
 
302 MEDICINE AND SURGERY 
 
 ERGOT, NOT PROPER. 
 
 Should you ever use ergot in cases of considerable 
 deformity of the pelvis ? Never, inasmuch as there 
 would be great danger of rupturing the uterus if 
 ergotic contractions were to be induced. 
 
 VERSION BY THE FEET IN DEFORMITIES OF THE 
 PELVIS. 
 
 Should you perform version by the feet in such 
 cases ? The propriety of this practice is at least 
 doubtful. 
 
 What would be the objection to this practice ? We 
 should increase the difficulty, if there was not room 
 for the child to pass, by removing the head from the 
 reach of instruments ' intended to draw upon it or 
 diminish its size. 
 
 Who has strongly advocated the propriety and ad- 
 vantage of turning with the view to bring down the 
 feet in cases of contracted upper strait ? Professor 
 Simpson, of Edinburgh. 
 
 PROFESSOR SIMPSON'S ARGUMENT. 
 
 What are his arguments in favor of this procedure ? 
 
 1. The fetal cranium is of a conical form, enlarging 
 from below upwards, and when the child passes as a 
 footling presentation, the lower and narrower parts 
 of the cone-shaped head is generally quite small 
 enough to enter and engage in the contracted brim. 
 
 2. The hold which we have of the protruded body of 
 the child, after its extremities and trunk are born, 
 gives us the power of employing so much extractive 
 force and traction at the engaged fetal head, as to 
 make the elastic sides of the upper and broader parts 
 of the cone (viz., the biparietal diameter of the cra- 
 nium) become compressed, and, if necessary, indented 
 b(3tween the opposite parts of the contracted pelvic 
 brim, to such a degree as to allow the transit of the 
 entire volume of the head. 3. The head in being 
 
OF THE LYING-IN CHAMBER. 303 
 
 arranged downwards into the distorted pelvis gene- 
 rally arranges itself, or may be artificially adjusted 
 so that its narrow bi-temporal, instead of its broad 
 bi- parietal diameter, becomes engaged in the most 
 contracted diameter of the pelvic brim. 4. The arch 
 of the cranium or head is more readily compressed 
 to the flattened form and size required for its passage 
 through a contracted brim, by having the compress- 
 ing power applied as in footling cases and extraction, 
 directly to its sides or lateral surfaces, than by hav- 
 ing it applied as in cephalic presentations, partly by 
 the lateral and partly to the upper surfaces of the 
 arch. 
 
 PREMATURE ARTIFICIAL DELIVERY. 
 
 What other plan does obstetric medicine propose 
 to prevent the occasion for the use of instruments in 
 cases of deformed pelvis ? The induction of artificial 
 premature delivery; 
 
 What is the proper stage of pregnancy for this 
 purpose ? The eighth month or a little earlier. 
 
 What is the proper mode of doing this ? Stimulate 
 the uterus to contraction, by titillating the internal 
 surface of the os uteri — or, if this do not succeed, by 
 puncturing the membranes. 
 
 What modes have been proposed as most suitable 
 for exciting the contraction of the uterus, when it has 
 been carefully decided to be proper to promote deli- 
 very prematurely? Professor Hamilton of Edin- 
 burgh, was in the practice of introducing a finger 
 into the os uteri every day or two, till he excited the 
 contractions sufficiently. Professor Simpson used 
 sponge tents for the same purpose. Others have re- 
 sorted to bougies, or flexible metallic sounds, and 
 carried them up some distance between the mem- 
 branes and the internal surfaces of the uterus. 
 
 Is it safe to puncture the membranes, while the os 
 and part of the cervix uteri is still closed ? It is not 
 prudent to rupture the membranes; if it can possibly 
 
B04 MEDICINE AND SURGERY 
 
 be avoided, before the os uteri is dilated to some 
 extent, and appears to be readily dilatable. 
 
 What are the probable chances for the life of the 
 child when delivered thus in the course of the eighth 
 month of gestation ? So far as information has been 
 collected on this subject, it appears that only about 
 one in two of children thus born, are delivered alive. 
 
 What size of the pelvis demands this practice if 
 you aim to avoid the hazards to the mother by the 
 operation of hysterotomy? When the diameter is 
 less than three inches, say two and three quarter 
 inches antero-posteriorly. 
 
 Suppose the diameter be less than this, what must 
 you have recourse to ? To gastro-hysterotomy, i. e. 
 the cesarean section ; or to the use of the crotchet. 
 
 Should you ever attempt either of these operations 
 while alone ? Never, if possible to have a consulta- 
 tion. 
 
 When the pelvis is very much contracted, which is 
 to be preferred, the crotchet or the cesarean section ? 
 If the child be alive, and the mother in good condi- 
 tion, it would be right to recommend the cesarean 
 section. 
 
 CESAREAN SECTION, OR GASTRO-HYSTEROTOMY. 
 
 What i'=5 meant by the phrase cesarean section^ or 
 gastro-hysterotomy? That section of the abdomen 
 and uterus through which the fetus, or the fetus and 
 placenta, may be removed, solely with a view to save 
 the life of the child, because the mother is already 
 recently dead, or because the natural passages are so 
 diminutive that it is impossible to remove the child, 
 however much mutilated, through them, without ine- 
 vitable destruction of the life of the mother also. 
 
 OBJECTIONS TO THE OPERATION. 
 
 What are the objections to the cesarean section ? 
 First, it involves the life of the mother in great jeo- 
 pardy, particularly if resorted to when she is in a 
 
OF THE LYING-IN CHAMBER. 305 
 
 state of excitement or exhaustion from ineifectual 
 labor. Second, it does not always preserve the life 
 of the child, though the risk of this is the least 
 objection. 
 
 TIME PROPER FOR PERFORMING IT. 
 If it appear clearly the duty of the consultation of 
 accoucheurs that the operation is necessary, when 
 should it be performed ? At as early a period of 
 labor as possible. It is particularly desirable that 
 the patient should have been subjected to as little 
 fatigue from parturient effort as possible, previous to 
 being subjected to so important an operation. 
 
 ACCIDENTS ATTENDANT UPON THE THIRD STAGE OP 
 LABOR— RISKS FROM TOO LONG DELAY IN THE DE- 
 LIVERY OF THE PLACENTA. 
 
 What hazards are known to result from the practice 
 of leaving the placenta in the uterus until spontane- 
 ous expulsion takes place ? Irritation, inflammation, 
 low fever, &c. 
 
 Should you ever leave your patient so long as the 
 placenta remains undelivered ? She should not be left 
 more than a few minutes at a time, because, although 
 in some cases no accident has happened from a long 
 continued retention, it is proper you should guard 
 against dangers by proper attempts to remove it early 
 after the child has been born. 
 
 MANAGEMENT OF SUCH CASES. 
 
 What practice is best for relaxing the mouth of the 
 uterus, and for inducing the contraction of the fundus 
 and the body ? Friction over the body of the ute- 
 rus ; the application of cold by sponges of cold water 
 or by a stream of cold water from a height, &c. 
 
 Is the practice of making cold and wet applications 
 upon the abdomen hazardous under such or any other 
 circumstances, except, perhaps, when the patient has 
 inflammation of the abdomen or viscera within it? 
 Many experienced practitioners have doubted the pro- 
 26* 
 
306 MEDICINE AND SURGERY 
 
 priety of the sudden application of cold to a part of 
 the body usually carefully protected by warm clothing, 
 and some express their belief that serious conse- 
 quences have resulted from the employment of it in 
 the cases now under consideration. 
 
 What should you do if external frictions and the use 
 of cold do not succeed ? Pass in the whole hand cau- 
 tiously, and seize the placenta with the fingers and 
 bring it down ; provided, however, the insertion of one 
 or more fingers has not been sufficient to effect this 
 purpose. 
 
 MANAGEMENT OF THE PLACENTA WHEN THE CORD IS 
 RUrTURED. 
 
 Is the cord sometimes so tender as to be very easily 
 broken ? It is in some cases severed by the slightest 
 traction upon it. 
 
 What practice should you resort to for the purpose 
 of removmg the placenta in the case of rupture of the 
 cord ? The fingers or the hand should be carefully 
 introduced within the vagina, and if necessary, within 
 the cavity of the uterus, and made cautiously to em- 
 brace as much of the mass as practicable, at the same 
 time allowing the uterus to expel it if possible ; if not, 
 draw it gradually in the direction of the axis of the 
 part through which it is to pass. 
 
 RETENTION OF THE PLACENTA. 
 
 Is retention of the placenta ever dependant upon 
 the manner in which its fetal surface ofiers to 
 the OS uteri? There is strong reason to believe 
 that in numerous instances of retention of the pla- 
 centa, or the delay in its expulsion is' owing to the 
 fact that the centre of the disc offers to the os uteri 
 and th_| circumference is too great to be allowed to 
 pass through the orifice of the uterus. 
 
 MANAGEMENT OF RETENTION OF THE PLACENTA. 
 
 What are the duties of the accoucheur in such 
 cases ? First to examine the situation of the pla- 
 
OF THE LYING-IN CHAMBER. 307 
 
 centa, and if it offers in the manner proposed, en- 
 deavor to fix the curved extremity of a finger into 
 some marginal point of the mass, make traction on it 
 and so arrange it that it shall offer that edge to the 
 axis of the uterus. 
 
 In attempting to do this, would not inversion of the 
 womb be hazarded ? Not at all if the operator do his 
 duty skilfully, making the entire change of the form 
 and position of the placenta within the uterine cavity, 
 the opposite hand being kept on the abdomen over the 
 anterior part of the body and fundus of the uterus, 
 especially if the operator keeps in mind the principle 
 that the change in the form and relations of the pla- 
 centa is to be effected within the cavity of the con- 
 taining organ, and without any tractive force in the 
 direction of its axis. 
 
 COAGULA BETWEEN THE PLACENTA AND UTERUS. 
 
 Does the presence of the coagula behind the pla- 
 centa, seem to retard its delivery ? This has been 
 regarded as one of the causes of delay in its expulsion. 
 
 Are there any positive means for diagnosticating 
 the existence of effused blood between the placenta 
 and the uterus ? Most commonly this is only sus- 
 pected when a part of the placenta can be felt at the 
 orifice, while the body is still large and the fundus is 
 high up in the abdomen. The only positive assurance 
 that there is more or less blood effused, is derived 
 from the observation that it escapes in greater or 
 less quantity by the side of the placenta through the 
 vagina. 
 
 WHAT TO DO IN SUCH CASES. 
 
 How should suspicion or proof of the existence of 
 fluid or coagulated blood behind the patient influence 
 the conduct of the attendants upon the patient ? The 
 suspicion of it should prompt the accoucheur to sa- 
 tisfy himself of the patient's general condition, espe- 
 cially in regard to the fulness and regularity of her 
 
308 MEDICINE AND SURGERY 
 
 pulse, and by auscultation to determine if possible 
 that there is not a second ovum above the placenta ; 
 then to insure contraction of the uterus, he or the 
 nurse should make free friction over, and even com- 
 pression upon, the abdominal tumor, to promote the 
 rapid and strong tonic contraction of the uterus. At 
 the same time he should pass a hand along the vagina 
 into the os uteri if necessary, seize the placenta, 
 and by a gentle but firm effort hold and draw it 
 down. 
 
 • CONTRACTION OF THE OS UTERI BEFORE THE PLACENTA 
 IS DELIVERED. 
 
 Does the contraction of the os uteri ever pre- 
 vent the delivery of the placenta ? This is pro- 
 bably a rather frequent cause of retention of the 
 placenta. 
 
 What varieties of contraction are there of the os 
 uteri ? That of the internal and that of the external os 
 uteri. 
 
 How do you ascertain this ? By the sense 
 of touch upon introducing a finger within the 
 orifice. 
 
 HOW TO ACT IN SUCH CASES. 
 
 What course should the accoucheur pursue in case 
 he finds the os uteri contracted upon the cord, and the 
 placenta thereby shut up in the uterus ? ^f the con- 
 traction is only very recent and the ring of the os 
 uteri is not very rigid, it will be his duty to hold the 
 cord in one hand, while he passes the other in the 
 form of a hollow cone with the cord in the centre, and 
 by this as his guide, gently but steadily carry first the 
 fingers and next the whole hand into the orifice, as he 
 gradually enlarges it till he can embrace the placenta 
 by his then expanded fingers ; this done, he must 
 make a careful rotary and downward traction upon 
 the mass, until he has brought it through the os uteri 
 into the vagina. 
 
OF THE LYING-IN CHAMBER. 309 
 
 How should the fundus of the uterus be supported 
 while both his hands are thus employed ? By the well 
 directed application of the hands of the nurse or 
 some other attendant, until his hand is fairly intro- 
 duced, but afterwards by the hand which was at first 
 occupied in holding the cord tense. 
 
 Should the hand be made to descend first, bringing 
 the placenta with it ? To avoid the dreadful accident 
 of dragging down the fundus of the uterus and caus- 
 ^ ing partial or complete inversion of the organ, it is 
 always most prudent for the operator to take great 
 care that the placenta is made to pass from his flexed 
 fingers by the hollow of his hand and wrist at least 
 into the vagina, that he may perceive by the hand in- 
 ternally, and the contour of the uterus externally, 
 that it has contracted regularly from its circumference 
 to its centre before he withdraws entirely the hand 
 which had been introduced. 
 
 What instrument may be used to assist in extract- 
 ing the placenta in these cases ? The placental hook 
 or wire crotchet of the late Professor Dewees, as 
 shown in fig. 133. 
 
 Fig. 133. 
 
 What are the objections to the use of this hook ? 
 It would seem to be a dangerous instrument unless 
 when very carefully used, since, if its point be passed 
 beyond the end of the finger it may be hooked into 
 the substance of the uterus, and sometimes when 
 apparently well fixed, tears out without doing more 
 than lacerating the placenta or the parts adjoining 
 to it. 
 
 What instruments have been proposed as a substi- 
 tute for this crotchet ? Dr. Bond's forceps, of which 
 a drawing is shown in fig. 134. 
 
 What advantage does this instrument offer over the 
 crotchet of Dewees ? Being curved nearly to corres- 
 
310 SURGERY AND MEDICINE 
 
 pond with the axis of the pelvis, it may be introduced 
 with more facility into the cavity of the uterus, along 
 the hand or fingers, and when inserted properly, by 
 expanding the blades they may be made to embrace 
 a portion of the placenta within their serrated lips, and 
 
 Fig. 134. 
 
 when traction is made upon them, if they cannot bring 
 the whole mass away at once, their withdrawal subjects 
 the patient to no hazard of injury. 
 
 RETENTION OF PLACENTA FROM IRREGULAR CONTRAC- 
 TION OF THE UTERUS. 
 
 What is the consequence of very violent and irre- 
 gular contraction of the body, as well as of the neck 
 of the uterus ? Prostration of the patient's strength, 
 great exhaustion, faintness, &c. 
 
 What should we rely upon most confidently, 
 for the relaxation of such spasm ? Free doses of 
 opium. 
 
 May contraction ever take place at the internal os 
 uteri ? It may, and perhaps most frequently does in 
 cases of retention of the placenta. 
 
 How should we overcome this constriction ? By 
 the gradual insertion of the fingers, and perhaps the 
 whole hand cautiously. In some cases bleeding and 
 other relaxing measures are necessary. 
 
 What other part of the uterus may become spas- 
 modically contracted ? Any other parts of the body 
 of the uterus. 
 
OF THE LYING-IN CHAMBER. 311 
 
 HOURGLASS CONTRACTION. 
 
 What is the peculiar con- Fig. 135. 
 
 traction called, in which the 
 fibres of the middle portions 
 of the body contract, while the 
 other portions remain some- 
 what relaxed ? Hourglass con- 
 traction. 
 
 Is there any danger of he- 
 morrhage in this case? Hemor- 
 rhage may take place both above 
 and below the constricted part. 
 This complication is probably 
 rare. 
 
 Does this kind of accident 
 require prompt attention ? It 
 should be attended to promptly, 
 because it usually is a case accompanied with much 
 suffering. 
 
 What have you to do to overcome it ? By fric- 
 tions on the abdomen, induce the fundus to contract, 
 then introduce your other hand into the uterus 
 and pass it up conically through the point of stric- 
 ture. 
 
 Should you try to pull the placenta away instantly ? 
 Efforts should be made to extract it cautiously, and 
 allow the contractions to take place regularly, as the 
 mass is removed. 
 
 How should you secure the regular contractions 
 of the uterus, while the hand is still in it? By 
 proper frictions upon the abdominal parieties over 
 the fundus of the uterus, while a hand is in the free 
 portions of its cavity, if possible. 
 
 How should you effect the relaxation of the stric- 
 ture, if the means just proposed do not succeed ? 
 Put the patient into a warm bath, give her opiates, 
 or bleed her. 
 
312 
 
 MEDICINE AND SURGERY 
 
 Fio;. 136. 
 
 ADHESION OF THE PLACENTA. 
 
 Is preternatural adhesion of the placenta very 
 common ? It is probably not by any means so com- 
 mon as is supposed by initial or inexperienced practi- 
 tioners. 
 
 Is the diagnosis of such adhesion easy ? It is not 
 always easily made out. 
 
 HOW TO TREAT ADHERENT PLACENTA. 
 
 How should you act in a case of real or sup- 
 posed adhesion of the placenta ? Pass up the hand 
 in a conical form, and when you reach the part, 
 expand it. 
 
 Which portion of your fingers 
 should you place in contact with 
 the uterus, in order to detach 
 the placenta ? The pulpy por- 
 tion when you can, but as this 
 would be difficult when the pla- 
 centa is at the fundus, it will 
 almost always be more effectual 
 to keep the dorsum of the hand to 
 the walls of the uterus, and the 
 inner surface of it to the pla- 
 centa, (as shown in fig. 136.) 
 
 Suppose the adhesions are very 
 firm, should you attempt to strip 
 off the whole placenta from the 
 surface of the uterus ? It should 
 always be done, if practicable, without injuring the 
 substance of the uterus. 
 
 CONSEQUENCES OF FAILURE TO EXTRACT IT. 
 
 What consequences are to be expected from re- 
 tention of part, or the whole of the placenta ? 
 Irritation, pain, inflammation of the uterus, and 
 putrefaction of the placenta, with the risk of the con- 
 sequences of absorption of pus. 
 
OF THE LYING-IN CHAMBER. 313 
 
 TREATMENT OF THE CONSEQUENCES. 
 
 How should you treat the case if putrefaction 
 should occur ? By detergent washes, carried up into 
 the cavity of the uterus by a suitable syringe and 
 with sufficient force to irrigate it thoroughly. 
 
 What kind of syringe should you use ? One of the 
 ordinary kind, which can be attached to, or inserted 
 into the end of a gum elastic catheter, or stomach 
 tube, which should be carefully introduced into the 
 cavity of the uterus, and the fluid then passed from 
 the syringe through it — or a syringe having a long 
 curved pipe, with a bulbous extremity, may be used 
 for the same purpose. The force pump injection-pipe 
 is the best kind of apparatus to be used. 
 
 What kind of fluid should be injected into the cavity 
 of the uterus ? That which is bland, mucilaginous, 
 and detergent, as flaxseed tea, solution of castile 
 soap, &c. 
 
 What kind will be proper when the exhalations 
 from the vagina become fetid, in consequence of 
 decomposition of a part or all the retained mass ? 
 They should be of an antiseptic character, as lime- 
 water and camomile tea, aromatic spirits of ammonia, 
 weak solution of creosote, chloride of lime, or soda, &c. 
 
 What general treatment should the patient receive 
 in cases of putrefaction of the retained placenta ? 
 Care should be taken to sustain her constitutional 
 vigor, by a generous diet, and even by stimulants, if 
 she become prostrated under the irritative fever, 
 which may ensue from te accident. 
 
 27 
 
314 PHYSIOLOGY AND PATHOLOGY 
 
 PHYSIOLOGICAL AND PATHOLOaiCAL CONDI- 
 TION OF FEMALES DURING THE REPRO- 
 DUCTIVE PERIOD OF LIFE. 
 
 Are we to regard the periodical local plethora and 
 ordinary uterine irritation or activity in the female 
 after puberty, as a physiological, or a pathological, 
 condition ? As strictly physiological, and pertain- 
 ing to the maturation of a germ. 
 
 Do any of the appendages of the uterus exert any 
 influence over the menstrual function ? The ovaries 
 appear to be indispensable to it, as upon their non- 
 existence the function does not occur, and upon their 
 removal it becomes suspended. 
 
 Admitting that we know very little of the cause 
 of the catamenia or menses, what does its regular 
 appearance indicate ? A healthy condition of the 
 genital organs, and a capability for procreation or 
 reproduction. 
 
 Are there no exceptions to the rule that women 
 cannot conceive unless they have menstruated ? 
 Some cases are recorded in which women have con- 
 ceived without having menstruated, but it is supposed 
 that with them, conception took place just before the 
 menstrual period would have occurred. 
 
 Which period is most favorable to conception, 
 before or after menstruation ? Immediately after 
 the secretion has taken place. 
 
 What opinion was formerly entertained respecting 
 the quality of the menstrual fluid ? That it was 
 extremely noxious both to animal and vegetable sub- 
 stances. 
 
 What is true in reference to its quality ? That 
 it possesses no noxious qualities when in a healthy 
 condition. 
 
OF THE HUMAN FEMALE. 315 
 
 HYGIENIC RULES TO BE OBSERVED, 
 
 What rules of conduct should be observed bj the 
 female during the menstruating portion of her life ? 
 All those hygienic rules which are necessary to en- 
 sure her a good physical and moral condition. 
 
 What conditions of her constitution should involve 
 the question of the propriety of her marriage ? The 
 existence of scrofula, rickets, phthisis, and such trans- 
 missible diseases. 
 
 What precautions should be employed in early life 
 to prevent the occurrence of such constitutional dis- 
 orders ? Every means should be used during child- 
 hood to develop and give tone to the various, tissues 
 of the system. 
 
 What must be regarded, in the present habits 
 of society, as injurious to the health of growing girls ? 
 The use of ligatures and corsets about the body, in 
 dress ; the want of free gymnastic exercises for tbe 
 development of the skeleton, and consequently of 
 the organs within it ; too much constraint and con- 
 finement of body in one position in the schools. 
 
 What is the value of pedestrian exercise in the 
 physical education of young ladies ? All physical 
 exercises, as gymnastics, and particularly those on 
 foot, as walking, jumping rope, and dancing in 
 'the open air, contribute greatly to the establishment 
 of the health and keeping all the secretions in proper 
 order. 
 
 What regulations should be enforced in regard to 
 diet ? The digestive organs should be kept in order 
 by a moderate allowance of nutritious but not stimu- 
 lating diet, composed principally of vegetable and 
 farinaceous substances. 
 
 What attention should be paid to the condition 
 of the skin ? It should be kept in a soft and tran- 
 spirable condition by cleanliness, regular bowels, and 
 a proper amount of warm clothing, particularly upon 
 the limbs. 
 
316 PHYSIOLOGY AND PATHOLOGY 
 
 What amount of sleep is necessary, and when 
 should it be obtained ? Not less than eight hours, 
 which should begin with the early part of the night. 
 
 What precautions are necessary with respect to 
 mental exercises or cerebral excitement ? To avoid 
 both to any considerable extent, and to discourage 
 precocity of intellect. 
 
 What care should be taken in reference to the moral 
 feelings ? They should be regulated, and the passions 
 should not be excited by reading, conversation, or 
 other means. 
 
 DISORDER OF THE MENSTRUAL FUNCTION, 
 
 What influence may much excitement produce at 
 the time at which the secretion ought to occur ? 
 Super-excitation of the system may so operate upon 
 the genital organs as to prevent the occurrence of the 
 secretion. 
 
 Under such circumstances what course should be 
 pursued ? The patient should be subjected to re- 
 stricted diet, saline cathartics, and sometimes even to 
 venesection. 
 
 How should we treat any nervous symptoms which 
 may occur in connection with the menstrual effort ? 
 It is not often necessary to interfere much with them : 
 mild anti-spasmodic remedies, such as spirits of nitre, 
 camphor water, assafoetida, and such articles may be 
 administered. 
 
 Suppose the capillary circulation be feeble, as in- 
 dicated by cold extremities, soft feeble pulse, &c., 
 what treatment ought to be adopted ? That which 
 would give tone and vigor to the system, as good 
 diet, proper exercise, bathing, pleasant company, and 
 agreeable mental excitement ; a proper course of 
 tonics, particularly mineral preparations, may be use- 
 fully employed. 
 
 AMENORRHCEA. 
 What is to be understood by the phrase, " retention 
 
OF THE HUMAN FEMALE. 317 
 
 of the menses? That they have never appeared, 
 however old the female may have become. 
 
 What is meant by the phrase, "suppression of. the 
 menses?" That having been once established, they 
 cease to appear during some part of the menstruating 
 period of female life. 
 
 What technical term have we to signify either of 
 these states ? Amenorrhoea. 
 
 Upon what causes may the tardy appearance of 
 the menses depend ? Defect, or absence, or want of 
 proper development of the organs of generation, par- 
 ticularly of the uterus, or ovaries, or both, or diseases 
 of them. 
 
 Do defects of this kind always interfere with the 
 health of the patient so circumstanced ? It some- 
 times happens that women so circumstanced enjoy 
 good health. 
 
 Why is a knowledge of this fact important ? That 
 females may not be subject to the powerful action of 
 medicines supposed to be emmenagogues or specifics 
 for producing the menses. 
 
 What proofs have we of the evil consequences of 
 attempting to force the menstrual secretion in some 
 of these cases of tardy appearance ? Many in- 
 stances on record, in which upon dissection, organs 
 were absent or but very partially developed, and one 
 particularly seen by Dr. Hodge, in which after long 
 and ineffectual treatment by emmenagogues, cathar- 
 tics, and serious injury to general health ; the profes- 
 sor in consultation, examined the patient but could 
 find no uterus. 
 
 Under what plan of treatment did this case improve ? 
 A general invigorating course, including proper exer- 
 cise in the open air. 
 
 Under what other circumstances may emansio men- 
 sium, or retention of the menses occur ? , When the 
 health is bad, and the organs partially developed, and 
 again when the health is bad and all the organs appa- 
 rently developed. 
 
 27* 
 
318 PHYSIOLOGY AND PATHOLOGY 
 
 What is the opinion of some experienced teachers 
 respecting the popular notion that the retention of 
 the^menses is the cause of the ill health ? That it is 
 the contrary of what is true, and that the ill health is 
 the cause of the retention in those cases in which the 
 organs were properly developed. 
 
 Upon what may this ill health depend? Upon 
 a bad diathesis, as phthisis, scrofula, &c. ; impro- 
 prieties in living, neglect of the means of proper 
 general physical development, errors in the physical 
 education, causing the female to remain a child until 
 a late period of her life. 
 
 What condition of the nervous system, is often 
 an accompaniment of amenorrhoea ? Neuralgia, hys- 
 teria, &c. 
 
 Is it probable that the uterus ever becomes the 
 seat of a congestion and irritation ? It probably 
 does so, in some cases, and it then appears as though 
 the system was above the secreting point. 
 
 What inconveniences might arise from stimulating 
 treatment in such cases ? It might bring on serious 
 consequences, as congestion, apoplexy, &c. 
 
 What then should be done ? Diminish cerebral 
 irritation by depletion, by cooling saline laxatives, 
 antimonials, &c. 
 
 What would be proper after this had been eifected ? 
 Seeking to restore the secretions by warm-bath, hip- 
 bath, warm injections, &c. Allowing the patient 
 demulcent drinks, as weak pennyroyal tea, &c. 
 
 Do purgatives interfere with the performance of this 
 secretion ? They do not, as has been supposed by some. 
 
 VARIETIES OF AMENORRHCEA. 
 
 Into how many varieties is suppression of the 
 menses divided ? Into two — acute and chronic. 
 
 How do ^^e distinguish acute suppression ? By the 
 action of its cause during the flow. 
 
 How does the cause operate in .chronic suppres- 
 sion ? During the interval of the secretion. 
 
OF THE HUMAN FEMALE. 319 
 
 Which is the severer form of suppression ? That 
 in which the cause acts and arrests the secretion 
 during its flow. 
 
 What class of females is most liable to suffer from 
 this suppression ? Those of irritable constitutions or 
 temperaments. 
 
 What may be regarded as predisposing causes of 
 suppression ? Irritability of the system. 
 
 What are some of the actual causes of affection ? 
 Certain moral influences, violent passions of' the 
 mind, frights from falls, sudden bad news, terror, 
 dread, rumors of wars, sudden transitions of tempera- 
 ture, &c. 
 
 How far may physical causes operate in this re- 
 spect ? The sudden application of cold to the exter- 
 nal surface — violent diseases, fever, inflammatory 
 affections, irritation of powerful medicines, stimu- 
 lating drastic cathartics, — all may act in the produc- 
 tion of the suppression of the catamenia. 
 
 How does sudden suppression affect the system ? 
 The effect of sudden suppression, or that of the 
 cause producing sudden .suppression, is often very se- 
 vere, and greatly disturbs the system which is most 
 predominant in the individual, producing hystei'ic con- 
 vulsions, &c., in the nervous ; apoplexy in the vascular, 
 or sanguineous temperament; attacks of gout, if the 
 patient have a gouty diathesis, &c. In some cases, se- 
 vere uterine neuralgia is induced by this check of 
 the secretory action. 
 
 TREATMENT OF AMENORRH(EA. 
 
 What are the indications for treatment ? They 
 must be founded on the temperament and diathesis of 
 the patient. The indication is always to diminish the 
 secondary irritation, and correct that condition of the 
 system which interferes with the proper action of the 
 uterus. Thus we are to clear the primae viae by vomit- 
 ing and purging, if obstructed, then commence with 
 the mildest anti-spasmodic medicines, as ether, assa- 
 
320 PHYSIOLOGY AND I'ATIIOLOGY 
 
 foetida, camphor, hyosciamus, if tlie nevous system be 
 much disturbed. 
 
 Under what circumstances may vascular depletion be 
 required ? When there is much plethora, or vascular 
 excitement, the lancet should be used : if there be 
 local pains without general vascular disturbance, cups 
 or leeches should be applied to the part aiFected. 
 
 Which should be resorted to first, vascular deple- 
 tion or anti-spasmodics ? . In cases of vascular excite- 
 ment, anti-spasmodics are of little avail, unless pre- 
 ceded by loss of blood, cathartics, or nauseants, 
 sufhcient to reduce the circulation. 
 
 When is the use of opium indicated ? Only when 
 the course just proposed has been tried, and other 
 anti-spasmodics have failed to quiet the system. 
 
 What is the best revulsive treatment in cases of sud- 
 den suppression ? - Plot pediluvia, long continued, and 
 rendered stimulating by some spices, as mustard, 
 ginger, &c. 
 
 What is probably one of the very best remedies we 
 possess for this state of things ? Copious enemata of 
 warm water. 
 
 What should be done conjointly with the use of enema- 
 ta ? Place the patient in bed and give her warm drinks, 
 as mint tea, pennyroyal tea, &c. to bring on perspiration. 
 
 Suppose, however, she be febrile ? Then the stimu- 
 lating drinks would be improper, till' she had been 
 purged and perhaps bled. 
 
 What should we hope to gain from the application 
 of warm poultices to the vulva ? They are useful, and 
 sometimes preferable to the custom of sitting the pa- 
 tient over the vapor of hot water, for the promotion 
 of secretion from the uterus. 
 
 When might leeches be applied to the genital or- 
 gans ? Whenever there appears to be a fulness of the 
 uterine vessels, and the secretion does not return to 
 their relief. 
 
 Where should they be applied ? To the pudendum, 
 to the vagina, or to the os uteri itself. 
 
OF THE HUMAN FEMALE. 321 
 
 How gliould the leeches be applied to the os and 
 cervix uteri? Bjdneans of a speculum, or proper 
 tubes capable of embracing the os uteri and sustaining 
 other parts. 
 
 When the system shall have been brought to its 
 proper standard by the means already proposed, and 
 the catamenia do not still appear, what additional 
 means should be used ? This would be the proper 
 time for the administration of emmenagogues so 
 called, as aloes, madder, senna, hellebore, Spanish 
 flies, &c. 
 
 Upon what cause does chronic amenorrhoea depend ? 
 Mostly upon bad condition of the general health, ow- 
 ing perhaps to serious disease in some organs, as 
 phthisis, hepatitis, &c. 
 
 In this case, to what part of the system should our 
 remedies be addressed ? To that affected — if the pul- 
 monary organs, to the lungs, if the hepatic system, -to 
 the liver, &c. 
 
 What train of functional disturbance mostly accom- 
 panies chronic amenorrhoea ? Spinal irritation, ce- 
 rebral congestion, and irregularities of the digestive 
 apparatus. 
 
 What kind of secretion sometimes affords a partial 
 substitute for the true menstruation ? Leucorrhoea, mu- 
 cous or muco-serous discharges from the uterus or 
 vagina, or from both. 
 
 What is the proper treatment for chronic amenorr- 
 hoea ? That which improves the general health, as 
 alteratives, general tonics, and those aperients which 
 act particularly on the lower bowels. 
 
 In what way do the so called emmenagogue medi- 
 cines usually act ? Some act generally upon the con- 
 stitution — some more locally upon the lower bowels — • 
 some upon the bladder, and a very few directly upon 
 the uterus itself. 
 
 With what organs doiss the uterus appear to have a 
 directly sympathetic connection ? With the mammae. 
 
 What advantage does this knowledge afford us in 
 
322 PHYSIOLOGY AND PATHOLOGY 
 
 the treatment of amenorrhoea ? That by stiinulating 
 the mammae, we have sometimes excited the secretory 
 action of the uterus. 
 
 What direct applications have been made to the 
 uterus with benefit ? Injections per vaginam, of ten 
 or more drops of acetate of ammonia to one ounce of 
 milk. 
 
 What means have been thought useful in promoting 
 the menstrual secretion, by acting directly upon the 
 nervous system? Electricity and galvanism. 
 
 What is to be said of the effect of physical excite- 
 ment of the organ by matrimony ? It may be 
 adapted to a few particular cases, but is often at- 
 tended by an aggravation of the condition of the 
 uterus, sometimes inducing permanent disease in it. 
 
 What are probably the very best general reme- 
 dies operating on the bowels we can use in amenorr- 
 hoea? Rhubarb and aloes in combination. 
 
 What substances have been thought useful by acting 
 on the kidneys or bladder ? The spirits of turpentine, 
 the copaiba, and various other balsamic preparations. 
 The tincture of cantharides has been regarded as use- 
 ful by many. 
 
 What other articles of the materia medica are sup- 
 posed to have a sort of specific action upon the uterus ? 
 Madder, guaiacum, savin, iodine, strichnine, and black 
 hellebore. 
 
 In what doses should the savin and the black helle- 
 bore be administered ? Half a grain of the extract, 
 or from five to ten grains of the powder of savin — 
 of the tincture of hellebore from ten or twelve drops 
 to a teaspoonful, two or three times a day, one or two 
 weeks before the expected time. 
 
 Can either of these powerful remedies be used in 
 any or every condition of the system ? They all re- 
 quire caution. The system should be properly pre- 
 pared for the action of either of them, by bleeding, 
 purging, &c., whenever there is a plethoric or an in- 
 flammatory diathesis. 
 
OF THE HUMAN FEMALE. 828 
 
 What plan of treatment may be continued through 
 the whole time, without regard to periods ? The hy- 
 driodate or other preparations of iron, madder, spirits 
 of turpentine, and tincture of cantharides. 
 
 RETENTION FROM PHYSICAL CAUSES. 
 
 By what causes may the menses be retained, when 
 the organs are well developed, and the health of the 
 female good ? By absence of the vagina, occlusion of 
 the OS tincse, closure of the hymen, vulva, or some such 
 mechanical obstacle to its escape. 
 
 What occurs in such cases ? The secretion goes 
 on, but the fluid is accumulated, because it has no 
 outlet. 
 
 What consequences result from this obstruction ? 
 In time, the abdomen swells, the condition of the pa- 
 tient excites suspicion of pregnancy, dropsy, or the 
 formation of a tumor, and the opinion of a physician 
 is appealed to. 
 
 DUTY OF THE PHYSICIAN IN SUCH CASES. 
 
 What course should he pursue ? First, make a 
 careful inquiry into the history of the case, then make 
 a proper physical examination of the parts. 
 
 What may he expect to find in case the occlusion 
 exists in the hymen ? Distension of the part, the 
 membrane of a dark blue color, with a sense of fluc- 
 tuation. 
 
 What may he expect to find in case the atresia ex- 
 ists in the orifice of the uterus ? If at the os tincae, 
 he may find a tumor like the extremity of an ellipse, 
 projecting into the vagina, and fluctuating under the 
 touch. If at the internal os-uteri, the neck and ex- 
 ternal os-uteri may be but little changed from natural, 
 but the body may be found expanded out into a sort 
 of globular tumor, somehat compressible to the touch. 
 
 What becomes of this aflection, if not relieved by 
 an operation ? Sooner or later an opening is formed, 
 and the fluid escapes. 
 
324 PHYSIOLOGY AND PATHOLOGY 
 
 What is the direction of the opening ? It is va- 
 rious ; sometimes in the rectum, and sometimes into 
 other parts. 
 
 If the hymen be entire, what kind of an opening 
 should be made into it ? Crucial, or stellated. 
 
 Suppose the vagina to be absent, what risk would 
 there be in attempting an incision for the escape of 
 the accumulated fluid ? It would be dangerous to at- 
 tempt operation for the exit of the retained menses 
 unless it were performed by one possessed of great 
 anatomical and surgical attainments. 
 
 When the obstruction exists in the uterus itself, 
 what plan should be adopted ? Attempts should be 
 made gradually to dilate the orifice by a series of 
 bougies. 
 
 Is this an operation easy to be accomplished? It is 
 often extremely difficult. 
 
 What is the true method of doing it ? Pull the os 
 tincae forward by a finger in the vagina, or anus, and 
 keep it pressed towards the pubis, to make the neck 
 of the uterus have the same axis as the inferior strait, 
 and then cautiously pass the bougie. 
 
 CHLOROSIS. 
 
 To what condition of the system is the term chlorosis 
 applied ? To that, in which about the menstruating 
 period of life, there is great pallor of the skin, and 
 torpor of all the functions of the system. 
 
 What does this state of the system indicate ? An 
 impairment or defect of the vis vit{?e, a general func- 
 tional derangement. 
 
 Why is it called chlorosis ? Because persons af- 
 fected with it, are vulgarly said to have green or fall- 
 ing sickness. 
 
 How does it generally begin to develope itself? By 
 a desire to eat outre articles ; as dirt, slate pencils, re- 
 cently quenched coals, &c. 
 
 What is the condition of the alimentary canal in 
 
OF THE HUMAN FEMALE. 325 
 
 such cases ? Torpid throughout ; digestion slow, bowels 
 constipated, stools clay colored. 
 
 What is the probable cause of the pallid, or pale 
 yellow or greenish color of the skin ? The extreme 
 torpor of the liver. 
 
 How is chlorosis to be distinguished from icterus ? 
 By the w^ant of the yellow deposit in the adnata of 
 the eyes. 
 
 What is the condition of the cerebral and vascular 
 systems in chlorosis ? The intellect is very torpid, 
 and the pulse soft and without force. 
 
 How is the nervous system affected ? The nerves 
 of sensation and motion, are sometimes greatly dis- 
 turbed, hence hysteria, and neuralgic pains. 
 
 What is at present to be said, respecting the plans 
 often adopted for the treatment of this affection ? The 
 practice is very often erroneous, especially when the 
 neuralgic pains in the side have been mistaken and 
 treated for pleurisy or inflammation. 
 
 What reasons may practitioners have had for diag- 
 nosticating inflammatory diseases and resorting to de- 
 pletion in these cases ? Probably, that in conjunction 
 with the pain, there is sometimes palpitation and fe- 
 brile excitement. 
 
 What are the consequences of the case becoming 
 chronic ? They are often serious and difficult of 
 cure. 
 
 What is the usual condition of the organs under 
 such circumstances ? They are sometimes found dis- 
 eased and altered, but most frequently they are in an 
 anemic condition. 
 
 What are the results of this disease ? Some patients 
 recover and get entirely well; while others become 
 affected with dropsy, &c. 
 
 Does the uterus ever perform its functions during 
 this chlorotic state ? Some patients have a slight, 
 serous menstruation — sometimes it even contains red 
 particles. 
 
 What conditions of life are most favorable to the 
 28 
 
1126 PHYSIOLOGY AND PATHOLOGY 
 
 occurrence of clilorosis ? All densely populated 
 places, where there is a deficiency of good air and ex- 
 ercise, and hence especially in the large manufactur- 
 ing towns of Europe, and even in this country where 
 girls are sent too early and confined too closely to 
 school. 
 
 TREATMENT OF CHLOROSIS. 
 
 What are the true indications for treatment in cases 
 of chlorosis? To give strength to the system by 
 restoring the healthy condition of the digestive appa- 
 ratus. 
 
 What is to be done to the reproductive organs, at 
 this time ? No especial attention is to be given to 
 them, until the constitution is improved. 
 
 What regard should be had to the full development 
 of all the organs in the body ? This is most impor- 
 tant, and every proper means should be availed of for 
 this purpose. 
 
 What kind of medicine should be used ? Such |1- 
 teratives as moderately increase the action of the mu- 
 cous membranes. 
 
 If calomel be employed, in what way ought it to be 
 administered ? In doses of from one eighth to half 
 of a grain, and cautiously repeated. 
 
 What regard should we have for the powers of di- 
 gestion during this course of medicines ? Carefully 
 avoid impairing the function of digestion, but rather 
 stimulating it. 
 
 Is it proper to use any additional alteratives ? The 
 preparations of sarsaparilla are appropriate in some of 
 these c^ses in conjunction with the calomel, or blue pill. 
 
 Why is iodine, or some of its preparations indi- 
 cated ? Because, in proper doses they stimulate the 
 organs of digestion. 
 
 What influence do the mucous secretions exert, if 
 left within the cavities in which they were formed ? 
 They irritate the system and disturb the digestive 
 function. 
 
OF THE HUMAN FEMALE. 327 
 
 How then ought they to be disposed of? They 
 should be carried off by proper laxative, or aperient 
 medicines. 
 
 What may be regarded as the best medicines for 
 this purpose ? Rhubarb, aloes, senna, castor oil, &c. 
 
 Under what circumstances would moderately stimu- 
 lating, or cordial, bitter tinctures, become useful ? 
 When there is a sluggish, or cold state of the sys- 
 tem. 
 
 What course should be adopted, when the alterative 
 and aperient plan have been carried into effect ? The 
 patient should be put upon the use of tonics ; as in- 
 fusions of camomile, or wild cherry bark ; or the pre- 
 paration of iron : as the oxide, the sulphate, and the 
 iodide of iron, or the pure metallic iron. 
 
 Is it reasonable to expect the catamenia to appear 
 before, or after the restoration of health ? Not until 
 after the health has improved. 
 
 DYSMENORK-HCEA. 
 
 What is meant by the term dysmenorrhcea ? Se- 
 vere pain during the act of menstruation. 
 
 How is the secretion in regard to amount and fre- 
 quency ? It may be, and generally is, regular in re- 
 gard to its return, but the quantity secreted is usu- 
 ally less, though some think it is rather greater in 
 some instances. 
 
 What opinions exist in reference to the cause ? 
 Some say the difficulty exists in the secretion of the 
 fluid, others that it is owing to an obstruction, or 
 difficult excretion of the fluid after it has been secreted. 
 
 What temperaments seem to be most liable to it ? 
 Nervo-sanguine temperaments. 
 
 At what age of menstrual life does it occur ? Wo- 
 men are subject to have it occur at any portion of 
 their menstrual life. 
 
 What is the usual condition of health in the inter- 
 vals ? Good : — if impaired, it mostly is so from some 
 other cause. 
 
328 PHYSIOLOGY AND PATHOLOGY 
 
 SYMPTOMS OF DYSMENORRHCEA. 
 
 What are the symptoms of dysmenorrhoea ? A 
 sense of coldness, nervousness, &c. Pain in the upper 
 part of the sacral region, thence round the ilia, or 
 through to the hypogastrium — sense of fulness and 
 bearing down in the pelvic region. 
 
 Are these feelings constant or paroxysmal ? They 
 occur in paroxysms, like labor pains ; indeed in some 
 cases it is difficult to distinguish them from efforts at 
 abortion. 
 
 What sympathetic disorders arise from, or accom- 
 pany the paroxysms of dysmenorrhoea ? Flatulence, 
 constipation, vomiting, bilious nervous headache, pal- 
 pitation, throbbing, &c. ; sense of fulness and actual 
 congestion in the lower part of the abdomen. 
 
 What is the usual duration of one of these parox- 
 ysms ? Sometimes this severe suffering continues for 
 a day or two, when the secretion appears and the pa- 
 tient becomes easier. 
 
 What is noticed as peculiar in the discharge in some 
 cases ? That it is membranous, and thrown off in 
 shreds, or in an entire sac resembling the shape of the 
 internal surface of the uterus. 
 
 What is probably the exact character of this mass ? 
 Opinions appear to be various. Some think it a co- 
 agulation of blood, and not the lymph of inflamma- 
 tion, as that formed in cases of croup. 
 
 What is the probable cause of the pain, if the idea 
 of a mere coagulation of secretion be correct ? The 
 pain would then seem to depend upon the severe con- 
 tractions of the uterus to expel the coagulum, &c. 
 
 What influence does this condition of the secretory 
 function of the uterus appear to have upon the general 
 health ? Very often the health of the patient in the 
 interval remains good, though the disease has con- 
 tinued to return with unabated severity from one to 
 twenty years. It is however true, that the health 
 
OF THE HUMAN FEMALE. 329 
 
 may become impaired in some cases, during the exist- 
 ence of dysmenorrhoeal state. 
 
 What is the condition of the mouth and neck of the 
 uterus in the female affected with dysmenorrhoea ? 
 In general the neck is tumid and the mouth a little 
 open. 
 
 What is known respecting the capability for con- 
 ception, in females affected with dysmenorrhoea ? 
 As a general rule, females so affected do not con- 
 ceive — but numerous exceptions to the rule exist. 
 
 CAUSES OF DYSMENORRH(EA. 
 
 What are the general predisposing causes of this 
 disease ? Temperament, particularly that of the 
 nervo-sanguine. 
 
 What may be regarded as occasional causes of this 
 disease ? Cold, violent mental emotions, fright, &c. 
 It has been brought on by matrimony — it is some- 
 times the result of metastasis of cutaneous or neural- 
 gic disorders, or of gastric affections. 
 
 What agency may displacements of the uterus exert 
 in the production of dysmenorrhoea ? It is very lia- 
 ble to follow any displacement of the uterus. 
 
 What may be considered as mechanical causes of 
 dysmenorrhoea ? Besides the various displacements of 
 the uterus which may be regarded to some extent de- 
 cidedly mechanical, causes are occasionally found in 
 obstructions of the internal and external os uteri, and 
 also in the canal of the cervix uteri. 
 
 What may be said of the severity of the pain in 
 some ,cases of dysmenorrhoea ? That it is greater 
 than that of labor. 
 
 What idea is entertained respecting the inflamma- 
 tory or neuralgic character of this affection ? Some 
 think it neuralgic or spasmodic, which is often true — 
 others regard it as inflammatory. By some good au- 
 thority it is thought that it most probably depends 
 upon excitement of the vascular system, upon a con- 
 gestion not amounting to actual inflammation. In 
 28* 
 
330 PHYSIOLOGY AND PATHOLOGY 
 
 other words, an exaltation of vitality — a nervous 
 excitement with vascular congestion. Some practi- 
 tioners, as Dr. Dewees, thought it depended upon 
 low or depressed action. 
 
 TREATMNT OF DYSMENORRHCEA. 
 
 How is the treatment of this affection to he di- 
 vided ? Into that which is to be applied during the 
 paroxysms, and that to be used in the interval. 
 
 What should first be resorted to in the paroxysm? 
 A free bleeding to the amount of thirty or forty 
 ounces — next, cups to the sacrum, or leeches to the 
 vulva, groin, or the uterus itself — then enemata of warm 
 mucilages, and as soon as the vascular excitement 
 has been allayed, the warm hip bath should be em- 
 ployed. 
 
 When may narcotics be resorted to ? As soon as 
 vascular excitement is allayed, anodyne enemata may 
 be used with advantage. 
 
 What anodynes are best in this case ? Dewees 
 recommended camphor enemata, and Parrish found 
 marked benefit from directing patients to take four 
 grains of camphor, three times a day, two or three 
 days before the time of the paroxysm. The Dover's 
 powder is also useful in allaying pain and exciting the 
 action of the skin. Other narcotics, as hyosciamus, 
 &c., are sometimes beneficial. 
 
 What other article has been thought useful in 
 diminishing the severity of the attack ? The acetate 
 of ammonia. 
 
 What should be done in the interval to prevent the 
 return of the paroxysm ? Endeavor to ascertain the 
 cause of the dysmenorrhoea, and if possible remove it. 
 Thus if the patient have displacement of the uterus, it 
 must be corrected. The same may be said of the 
 digestive organs, which should be restored if out of 
 health, by proper exercise, alteratives, tonics, and 
 laxatives. 
 
OF THE HUMAN FEMALE. 381 
 
 Are patients ever benefited by rest ? It has been 
 thought useful in some cases. 
 
 What may be said of cold bathing ? It is useful 
 in the intervals to keep down any inordinate vascular 
 excitement. 
 
 Can every patient bear the action of cold bathing ? 
 Not every one, and hence it must be tried cautiously. 
 To those whom it suits it is very useful. 
 
 What internal remedies have been proposed in the 
 interval as useful in the prevention of the return^ of 
 the paroxysms ? Sulphuric acid, sulphate of zinc, 
 preparations of senega, volatile tincture of guaia- 
 cum, &c. 
 
 What can be said of the efficacy of the last article, 
 so highly recommended by Dr. Dewees ? Experrience 
 has taught that it is not useful in all cases. 
 
 What should be the immediate object of the treat- 
 ment just before the expected paroxysm ? To relax 
 the system and prevent spasm by using the warm 
 bath — by retiring early to bed — by opening the 
 bowels — by large warm mucilaginous enemata — by 
 the use of warm injections into the vagina — warm 
 cataplasms to pudendum, and by a moderate use of 
 anodynes. 
 
 What is the proper treatment of mechanical dys- 
 menorrhoea ? Some practitioners are in the habit of 
 dilating the constricted portion of the mouth or neck 
 by bougies of different sizes. 
 
 Can this plan be relied upon as effectual ? It has 
 not succeeded in all cases, though it generally miti- 
 gates the suffering. 
 
 MENORRHAGIA. 
 
 What are we to understand by the term menorrha- 
 gia ? An increased or excessive secretion of the 
 menses. 
 
 Are we to receive this t§rm in a positive or relative 
 sense ? Menorrhagia is a relative term, as different 
 persons differ so much in regard to the amount, and 
 
332 PHYSIOLOGY AND PATHOLOGY 
 
 the same person may be so diiferent at different 
 times in this respect, that it is to be considered as a 
 menorrhagia, only when it is productive of bad conse- 
 quences. 
 
 What is the pathology of menorrhagia ? It is evi- 
 dently in some cases the result of an inflammatory 
 action, but in many females it is accompanied by a 
 feeble state of the system. 
 
 What period of life is most incident to it ? It 
 most commonly occurs at the latter part of menstrual 
 life, though some young women are subject to it. 
 
 CAUSES OF MENORRHAGIA. 
 
 What are some of its causes? Nervous excite- 
 ment, vascular excitement, fevers, &c., cold checking 
 perspiration, causing internal congestions, &c. 
 
 By what is it aggravated ? By some diseases and 
 displacements of the uterus, as anteversion, retrover- 
 sion, &c. 
 
 With what is menorrhagia easy to be confounded ? 
 With hemorrhage from the uterus, caused by polypi, 
 ulcers, cauliflower excrescences, &c. 
 
 What are the only positive means of discrimin- 
 ation in such cases ? Careful physical examination. 
 
 With what other aff'ection may menorrhagia be con- 
 founded ? Abortion and its attendant hemorrhage 
 and lochia. 
 
 TREATMENT OF MENORRHAGIA. 
 
 Upon what should the treatment be founded? As 
 accurate a knowledge as possible of the cause. 
 
 What kind of treatment is mostly indicated ? An 
 antiphlogistic treatment, sometimes involving san- 
 guineous depletion — then revulsives to the lower ex- 
 tremities, by dry warm feet, blisters, setons, and sti- 
 mulating liniments, &c., but occasionally the patient 
 requires tonics. 
 
 What internal remedies should be given ? The 
 saline laxatives, saline mixture, digitalis, &c., and 
 
OF THE HUMAN FEMALE. 333 
 
 when the excitement is alkyed, small doses of ergot 
 should be administered. 
 
 What treatment seems peculiarly proper in the 
 intervals ? The application of cold, moderate at first, 
 but gradually increasing in intensity, as the cold bath, 
 cold douches, &c. 
 
 Upon what do the irritative forms of monorrhagia 
 depend ? Upon an irritable condition of the uterus, 
 perhaps the result of over excitement of the organ. 
 
 Towards what point should our attention be parti- 
 cularly directed in such cases ? The condition of the 
 uterus. ■ 
 
 What is the result to the patient, from protracted 
 monorrhagia, arising from any of the several causes ? 
 Extreme debility, anemia, dropsy, and sometimes com- 
 pletely broken health. 
 
 Which should claim our attention most, the consti- 
 tution or the discharge ? Gooch, says in this case, 
 take care of the discharge ; but Hodge, says very 
 properly, take care of both. Remove all aggravating 
 causes ; thus, if displacements exist, rectify them, 
 abstain from all sexual excitements, and take care to 
 improve the tone of the system, support patient with 
 animal food, &c., clothe her warmly, particularly 
 about the feet, give her a proper allowance of wine, 
 make use of rough frictions and other revulsive re- 
 medies, as dry cups, rubefacients, and particularly 
 blisters. 
 
 What internal remedies may be administered, as 
 astringents, to check the discharge ? The sugar of 
 lead, or the sulphate of zinc ; one of the best prepara- 
 tions, is probably rhatany. Monesia, and infusion 
 of red roses have been recommended, so also, have 
 small doses of ergot, say four or five grains, four or 
 five times a day. 
 
 LEUCORRH(EA. 
 
 Are females liable to any other affections during 
 the menstrual life, which seem to depend upon it? 
 
334 PHYSIOLOGY AND PATHOLOGY 
 
 They are, particularly to % white secretion from the 
 uterus and vagina, sometimes from both. 
 
 What is this white secretion called ? Fluor-albus, 
 or leucorrhoea, or vulgarly " whites." 
 
 CAUSES OF LEUCORRIKEA. 
 
 Upon what does this secretion appear to depend ? 
 The application of specific virus, as that of gonor- 
 rhoea ; the presence of some irritating body, as po- 
 lypus, and other tumors ; and it may arise from any 
 of the ordinary causes of inflammations. By some, 
 indeed, it is regarded as uterine catarrh. 
 
 DIFFICULTIES OF DIAGNOSIS. 
 
 What difficulties are there in the way of correct 
 diagnosis ? Perhaps, principally, the ignorance of 
 physicians, growing out of the reluctance on the part 
 of patients, to make their true situation properly 
 known. 
 
 Into what divisions should we separate leucor- 
 rhoea? Into uterine leucorrhoea, and vaginal leu- 
 corrhoea, a distinction some think important to be 
 made. 
 
 What are the rational signs of leucorrhoea being 
 uterine ? 1. It often comes on as the precursor of 
 beginning menstruation. 2. It sometimes occurs im- 
 mediately before the red discharge, and again exists, 
 after the red discharge has ceased, thus leaving the 
 patient only one or two weeks freedom from any dis- 
 charge. 3. Sometimes uterine leucorrhoea entirely 
 substitutes the red menstrual secretion. 
 
 What other circumstances have been noted in re- 
 gard to it ? It sometimes comes on about the critical 
 period ; rarely is seen after the fiftieth year of life, 
 and is most frequently preceded or accompanied 
 by symptoms of uterine irritation ; it also often 
 follows abortion, and even some cases of parturition 
 at term. 
 
 What symptoms are usually attendant upon the 
 
OF THE HUMAN FEMALE. 335 
 
 irruption of leucorrhoea ? Sometimes they are acute, 
 resembling those of menstruation, or even of dysme- 
 norrhoea; as pain in the back, fever, sometimes ner- 
 vous disturbance, as hysteria, &c., flatulency, dysuria, 
 pain down the thighs, fulness and sense of tension of 
 the labia ; after these bad feelings have existed a time, 
 the discharge usually comes on. 
 
 CHARACTER OF THE DISCHARGE. 
 
 What is the general character of the discharge ? 
 Generally it is serous, or watery, and perfectly tran- 
 sparent ; sometimes it is mucous, and occasionally it 
 is albuminiform and adhesive. 
 
 Whence is this adhesive secretion thought to 
 originate ? From the glands in the neck of the 
 uterus. 
 
 What are some of the physico-chemical characters 
 of uterine leucorrhoea ? Columbat, upon the author- 
 ity of Donnd, says mucus secreted by the uterus is 
 always alkaline, restores the blue color of the litmus 
 paper ; turns the syrup of violets green, and has 
 such a slimy, ropy and tenacious consistence, that 
 it can be detached from the os uteri only with great 
 difficulty. 
 
 How long may the disturbances resulting in leu- 
 corrhoea continue ? From a few hours to several 
 days. 
 
 CHRONIC LEUCORRHCEA. 
 
 What are the symptoms of chronic leucorrhoea ? 
 They are the same as, but less intense than, the 
 acute. They sometimes occur in the interval of the 
 menses, though the discharge sometimes substitutes 
 the catamenia. Chronic leucorrhoea is usually less 
 inflammatory, but still it exhausts the patient if long 
 continued. 
 
 What is the result to the constitution, of the 
 exhaustion by such secretions ? Increased irrita- 
 bility, in proportion to the reduction of strength. 
 
336 PHYSIOLOGY AND PATHOLOGY 
 
 What is probably the correct opinion respecting 
 many cases of disease in females called spinal irrita- 
 tion ? That in very many cases they originate in 
 irritation, from displacement or otherwise, in the 
 uterus. 
 
 How does Dr. Hodge trace up the chain of morbid 
 nervous actions or sympathies in these cases ? If a 
 patient have uterine irritation or leucorrhoea, irrita- 
 tion is extended to the spine, and may finally induce 
 universal neuralgia — as odontalgia, otalgia, &c., &c., 
 dyspnoea, palpitation, dyspepsia, &c. 
 
 To what point should we direct our remedies in 
 such cases ? To the cure of the original uterine irri- 
 tation, and then the other affections will subside, if 
 they have not been too long continued. 
 
 What characteristics of the discharge distinguish 
 the chronic from the acute form of leucorrhoea ? In 
 the chronic form the discharge is usually thinner than 
 in the acute variety. 
 
 Which variety is most obstinate and difficult to cure? 
 That which is thick like albumen. 
 
 What relation does this leucorrhoeal secretion hold 
 to the morale of the female who is subject to it ? Cer- 
 tain moral causes or impressions act upon this secre- 
 tion to aggravate it, and this again seems to re-act upon 
 the morale of the patient and render it more irritable. 
 
 How are we to explain the occurrence of leucorrhoea 
 in place of menstruation ? In some cases the excite- 
 ment in the uterus is not sufficient to cause a red dis- 
 charge ; when the excitement is not very great we 
 may have leucorrhoea ; but again, when the excitement 
 is inordinately high, even monorrhagia may be the con- 
 sequence. 
 
 What are some of the prominent causes of leucorr- 
 hoea ? Want of cleanliness, over stimulation of the 
 organs by prostitution, &c. 
 
 Stimulating emmenagogues, the irritation of foreign 
 bodies as pessaries, &c. , particular diseases of the 
 
OF THE HUMAN FEMALE. 337 
 
 uterus, including displacements, abortions, remains of 
 placenta, &c. &c. 
 
 Are we to regard leucorrhoea as the result of an in- 
 flammatory action ? By some very respectable autho- 
 rity it is regarded as rarely inflammatory, but as the re- 
 sult of a moderate degree of irritation or excitement. 
 
 How is simple leucorrhoea to be distinguished from 
 the specific affection called gonorrhoea ? In gonorr- 
 hoea there is usually ardor urinse, and it is said by some 
 surgeons that a discharge may be actually squeezed 
 from the urethra in cases of gonorrhoea, while neither 
 of these symptoms attend simple leucorrhoea. 
 
 How are we to diagnosticate uterine from vaginal 
 leucorrhoea ? By the fact that the former is connect- 
 ed with menstruation, sometimes complicated with it, 
 and sometimes becomes a vicarious substitute for it. 
 
 What are the distinguishing characters of true vagi- 
 nal leucorrhoea as described by some of the French physi- 
 ologists ? True leucorrhoea is thick and creamy, will 
 not adhere to the fingers ; reddens litmus paper and 
 appears to be composed of little oval bodies, resemb- 
 ling pellicles Or scales from the mucous membrane. 
 
 What are the microscopic signs of the existence of 
 venereal vaginitis, or blenorrhagia 'r* Columbat sa3^s the 
 discharge is always composed of pus mixed with the 
 proper mucus of the vagina. Donne declares that pus 
 globules are discovered by placing a drop of the muco- 
 purulent fluid between two fine glasses, and examining 
 them with the microscope of 250 to 300 diameters. 
 These infusory animals, whose bodies are transparent, 
 and of round or oval form, with a diameter of jio ^^ 
 j'y of a millimetre, are most commonly united in 
 groups of from two to six individuals — when examined 
 by the light of a lamp they may sometimes be seen to 
 move, more especially to agitate in every direction a long 
 filiform and very delicate appendage, which serves to 
 distinguish them from the spherical and inanimate glo- 
 bules of true phlegmonous pus, in which latter the trico- 
 monas never is observed. 
 
 29 
 
3 '18 PHYSIOLOGY AND PATHOLOGY 
 
 What is a Millimetre ? The thirtj-nlne thousandth 
 part of an inch. 
 
 TREATMENT OF LEUCORRHCEA. 
 
 What rules of treatment are we to observe for ute- 
 rine leucorrhoea ? The same that have been laid down 
 for the management of cases of emansio mensium or 
 chlorosis. When connected with monorrhagia, to be 
 treated as such. 
 
 What is to be done with those cases of leucorrhoea 
 dependant upon displacement of uterus, the presence 
 of foreign bodies, or diseases of the uterus ? Remove 
 the cause by appropriate treatment, and the leucorr- 
 hoea will soon subside. 
 
 What treatment is necessary for the acute form of 
 leucorrhoea ? Some cases require antiphlogistics, as 
 general bleeding, or cups, leeches, and alteratives, and 
 after reduction of general excitement, the use of pro- 
 per local remedies, as tepid and cold injections of mu- 
 cilage into the vagina. If much irritation exists in the 
 parts, warm fomenting injections should be used to 
 favor the discharge. 
 
 What should be done if the disease persist notwith- 
 standing the use of these remedies ? Revulse, by blis- 
 ters upon the sacrum, and hypogastrium ; and if these do 
 not succeed, treat it as a case of uterine irritation. 
 
 What is the duty of the physician in attempting the 
 management of chronic cases of leucorrhoea ? To dis- 
 cover if possible, and remove the predisposing, the 
 actual and the aggravating causes. 
 
 What may be said respecting the use of local reme- 
 dies ? That in general too much reliance is placed 
 upon them, and too little regard had to the improvement 
 of the general health by proper constitutional remedies. 
 
 What remedies have been thought to act directly 
 upon the secretory surfaces of the uterus and vagina ? 
 Of those to be used internally or by the stomach, the 
 balsam of copaiba, the spirits of turpentine, the tinc- 
 ture of cantharides. In the menorrhagic leucorrhoea, or 
 
OF THE HUMAN FEMALE. 839 
 
 that complicated with menorrhagia, the ergot has 
 been prescribed ; some of the preparations of iodine 
 have been thought useful ; externally the use of con- 
 tinued blisters, or of pustulation from tartar emetic 
 ointment, with cold douches to the back and into the 
 vagina, have been useful, in allaying the local irritation. 
 When may we hope to derive benefit from astrin- 
 gent injections? When the constitutional and local 
 excitement have been subdued by the means already 
 pointed out. 
 
 VAGINAL LEUCORRHCEA. 
 
 What is to be said respecting the frequency of va- 
 ginal leucorrhoea ? It is more common than that from 
 the uterus, and very many females are incident to it. 
 
 What are the causes of vaginal leucorrhoea ? The 
 irritations from certain foreign bodies in the vagina, 
 as pessaries, &c. The use of instruments in terminat- 
 ing labor, or abortion ; violence done to the vagina in 
 the commission of rape, &c. Chemical or vital irri- 
 tants, as stimulating injections, the escape of urine into 
 vagina, acrid discharges from the uterus, the presence 
 of tumors in the uterus and vagina, &c., excessive ve- 
 nery, or prostitution, &c. &c. 
 
 How far may leucorrhoeal discharge depend upon 
 enfeebled condition of the general health ? It is some- 
 times dependant upon this condition of the general 
 health entirely. 
 
 To what extent is it dependant upon sympathetic 
 irritation in other parts ? It is known in some instan- 
 ces to be caused by gastric irritation, by ascarides in 
 the rectum, by diseases in the anus, as hemorrhoids, 
 fistulae, &c. 
 
 How far may habits of life, and the condition of cli- 
 mate operate in its production ? They may have con- 
 siderable influence. The women Avho use foot stoves, 
 who indulge in various luxurious habits, or who reside 
 in very moist climates, are said to 'he more prone to it 
 than those under different circumstances. 
 
340 PHYSIOLOGY AND PATHOLOGY 
 
 VAGINITIS. 
 
 To what state of the vagina is it owing ? General- 
 ly to an inflamed state of the canal. 
 
 Is it more common in the married or unmarried fe- 
 male ? In the married female, though even very 
 young girls are sometimes affected with it. 
 
 What are the symptoms of vaginitis ? There is p^ 
 sense of fulness in the pelvis, sometimes, though rarely 
 pain, but more frequently a sensation of heat in the 
 course of the vagina : with this there is often tenes- 
 mus, and a mucous discharge from the rectum, also 
 dysuria, the urine being natural in quality, but the ca- 
 nal of the urethra irritable from the extension of the 
 irritation from the vagina. 
 
 DIFFERENT STAGES. 
 
 Into how many stages do some authors divide this 
 aifection ? Into two, the acute or severe, and the 
 chronic or mild stages, or forms. 
 
 What is the usual character of the discharge in the 
 severe form ? It is acrid, sometimes red, like bloody 
 serum. 
 
 What is it when the inflammation is milder ? It re- 
 sembles mucus or muco-puruloid matter ; sometimes 
 it is of a greenish color ; when the affection has be- 
 come decidedly chronic, the discharge is usually of a 
 thin yellowish color. 
 
 How does acute vaginitis usually terminate ? By 
 resolution, or it runs into a chronic or milder form. 
 
 To what extent does it go when it is very severe 
 and somewhat protracted ? It then may involve the 
 muscular or fibrous coat ; unless, however, the mucous 
 coat shall have been destroyed b}^ the inflammation, or 
 ulceration, or by a wound, the surfaces do not become 
 adherent to each other. In some instances, moreover, 
 sloughing does actually take place. 
 
 GONORRHO^AL VAGINITIS. 
 What is the diagnosis of gonorrhoeal inflammation 
 of the vagina ? In this variety of vaginitis there is ar- 
 
OF THE UUMAN FEMALE. 341 
 
 dor urinae, inflammation in the inguinal lymphatics, 
 and in the severer forms, ulcerations of the os tincae 
 have been observed. 
 
 Is it necessary that the vaginitis shall be of a speci- 
 fic character, to produce an irritation in the penis from 
 the act of coition ? Leucorrhoea per se may be so acrid 
 as to cause irritation in the male organ when exposed 
 to contact with it. 
 
 TREATMENT OF VAGINITIS. 
 
 What is the appropriate treatment of acute leucor- 
 rhoea ? Vascular and intestinal depletion, revulsive, 
 &c. If the general vascular system be affected, ven- 
 esection, saline cathartics, low diet ; — locally, cups to 
 the back, or leeches to the vulva ; then promote secre- 
 tion by warm hip bath, warm mucilaginous injections 
 into the rectum and vagina. 
 
 What is proper after the inflammation has been re- 
 duced ? Astringent washes, as solutions of sulphate or 
 acetate of zinc, acetate of lead, alum, borax, nitrate 
 of silver. 
 
 What peculiar effect does alum produce ? It coagu- 
 lates the secretion, particularly if the alum be previ- 
 ously burnt, or thoroughly dried. 
 
 Suppose the inflammation to have been such as to be 
 followed by adhesions of the walls of the vagina, what 
 treatment should be persued ? The contractions and 
 occlusions thus formed should be overcome by the use 
 of bougies or other proper dilating instruments. 
 CHRONIC LEUCORRHCEA. 
 
 What are some of the causes of chronic leucorrhoea ? 
 Chronic inflammation of the vagina, displacements of 
 the uterus, ulcerations in the vagina, or uterus, &c. 
 
 Can chronic leucorrhoea be readily distinguished 
 from chronic gonorrhoea ? It is almost impossible to 
 make out the difference between them. 
 
 TREATMENT OF CHRONIC LEUCORRH(EA. 
 
 What are the general indications in the treatment 
 29* 
 
342 PHYSIOLOGY AND PATHOLOGY 
 
 of the chronic form of leucorrhoea or vaginitis ? To 
 improve the general health by the use of fresh air, 
 wholesome diet, tonics, alteratives, as preparations of 
 iodine, &c. ; then resort to local treatment ; if there be 
 ulcerations, first cure them. As alterative remedies, 
 the balsam of copaiba, and tincture of cantharides, 
 have had some reputation. 
 
 Have we probably any specific for the cure of this 
 complaint ? Nothing which can be relied upon as 
 such. 
 
 What kind of topical applications are best when 
 the system has been prepared for their use ? As- 
 tringent washes of decoctions of logwood, nutgalls, oak 
 bark, &c. 
 
 Should any rule be observed in reference to the 
 mode of application ? They should be passed slowly, 
 but far up, to distend the whole vagina, and bring the 
 remedy in contact with the whole mucous surface. 
 
 What mineral astringents are useful ? The sulphate, 
 or acetate of zinc, or of lead, one drachm to half pint 
 of mucilage of gum arable, to render it slightly ad- 
 hesive to the vaginal surface. The alum, as mentioned 
 in the reduced state of acute vaginitis, is particularly 
 useful. 
 
 What is the probable origin of the pure milky white 
 discharge which occurs in some cases ? Its origin is 
 not well defined ; it is sometimes supposed to come 
 from the glands of the neck of the uterus, but it has 
 been seen issuing from the vulva. 
 
 What is the best mode of cure of the peculiar state 
 giving rise to this discharge ? The application of the 
 solid nitrate of silver, or a strong solution of the arti- 
 cle to the part affected. 
 
 PAIN IN THE BACK, &c., NOT ALWAYS DEPENDANT UPON 
 VAGINITIS. 
 
 Upon what affections besides those of the uterus 
 may the pain in the back, &c., depend ? It may be 
 caused by some disease in the kidneys, in the bladder, 
 
OF THE HUMAN FEMALE. 343 
 
 &c., or it may be of a neuralgic, or rheumatic origin, 
 independent of any uterine afiection. 
 
 In those dorsal or lumbar pains accompanying dis- 
 turbance of the uterus, is the pain constant or inter- 
 mittent ? It is sometimes intermittent, paroxysmal, 
 and of a neuralgic character ; it is mostly moderated 
 by assuming the recumbent position ; though some- 
 times the pain is constant even when lying down. 
 
 Are these painful sensations necessarily the result 
 of inflammation ? They do not always depend upon 
 inflammation, but frequently upon a state of irritation. 
 
 IRRITABLE UTERUS. 
 
 What are we to understand by the phrase " ijTitahle 
 uterus f A morbid sensibility of this organ, without 
 inflammation or change of structure ; a condition 
 which has continued in some cases for several years 
 without afi'ecting any organic lesion perceptible to the 
 senses. 
 
 What influence does this irritability of the uterus 
 appear to have over the exercise of its functions ? It 
 causes them all to be painfully performed. 
 
 What is the eff'ect of touching the uterus while it is 
 in an irritable state ? It is extremely painful, some- 
 times causing the patient to scream. 
 
 Can the function of reproduction be carried on 
 in cases of irritable uterus ? Sterility mostly, though 
 not perhaps always, accompanies irritable uterus. 
 
 What are the principal causes of irritability of the 
 uterus ? Disturbance of function, and displacements 
 of the uterus ; in some cases, it is dependent upon 
 the character of the constitution, frequent labors, 
 abortions, &c. 
 
 By what circumstances is the sensibility aggra- 
 vated ? By distension of bladder, or rectum ; by 
 any severe exercise which causes pressure upon the 
 uterus. 
 
 Is this afl'ection necessarily complicated with any 
 other ? It often exists entirely alone, but in some 
 
344 PHYSIOLOGY AND PATHOLOGY 
 
 instances it is combined with an inflammatory state of 
 the organ. 
 
 What influence may depressed or disturbed states 
 of mind have over the production of this affection ? 
 They may exert so potent an influence as to require 
 the condition of the mind to be improved before any 
 other treatment can be eff'ectual. 
 
 What consequences may irritable uterus produce if 
 not speedily cured ? Dysmenorrho^a, or menorrhagia, 
 or a train of morbid sensibility, or nervous excitability, 
 hysteria, spinal irritation, &c. 
 
 TREATMENT OF lERITABLE D TERUS. 
 
 What are the curative indications in irritability of 
 the uterus ? The removal of any or all the causes 
 which have produced it. Thus, if there be any dis- 
 placement of the uterus, it must be properly restored, 
 and kept in its proper situation by mechanical or 
 other efficient means. If it has come on after any 
 violent effort of the uterus, as after labor, or abortion, 
 the patient must be kept quiet, and her bowels moder- 
 ately open ; if there be any local inflammatory excite- 
 ment, leeches may be applied to the sacrum or groins. 
 
 Is there any objection to the application of leeches 
 directly to the uterus in case of irritability of that or- 
 gan ? Their application would be painful, and some- 
 times aggravating. 
 
 What constitutional remedies should be employed ? 
 During the three weeks immediately succeeding the 
 menstrual discharge, she should use the cold bath, 
 either local or general, with a view to obtain a reaction 
 and healthy glow of warmth, and by thus increasing 
 the strength, diminish the irritability of the nervous 
 system ; cold douches down the back — cold water 
 into the vagina — large quantities of cold water into 
 the rectum and colon to distend them, and produce 
 the two-fold eff'ect of removing the feces and giving 
 tone to the nerves. 
 
 What rule for diet and exercise should be observed? 
 
OF THE HUMAN FEMALE. 345 
 
 In the tnore chronic or protracted form, the diet 
 should be nutritious, and solid or animal, and not en- 
 tirely vegetable. The patient should be carried out 
 into the open air whenever possible, and she should 
 use exercise on foot whenever she is able, without 
 aggravating her symptoms. 
 
 What is to be said respecting counter-irritants? 
 They, such as tartar emetic, croton oil, moxa, and per- 
 petual blisters or setons seem to be in general too irri- 
 tating to the system, and rather aggravate than relieve. 
 
 Under what circumstances are narcotics called 
 for ? During severe attacks of pain, the cicuta in 
 two grain doses, three or four times a day, gradually 
 increasing the quantity if necessary ; stramonium, 
 belladonna, hyosciamus, lactucarium, &c., are some- 
 times very useful in allaying the pain, provided the 
 use of them is continued through several weeks. 
 
 What alterative tonic have we which is often useful 
 in these cases ? Lugol's solution of iodine, or the hy- 
 driodate of potash. Five, ten, or twelve drops, three 
 times a day, of the strong solution, continued a long 
 time, often improves the appetite and the vigor of the 
 general system. 
 
 What other parts of the pelvic viscera of the fe- 
 male have been observed to be subject to this morbid 
 irritability ? The vagina, vulva, and urethra. 
 
 What treatment is proper for these cases ? The 
 same as for irritable uterus. 
 
 DISPLACEMENTS OF THE UTERUS— PROLAPSUS. 
 
 To what variety of displacements is the uterus sub- 
 ject ? To prolapsus in its several degrees — to retro- 
 version partial and complete — to anteroversion — to 
 anteflection — to retroflection, and to a hernial dis- 
 placement. 
 
 Are either of these displacements capable of being 
 positively diagnosticated by the rational or sympa- 
 thetic signs ? No ; there are numerous other affec- 
 tions liable to occur in the female pelvis, which give 
 
846 PHYSIOLOGY AND PATHOLOGY 
 
 signs strongly resembling displacements. Thus, con- 
 gestions of the uterus, irritable uterus, irritable 
 urethra, irritable vagina, irritable rectum, polypous and 
 other tumors in the uterus or vagina, ascarides in the 
 rectum, or accumulation of hardened feces in that 
 intestine, have all produced sympathetic symptoms 
 similar to those of prolapsus or other displacements. 
 
 SYMPTOMS ATTENDANT UPON DISPLACEMENTS OF 
 THE UTEEU&. 
 
 What are the symptoms usually attendant upon 
 displacement ? Many of the symptoms of local in- 
 flammation — weight in the pelvis wliile in the erect 
 position — bearing down — disposition to strain, as if 
 to evacuate the bladder or bowels — sensation as 
 though something must fall away — pain in the sacro- 
 lumbar region, thence all round to the hypogastrium ; 
 pains in the bones of the pubes, probably from the 
 stretching of the round ligaments : this is relieved at 
 once by lying down — pains sometimes intermittent, 
 like those of labor — a more or less fixed pain in the 
 side, sometimes in one side, sometimes in the other, 
 sometimes in the one inguinal region or the other, and 
 often with a sense of dragging from the umbilicus. 
 
 What effect has certain states of the bowels on the 
 feelings of patients who have displacements of the 
 uterus ? If the bowels are moved regularly and with- 
 out effort, and the patient is not in a highly irritable 
 condition, she may feel comparatively well ; but if the 
 bowels be constipated, the weight of the feces aggra- 
 vates the feelings of the patient : and if she hajve a 
 diarrhoea, the frequent actions of the bowels greatly 
 increase her distress, by still more dragging down the 
 uterus. 
 
 Which most sympathises in this local disturbance 
 of the uterus, the vascular or nervous system ? The 
 vascular system is usually little affected, but the ner- 
 vous sympathies often become very extensive ; thus, 
 the spinal marrow, or the brain itself, takes on the char- 
 
OF THE HUMAN FExMALE. 347 
 
 acter of spinal or cephalic irritation, and in time the 
 neuralgia of almost every organ may occur in succes- 
 sion or simultaneously. 
 
 What appears to be proof that this irritation has 
 depended upon displacement of the uterus? The 
 fact in some cases instantly, and in most others sooner 
 or later, all these distressing affections have ceased 
 after the restoration of the uterus to its proper place. 
 
 TRUE METHOD OF DIAGNOSIS. 
 
 As there are many other affections already alluded 
 to, which cause symptoms resembling displacements 
 of the uterus, is it proper that the physician should 
 at once determine, by physical examination, what the 
 true diagnosis is? This should be regarded as a fun- 
 damental rule in the duty of treating diseases, but as 
 in this case the feelings of both patient and physician 
 should be spared if possible, it has been advised first 
 to treat all these acute symptoms by rest in bed, with 
 the head and shoulders low, light diet, laxative medi- 
 cine, warm fomentations, warm injections, and if ap- 
 parently necessary, leeches to the groins, and the in- 
 ternal use of such mild narcotics, as will, under 
 ordinary circumstances of irritation, quiet the sys- 
 tem. 
 
 TREATMENT OF DISPLACEMENTS. 
 Suppose the train of symptoms denoting engorge- 
 ment, irritability, or displacement of the uterus, should 
 occur in a patient at any time, what treatment should 
 be adopted ? If after a careful examination by the 
 touch, of the parts concerned, prolapse or retrover- 
 sion is detected, it should be reduced, if possible, 
 at once, and if this do not afford the desiied relief, 
 let the patient be kept in a horizontal position on a 
 bed or sofa for the requisite number of days, even if 
 the time so occupied continue for several weeks, in 
 order to give the parts an opportunity to recover their 
 healthy condition, and as soon as the parts will bear 
 
348 PHYSIOLOGY AND PATHOLOGY 
 
 it, a proper pessary should be used to support it, if the 
 vagina and the uterine ligaments have not sufficient 
 tone to justify the hope that the recovery may be well 
 secured without it. 
 
 When the acute symptoms have been relieved by 
 rest or otherwise, what is mostly necessary to com- 
 plete the cure or afford permanent relief to the displace- 
 ment, while the patient is recruiting her general health 
 by exercise ? Such mechanical support as will retain 
 the uterus in its proper situation until the general 
 health becomes restored, and the ligaments of the 
 uterus acquire their natural tonicity. 
 
 PESSARIES. 
 
 What is the general history of the artificial means 
 of support for the uterus ? From the earliest re- 
 cords of medicine, instruments called pessaries have 
 been in use. They have been composed of various me- 
 dicated substances, which have been supposed to exert 
 resolvent, or softening, or astringent, or tonic influ- 
 ences upon the parts with which they were placed in 
 contact. In most cases, recently, they are used for the 
 purpose of affording mechanical support to a prolapsed 
 vagina, bladder, or uterus. 
 
 Of what is the pessary usually made ? Of cork, 
 covered with wax ; of linen stuffed with hair, or wool, or 
 oakum, and varnished ; of sponge; of box-wood, ivory; 
 of coiled wire covered with leather or gummed cloth ; 
 of caoutchouc bags or balls ; of small bladders, or 
 birds' craws filled with air ; of eggshells from which 
 the contents had been extracted ; and various other 
 materials which circumstances might seem to indicate 
 or ingenuity invent. Some persons have sewed up 
 tan in linen bags, soaked them in wine, and while so 
 moistened inserted them into the vagina. 
 
 What are some of the varieties of form of the pes- 
 sary ? Globular, globe-depressed on one, or opposite 
 sides; oblong, bung or biscuit-shaped, cylindrical, or 
 cyiindroidal, ovoidal : — indeed of almost e\erj other 
 
OF THE HUMAN FEMALE. 349 
 
 imaginable variety of shape, according to tlie supposed 
 condition of the parts to which they were to be ap- 
 plied. Some have been made ring-shaped, others like 
 an oval link of a chain ; some of these have been thus 
 oval with the conjugate diameter shortened, making it 
 resemble the figure of the plane of the superior strait ; 
 others, oblong and curved on one of the' planes or 
 aspects, to look like the frame of a large shoe-buckle ; 
 while others again have been finished like a huge letter 
 U, or bow of an ox-yoke, and curved upon one of its 
 broad planes with a view to adapt such curvature to 
 the natural axis of the vagina. Quite recently we 
 have a ring made of watch-spring steel and covered 
 with gutta percha, that it may be compressed into a 
 long ellipse at the time of inserting it, and afterwards 
 expand to the capacity of the vagina. 
 
 What are the materials of which the pessary should 
 be composed whenever practicable ? Glass, or silver 
 well gilt, or pure gold. 
 
 What are mostly entitled to preference ? 1. The 
 common flat circular form. 2. The ring-shaped, with 
 very thick edges. 3. The oval-rfng, curved upwards 
 at one or both extremities. 
 
 What is the objection to the globular pessary ? 
 1. It is introduced through the osteum vaginae with 
 difiiculty. 2. It does not always sustain the uterus 
 in its natural situation. 3. It is often extremely diffi- 
 cult to remove it when it has been introduced. 
 
 What position should the round flat pessary occupy 
 in the vagina ? It should be parallel with the rec- 
 tum, that is, its convex surface should be applied to 
 the rectum, with its upper edge in the cul-de-sac of 
 the vagina, and its lower edge upon the perin«3um. 
 
 Is the uterus then supported in the direction of the 
 thickness, or the diameter of the pessary ? It cannot 
 be eifectually supported in any other than the direc- 
 tion of the diameter of the pessary. 
 
 In what way does the pessary appear to act in the 
 support of the uterus ? As a lever, of which the con- 
 30 
 
B^ PHYSIOLOGY AND PATHOLOGY 
 
 vex surface rests upon the rectum as a fulcrum, and 
 the muscles of the perinneum act at the lower edge, 
 while the uterus is supported upon the upper edge. 
 
 Which form of pessary has been regarded as best 
 for the support of a retroverted uterus ? The oblong 
 or elliptical ring pessary, which must be long enough 
 to have one of its extremities go up behind the neck 
 and under the body of the uterus, while the other end 
 is supported by the perinoeum, or by the pubes. 
 
 What class of pessaries are supposed to be best for 
 females who have had many children, or those affected 
 with irritable uterus, or those who have ulcerations 
 upon the os uteri ? First, the oval pessary ; next, 
 the ring pessaries with edges sufficiently thick to 
 elevate the uterus from contact with the floor of the 
 vagina. 
 
 What consequences may result from having the 
 pessary too small ? Both pessary and uterus may 
 become prolapsed or retroverted. 
 
 What is to be said of the stem pessary, or the pes- 
 sary resembling the stem and bottom of a wine-glass ? 
 It is usually too irritating to be useful. 
 
 What is the first thing essential to the successful 
 use of the pessary ? That the uterus be replaced in 
 its natural situation, for without this the pessary will 
 fail to answer the purpose intended. 
 
 MANNER OF INTRODUCING THE PESSARY. 
 
 What is the proper method of introducing a pes- 
 sary ? Frequently it is sufficient that the patient lie 
 upon her left side, with her hips to the edge of the 
 bed. It is usually more convenient for the practi- 
 tioner that she lie upon her back, and in some diffi- 
 cult cases it is necessary that she have her hips 
 brought to the foot of the bed, and her feet on chairs 
 each side of the seat of the practitioner. The vulva 
 is then to be well lubricated, and the posterior com- 
 missure so put upon the stretch by the index finger 
 of one hand, as to dilate the orifice of the vagina. 
 
OF THE HUMAN FEMALE. 351 
 
 The pessary also, well lubricated, is now to be intro- 
 duced edgewise in the direction of the long diameter 
 of the vagina, by making it press firmly upon the 
 finger, which rests upon the posterior commissure, 
 and taking care not to allow the upper edge to con- 
 tuse either of the nymphse, press firmly but gradually 
 onward, until it has entered the orifice of the vagina 
 — then observing that it turns over with its concave 
 surface upwards — continue pressing upon its anterior 
 edge till it is made to rest in the fossa in the perin- 
 seum behind the posterior commissure of the vulva, 
 having its upper edge completely imbedded in the cul- 
 de-sac of the vagina. 
 
 At what part of this operation does the patient 
 experience pain ? While the instrument is passing 
 through the orifice of the vagina. It is usually in- 
 stantly relieved, as soon as the pessary has fairly 
 passed beyond this point. 
 
 Would it not be best to replace the uterus with the 
 finger, before attempting the introduction of the 
 pessary ? It would always ^ be best, and in those 
 cases in which the finger is too short for carrying 
 up the fundus in cases of retroversion, it is best to 
 elongate it by carrying up upon it a flexible metallic 
 bougie, with which the organ may be replaced. 
 
 What advantage can be gained by passing a finger 
 into the rectum in these cases ? The replacement 
 may thus often be facilitated, but operations through 
 the rectum are often very painful to the patient. 
 
 What instructions should be given to the patient, 
 if she should feel that the lower edge of the pessary 
 presses anteriorly ? To insert the finger into the 
 vagina, and press the instrument backwards and ra- 
 ther downwards. 
 
 What sensation does the patient usually experience 
 after the pessary is properly placed ? Sometimes, 
 immediate relief; this however is not always the case 
 for a few days. In some cases, moreover, it cannot be 
 borne. 
 
352 PHYSIOLOGY AND PATHOLOGY 
 
 How long Is it usually requisite for a patient to 
 continue the use of the pessary ? So long as it re- 
 mains in its proper position without exciting irrita- 
 tion. Whenever it causes any considerable uneasiness, 
 it will be proper to have it removed to be regilded, or 
 to have a substitute of a different size. 
 
 How long may she usually wear a glass, or a gilt 
 pessary without removing it ? In general six months ; 
 at the end of which time it is usually necessary that 
 she have it removed to be re-gilded, or to substitute 
 one of diiferent size, whether it be of glass or other 
 material. 
 
 How are such pessaries to be kept clean in the 
 vagina ? By the use of injections. 
 
 What can be said of the elytroid pessary of Clo- 
 quet ? That it is not found to answer the desired 
 purpose. 
 
 OBJECTIONS TO PESSARIES. 
 
 What are some of the evil consequences which 
 may result from pessaries ? Irritation, inflamma- 
 tion, ulcerations of the vagina and orifice and neck 
 of the uterus ; when injudiciously employed, or un- 
 suitably constructed, the neck of the uterus has 
 become strangulated in the perforation of the flat 
 pessary, &c. 
 
 What is probably the cause of the objections to the 
 use of pessaries for the relief of prolapsus and other 
 displacements of the uterus ? The fact that they are 
 often made of improper materials, unsuitable forms, 
 and that those who insert them misapprehend the 
 manner of application, and their mode of operation 
 for the support of the displaced organs. 
 
 What should be done if the pessary be found pro- 
 ducing any injury ? It should be removed and its 
 use entirely abandoned, or it should be substituted by 
 one adapted to the case. 
 
 Is difficulty ever experienced in attempts to remove 
 pessaries ? So much difliculty has occurred in at- 
 
OF THE HUMAN FEMALE. 353 
 
 terapts, in some instances, that various instruments 
 have been brought into requisition to aid in the 
 removal of them, as forceps, scissors, hooks of various 
 kinds. 
 
 What simple instrument has been found successful 
 in most of the cases in which the fingers alone proved 
 insufficient ? One about eight inches long, with a 
 fenestrated curve at one extremity, to act as a sort 
 of vectis, while the other end is made into a hook, as 
 shown in 
 
 Fig. 137. 
 
 ^ 
 
 IIow may this instrument be used ? The hooked 
 extremity may be inserted into the opening of the 
 flat or ring pessary, and be used to assist in with- 
 drawing it when it has been properly turned upon its 
 edge, with the point of the finger applied on the op- 
 posite sides and upon the end of the hook to guard it 
 from injury to the patient. The concave surface of 
 the curved extremity may be applied upon the super- 
 fice of a globular pessary, and by the aid of a finger 
 may be employed in scooping the instrument from the 
 vagina through the vulva. 
 
 PROLAPSUS OF THE UTERUS. 
 
 What are we to understand by prolapsus of the 
 uterus ? Its precipitation along the canal of the 
 vagina. 
 
 How many degrees of prolapsus are there ? Three. 
 First — descent, where the position is slightly altered, 
 without however any marked deviation of the axis of 
 the uterus, but with the neck often bent a little for- 
 ward. Second — precipitation or prolapsus, where 
 the organ has descended low into the vagina, and has 
 changed the direction of its axis, from a correspon- 
 30* 
 
354 PHYSIOLOGY AND PATHOLOGY 
 
 dence with that of the superior strait to that of 
 the cavity, or even inferior strait, with its anterior 
 surface upwards. Third — procidentia, or complete 
 prolapsus, where the organ with part or all of its 
 appendages, has escaped the Vulva, with its axis 
 corresponding more or less to the axis of the whole 
 body. 
 
 ORDINARY CAUSES OF THIS ACCIDENT. 
 
 What is the most common cause of prolapsus ? 
 Increased size and weight of the organ, particularly 
 when accompanied by relaxation or elongation of 
 the ligaments, and especially of the utero-sacral 
 ligaments. 
 
 During what period of pregnancy is the uterus 
 most likely to become prolapsed ? Between the first 
 and the fourth months, while the organ is heavy and 
 yet not large enough to be supported by the bony 
 structure of the pelvis ; again, shortly after parturi- 
 tion, while the organ is still large and heavy, and the 
 ligaments very much relaxed or elongated. 
 
 What ligaments are most important to the support 
 of the uterus in situ ? The utero-sacral, or posterior 
 ligaments of the uterus. 
 
 What part does the vagina perform in the support 
 of the uterus ? Probably none at all ; though in this 
 respect obstetric anatomists differ in opinion. 
 
 What influence should the knowledge of the risk 
 of accidents have upon our management of puerperal 
 females ? They, that is, any others than perhaps 
 savages and very laborious women, should be kept in 
 the horizontal position several days after parturition, 
 until the uterus may have approached to its usual 
 size, and the ligaments have regained their usual ton- 
 icity and degree of contraction. 
 
 What are the exciting causes of prolapsus, in single 
 or unimpregnated women ? Great muscular exertion, 
 which sometimes induces it in strong girls; sudden and 
 severe fulls^ constriction of the upper portion of the 
 
OF THE HUMAN FEMALE. 355 
 
 body, and consequent pressure upon the intestines, 
 and through them upon the pelvic viscera, as produced 
 by tight lacing, severe straining to relieve constipated 
 bowels, &c. 
 
 What is the ordinary mode of treating prolapsus 
 uteri ? That which w^as alluded to under the head of 
 displacements generally — astringents conveyed into 
 the vagina, pessaries, &c. 
 
 What surgical means have been devised for the 
 radical cure of procidentia uteri ? The removal of a 
 portion of the mucous membrane of the posterior or 
 anterior part of the vagina, then bringing the edges 
 together, so that by their adhesion the vagina may be 
 diminished in size. 
 
 BANDAGES AND COMPRESSES IN DISPLACEMENTS OF 
 THE UTERUS. 
 
 What is the modus operandi of most of the band- 
 ages now in use professedly for prolapsed uterus ? 
 They compress the inferior part of the abdomen, and 
 may be properly called abdominal supporters ; but at 
 the same time, they either force down the small in- 
 testines into the cavity of the pelvis upon the uterus, 
 or by the firm pad placed in front of the abdomen, 
 and directly above the pubes, they form such a 
 plane as to cause the abdominal viscera to descend 
 into, or towards the pelvis, when pressed upon from 
 above by the diaphragm and other respiratory 
 muscles. 
 
 Whaf is the eifoct of the perinaeal pad and straps ? 
 They contribute in conjunction w^ith the circular 
 b^nd, to subject the uterus to more or less compres- 
 sion, in consequence of its pressing up the perineum 
 to the orifice of the uterus. 
 
 With what other displacement of the uterus may 
 prolapsus be confounded ? With antero-version, an- 
 tero-flexion, latero-flexion, retro-flexion, and partial, 
 or even complete retroversion. 
 
356 PHYSIOLOGY AND PATHOLOGY 
 
 ANTEVERSION OF THE UTERUS. 
 
 What is meant by the term anteverswn of the 
 uterus ? That condition of the uterus in which 
 its body and fundus are thrown forward against the 
 bladder. 
 
 Is this of frequent occurrence ? It is be- 
 lieved^ to be rare, and especially in the unmarried 
 female. 
 
 What symptoms does it produce ? Several of 
 those attendant upon prolapsus and retroversion, but 
 especially does the patient complain of sense of pres- 
 sure against the bladder ; sometimes this feeling is so 
 strong as to have given rise to the idea that calculus 
 existed in the bladder. 
 
 What attempts are to be made to remove the 
 cause of such distressing symptoms ? The indica- 
 tions are to restore the displaced fundus to its proper 
 situation, and retain it if possible by a well adjusted 
 pessary. 
 
 Does this displacement of the uterus appear to ex- 
 ert any influence over the susceptibility for impregna- 
 tion, or the capability of the uterus to fulfil its office 
 as a gestative organ ? Since deviations from the nor- 
 ma] positions of the uterus, generally more or less 
 modify the susceptibility for impregnation, mostly di- 
 minishing it, and sometimes destroying it altogether, 
 it is probable that anteversion is often unfavorable to 
 the necessary contact of the two germs ; a«d it is 
 known that in some cases the woman was subject to 
 successive abortions until after the anteverted uterus 
 had become permanently restored to its proper rela- 
 tion with the vagina, and other pelvic viscera. 
 
 RETROVERSION OF THE UTERUS. 
 
 What is meant by the term retroversion of the 
 uterus ? Retroversion consists in the turning of the 
 womb backwards into the hollow of the sacrum, so 
 that its anterior face looks towards the concavity of 
 
OF THE HUMAN FEMALE. 
 
 357 
 
 that bone. While its orifice is carried towards the 
 top of the symphysis of the pubes, so that its inverted 
 axis is nearly or quite in the relation with the axis 
 of the superior strait of the pelvis, — its posterior face 
 is made to come in contact with the posterior surface 
 of the vagina, and its fundus and nearly all its body 
 is depressed into the cul-de-sac of the pelvic peri- 
 tonaeum. See fig. 138. 
 
 Fig. 138. 
 
 SYMPTOMS OF RETROVERSION OF THE UTERUS. 
 
 What symptoms does this displacement usually pro- 
 duce ? In nearly every respect they are the same as 
 arise from prolapse of the uterus. In many of the 
 cases the patient, with strong desires, can pass no 
 urine at all, or at best usually only a few drops at a 
 time. 
 
 What circumstances may complicate this diagnosis 
 of retroversion ? The existence of tumors in the sub- 
 peritonseal cellular tissue, or the descent of an ovary 
 into the cul-de-sac below the utero-sacral ligaments. 
 PARTIAL OR INCOMPLETE RETROVERSION. 
 
 Is there not a less considerable displacement of the 
 
358 PHYSIOLOGY AND PATHOLOGY 
 
 body of the womb backward, still accompanied by 
 many very annoying and distressing sensations ? 
 Some patients are afflicted with what has been called 
 a partial retroversion or tilting backwards of the ute- 
 rus ; the ligaments are put less considerably upon 
 the stretch, and the bladder and rectum probably 
 less severely pressed upon ; but it would seem to be 
 proper to regard this kind of displacement a prolapse 
 rather than a retroversion of the organ. 
 
 CAUSES OF RETROVERSION OF THE UTERUS. 
 What are some of the prominent causes of retro- 
 version of the uterus ? Too great a distension of the 
 bladder, too severe and long continued compression 
 of the abdomen by tight lacing ; sudden shocks to the 
 system by falls, leaping, dancing, carrying great 
 weight, &c. 
 
 TREATMENT OP RETROVERSION. 
 
 How should you reduce retroversion of the non- 
 gravid uterus ? Evacuate thoroughly as possible the 
 bladder and the rectum. Place the patient on her 
 left side in bed, properly covered, with her hips easily 
 within reach, lubricate the index finger, and carry it 
 into the genital fissure till it reaches the tumor in the 
 lower part of the pelvis, then pass it slowly and 
 steadily upwards if possible, till it reaches as far as 
 the finger can carry it ; if this attempt be successful, 
 transfer the finger to the os uteri, and as gently carry 
 it backwards till it is restored to its proper relation 
 with the axis of the superior strait. 
 
 If this plan fail, in what other attitude of the pa- 
 tient would it be best to repeat the attempt at reduc- 
 tion ? Request the patient to place herself on her 
 knees on the bed, and to bring her chest as much as 
 possible in contact with it. 
 
 What instruments have been proposed to aid in 
 replacing a retroverted uterus ? One by Professor 
 Meigs, and two, a simple and compound one, by Dr. 
 H. Bond. 
 
OF THE HUMAN FEMALE. 6b\} 
 
 PROFESSOR MEIGS' INSTRUMENT. 
 "What does Dr. Meigs in his " Letter to his Class " say- 
 respecting the use of instrumental means in replacing 
 a retroverted uterus ? He there states, that it some- 
 times happens that the surgeon cannot succeed with 
 two fingers of the right hand, in carrying the retro- 
 verted uterus so far upwards along the course of the 
 sacrum, as to compel it to rise above the promontor}'" 
 of the bone, and thus be set at liberty from its im- 
 prisonment in the lower basin of the pelvis. In order 
 to effect this, the fingers are required to be longer 
 than the usual length. By means of the little instru- 
 ment of which fig. 139 is a representation, you will 
 
 Fig. 139. 
 
 be enabled to carry it much farther than with the 
 fingers. The instrument is made of steel, and it is 
 conveniently curved to suit the form of the back part 
 of the excavation. Conducted along the left indica- 
 tor finger, to the cul-de-sac, behind the vaginal cer- 
 vix, it may be pressed against the overset womb, which 
 is readily pushed upwards by it. It is also a conve- 
 nient instrument for drawing down the cervix from the 
 pubes ; that part of the organ being taken hold of by 
 the ring. The whole instrument, from the top of the 
 ring to the end of the handles, is just eleven inches 
 in length. 
 
 DR. HENRY BOND'S INSTRUMENT. 
 What are Dr. Henry Bond's description and illus- 
 tration of an instrument called by hira the " Uterine 
 Elevator," with w^hich he has several times succeeded 
 in replacing retroverted uteri when other means had 
 
360 PHYSIOLOGY ^ND PATHOLOGY 
 
 failed ? The instrument consists of two blades — the 
 anal and the vaginal — and of a clamp-headed screw 
 and nut to fasten them together. The anal blade, in- 
 cluding the body and the stem, is about 9 or 10 
 inches long, and made with the curvature of a radius 
 of about 8 inches. The body of this blade, to which 
 belongs the handle of the instrument is about 3 inches 
 long and made square. Upon this the other blade 
 rests firmly, or slides, as circumstances shall require. 
 The vaginal blade, curved upon a radius of about 7 
 inches, has a large groove two inches long, exactly 
 fitted to receive the body or square part of the 
 other blade, so as to slide upon it, and to retain 
 a firm attachment by means of the screw. The 
 groove has a fenestra through its upper side, an inch 
 and a quarter long, and wide enough to give passage 
 to the screw, when this is placed longitudinally. That 
 part of the screw which is within the fenestra, when 
 the blades are attached together, is square, so as to 
 prevent its rotation while the nut is turned. 
 
 Each blade terminates in an ivory tip. That on 
 the anal blade is oval, an inch and a half long and 
 five-eighths of an inch in diameter. The steel stem 
 of the blade is bent so as to be inserted into the 
 end of the tip, and, at the point of insertion, it has a 
 joint, allowing the tip (when it is introduced or with- 
 drawn per anum) to be thrown out so that it pass in 
 and out endwise. The ivory is cut away or grooved 
 so as to give lodgement to the stem, presenting 
 no salient point. The joint should be made to 
 work freely ; and after the tip has passed the anus, 
 it will very readily assume its proper transverse posi- 
 tion, and be as firm and steady as if it had been 
 riveted on, without any joint. The ivory tip on the 
 vaginal stem is oval, about ten-eighths of an inch in 
 length and five-eighths in diameter, approaching 
 nearly to a cylinder with spherical ends over. The 
 distance between the tips and the junction of the 
 blades is about six and a half inches. 
 
OF THE IIUxMAN FEMALE. 
 
 361 
 
 What are the directions for the manner of using it ? 
 In using the instrument, detach the blades from 
 each other ; introduce the anal tip into the rectum, 
 then the other tip into the vagina ; then fasten the 
 blades together bj means of the screw. Be particu- 
 lar to keep the blades parallel with the axis of the pel- 
 vis, and never thrust or pass them forward with a 
 rash inconsiderate haste. By means of the slide of 
 one blade, upon the other, the tip of the vaginal 
 blade may be placed higher or lower, as circumstances 
 may require. If the fundus uteri has sunk low be- 
 tAveen the vagina and rectum, shove up the moveable 
 blade, so that the two tips may be nearly on a level. 
 In this position of the tips, it is intended that the 
 space between them shall be only sufficient for the va- 
 gina and rectum, without pressing them — a space not 
 exceeding three-eighths of an inch. If the fundus 
 does not lie low, or if the instrument has been shoved 
 up as high as the vagina will easily admit, loosen the 
 screw, and, without allowing the vaginal blade to re- 
 treat, carry up the anal blade in such a manner as to 
 throw the fundus forward into its normal position. 
 The instrument described may be called the Double 
 Uterine Elevator, and is adapted to the most difficult 
 obstinate cases. Fig. 140, reppresents the double ele- 
 vator, with the blades attached together. 
 
 Fig. 140. 
 
362 
 
 PHYSIOLOGY AND PATHOLOGY 
 
 What dees he say about the *' Single Uterine Eleva- 
 tor?" In a large majority of cases of retroversion and 
 retroflexion, the Single Uterine Elevator sufficiently 
 meets the indication. It consists of a shaft or stem about 
 seven or eight inches long, Avith a suitable handle on 
 one end, and the other end finished with an ivory tip 
 and a joint like that on the anal blade, just de- 
 scribed. The stem should be slightly curved, so as to 
 correspond with the axis of the pelvis, but the handle 
 and two or three inches of the stem next to it should 
 be bent in an opposite direction, so that when the in- 
 strument is introduced into the rectum, the handle of 
 it should not interfere with the edge of the finger in 
 the vagina at the same time. It is confidently as- 
 serted that these single elevators will be found more 
 efficient and more safe in all these cases, where Dr. 
 Simpson's sound is used to ascertain and rectify the 
 position of the uterus. 
 
 Fig. 141, represents the single elevator, with the 
 tip put in a position to be passed through the anus. 
 
 Fig. 141. 
 
 Fig. 142. Fig. 142, exhibits a direct view of this 
 
 tip, and its position after it has passed 
 the sphincter. 
 
 What treatment is usually required af- 
 ter the retroverted uterus has been re- 
 stored to its proper position? In recent 
 cases, if the tone of the pelvic viscera and 
 the muscular system is good, it is rarely necessary to 
 
OF THE HUMAN FEMALE. 363 
 
 do more than to have the patient keep her bowels in 
 an open state, empty her bladder seasonably, and 
 avoid any active exercise for some days. But under 
 almost any other circumstances, it will be necessary 
 for her to wear a pessary to support the organ, for 
 some, and perhaps for a long time. 
 
 RETROFLEXION OF THE UTERUS. 
 
 What other peculiar condition of the uterus' is 
 there, in which the body may be carried more or less 
 backward ? Retro-flexion, in which the uterus is 
 bent backwards upon itself, in such manner that the 
 mouth and a portion of the neck may have their usual 
 direction, while the fundus, body, and part of the 
 neck are so bent backwards as to form an angle with 
 the inferior portion. 
 
 Is it an affection easily to be managed ? In gene- 
 ral it is not ; it is probable that it often depends upon 
 some mechanical cause, as the pressure of impacted 
 feces in the sigmoid flexure of the colon, the presence 
 of ovarian or other tumors, &c. 
 
 TUMORS IN, OR SPRINGING FROM, THE UTERUS. 
 
 To what part of the uterus may the more solid 
 tumors be attached? Some spring from the outer 
 surface under the peritonasal coat, others on the 
 inner surface, and others again have their origin in 
 the substance proper of the organ. 
 
 What is the character of these morbid growths ? 
 Sometimes they appear to be purely fibrous, some- 
 times encysted, that is, having a fluid, mucous, 
 serous, puruloid, or tubercular matter in the centre, 
 or in several foci, surrounded by a fibrous envelope. 
 Sometimes again they appear to be entirely fleshy, 
 and at some others they are calcareous or osteo- 
 sarcomatous. 
 
 NOT ALWAYS EASILY DIAGNOSTICATED. 
 
 Is the presence of tumors within the uterus, always 
 
364 PHYSIOLOGY AND PATHOLOGY 
 
 easily diagnosticated ? It is sometimes very difficult 
 to do so. It has however been observed, that in 
 many of these cases the uterus seems to be elongated 
 to such a degree as to admit of the introduction of a 
 female catheter or sound nearly its entire length into 
 its cavity. 
 
 What sensations does the patient usually expe- 
 rience, when the tumor becomes so large as to rise 
 above the superior strait of the pelvis ? The me- 
 chanical inconveniences which usually attend preg- 
 nancy arrived at the same degree of developement — 
 the general health may be good. 
 
 By what means is it to be distinguished from preg- 
 nancy ? By auscultation and ballottement. 
 
 Is it easy to discriminate between the existence of 
 tumors in the uterus, and those in the ovaria, or either 
 of these from extra-uterine fetation ? The diagnosis 
 would be in general difficult. 
 
 What consequences may result from inflammatory 
 action in tumors, otherwise quiescent, and producing 
 little irritation ? When such tumors become the seat 
 of inflammation, more or less rapid changes in their 
 structure may take place, and serious results may 
 follow. 
 
 TREATMENT OF TUMORS OF THE UTERUS. 
 
 What treatment should in general be employed ? 
 Those which are palliative, or simply discutient, as 
 the iodine, cicuta, tartar emetic by inunction, &c. 
 Attempts at removal by the knife would in general 
 be improper. 
 
 By what means may the distressing sense of pres- 
 sure upon the rectum, and neck of the bladder be 
 relieved ? Occasionally by the use of suitable pessa- 
 ries. 
 
 POLYPUS OF THE UTERUS. 
 What name is given to the pediculated tumors 
 which spring from the uterus ? Uterine polypi. 
 
OF THE HUMAN FExMALE. 365 
 
 What is their general character ? They are mostly 
 fibrous, smooth to the touch, and very vascular, and 
 covered by a smooth membrane. Some are more of a 
 mucous character, and others again are hard and 
 glandular in structure ; those partaking of this parti- 
 cular formation, are thought most frequently to 
 spring from the glandulae nabothi, about the neck 
 of the uterus. 
 
 What portions of the uterus do they generally 
 spring from ? From the mucous membrane of the 
 cavity, of the body, of the neck, and from the orifice 
 of the uterus. 
 
 What symptoms usually accompany uterine polypi ? 
 They are very various — mostly they are those of 
 a nervous character, none of which are pathog- 
 nomonic. There is mostly leucorrhoea, sometimes 
 dysmenorrhoea, menorrhagia, and almost always a 
 sensation of prolapsus. 
 
 With what other afi'ectlons of the uterus have 
 polypous tumors been confounded ? With preg- 
 nancy, with prolapsus, with retroversion, and more 
 readily than with either, chronic inversion of the 
 uterus. 
 
 How is it to be distinguished from pregnancy ? It 
 can be confounded with pregnancy only when the 
 tumor is formed and retained within the cavity of the 
 uterus, but then the constancy or frequency of the 
 discharge, together with the patulous orifice of the 
 uterus, should clear the diagnosis, or at least deter- 
 mine that true pregnancy does not exist. 
 
 IIow can we discriminate between polypus and pro- 
 lapsus, or retroversion of the uterus ? First : By the 
 character of the tumor when it is a prolapsus, the 
 shortening of the vagina, and the recognition of the 
 descent of the body, upon examination through the 
 rectum ; and also, the situation of the os tincre. 
 Second : From retroversion, because in this sort of 
 displacement, the orifice of the uterus, is thrown 
 31* 
 
366 PHYSIOLOGY AND PATHOLOGY 
 
 strongly forward, and no pedicle can be recognised 
 by the finger in the vagina or rectum. 
 
 From what peculiar condition of the uterus is it 
 very difficult to distinguish it ? Chronic inversion of 
 the uterus. The distinction must be based partly 
 upon the history of the affection, and the result of a 
 careful physical examination. 
 
 TREATMENT OF POLYPUS OF THE UTERUS. 
 
 What class of uterine tumors call for and admit 
 of removal by surgical means ? Those which are pedi- 
 culated, as polypus, and as cauliflower excrescences. 
 
 Which is the better and the safer mode of removal, 
 by the knife or scissors, or by the ligature ? In a 
 large majority of cases by the ligature. 
 
 Is it always easy to cast a ligature upon a polypus 
 whose pedicle is within the os uteri high up in the 
 pelvis ? The embarrassment is such that very many 
 devices have been proposed to enable the surgeon to 
 accomplish the operation, and it is probable that the 
 double canula of Gooch is the most useful. 
 
 INFLAMMATION OF THE GENITAL ORGANS. 
 
 How are we to study or regard inflammatory affec- 
 tions of the organs of generation in the female ? 
 In relation to the tissue which is affected. Thus, 
 in inflammation of the mons veneris the effects 
 of the disease are modified by the density of the 
 structure ; hence when it suppurates, the pus being 
 bound down, burrows more or less as though under a 
 fascia. 
 
 In what respect does inflammation of the vulva 
 differ from that of the mons veneris ? This structure 
 being much less firm, great tumefaction from sanguine 
 congestion and edema are apt to follow. Suppura- 
 tion also takes place more readily. 
 
 With what is common inflammation of the vulva 
 often complicated ? With an aphthous eruption, as 
 seen sometimes in the mouths of young children. 
 
OF THE HUMAN FEMALE. 3GT 
 
 What class of females are subject to inflammation 
 of the uterus ? It is liable to occur in single as well 
 as married women, and in the pregnant and non-preg- 
 nant condition. 
 
 What is it called when it attacks the substance of 
 the uterus ? Hjsteritis, or metritis. 
 
 HYSTERITIS OR METRITIS. 
 
 To what grades of inflammation is this organ lia- 
 ble ? As most others, to acute and chronic inflam- 
 mation. 
 
 What are some of the causes of metritis or 
 hysteritis ? Blows, falls, sympathetic irritation in 
 oj:her organs, violence to the uterus during partu- 
 rition, &c. The causes which produce dysmenor- 
 rhoea, also sometimes give rise to metrit's. The 
 uterus may also become inflamed from the applica- 
 tion of syphilitic virus applied directly to it, or it 
 may have been indirectly communicated along the 
 vagina. 
 
 To what other specific inflammation is the uterus 
 liable ? To gout or rheumatism. 
 
 SYMPTOMS OF METRITIS. 
 
 What symptoms accompany metritis ? Chill, 
 fever, pain in the back, but particularly in the hypo- 
 gastrium. The bladder is irritated and little urine 
 can be retained, great pain is experienced in any 
 attempt at motion ; when the attack is severe the 
 patient is obliged to lay down upon the back, have 
 the legs drawn up to take off" all pressure from 
 the affected part. In the milder forms there is less 
 pain, and little or no sympathetic sign of the local 
 aff'ection. 
 ^ What condition of the parts is found on physical 
 examination ? Vagina and uterus hot, the uterus 
 thickened, hard, congested, heavy, and painful to 
 the touch. 
 
368 PHYSIOLOGY AND PATHOLOGY 
 
 MODES OF TERMINATION OF METRITIS. 
 
 What are the varieties of termination of metritis ? 
 Resolution, abscess, chronic inflammation, induration, 
 and ramollissement or softening. 
 
 What is the general character of induration of the 
 uterus ? First : The whole uterus, with its neck, is 
 large. Second : The organ maj frequently be felt 
 above the pubes, regular in shape, and little if at all, 
 sensitive to the touch. Third : Balanced upon the 
 point of the finger it feels heavy, and by this weight 
 in the vagina it causes the sensation of prolapsus. 
 
 Does this induration pass speedily into any other 
 form of disease ? It often remains stationary for a 
 long time, even during the balance of life without 
 injury to the patient. 
 
 Is it always free from morbid sensibility, when in 
 this indurated state ? It is not ; on the contrary, it 
 sometimes remains irritable for days, weeks, and even 
 years, and this irritation, as has been said already, is 
 sometimes kept up by the displacement of the organ, 
 whether it be prolapsed, or retroverted. 
 
 Are the functions of menstruation and reproduc- 
 tion necessarily interfered with by the occurrence of 
 induration of the uterus ? Patients may continue to 
 menstruate, but if they become pregnant, they will 
 be likely to abort. 
 
 Is ramollissement or softening of the substance of 
 the uterus usually extended to the entire organ ? 
 It is perhaps altogether a rare mode of termination 
 of inflammation, but when it does so occur, it is more 
 frequently confined to a part, than extended to the 
 whole organ. 
 
 ABSCESS OF THE UTERUS. 
 What parts of the uterus may be the seat of ab- ^ 
 acess ? Sometimes it occurs in the substance, and 
 points towards the cavity of the abdomen or pelvis, 
 sometimes it opens upon the inner surface of the 
 uterus. 
 
OF THE HUMAN FEMALE. 869 
 
 When the abscess points towards the external sur- 
 face of the uterus, what process is usually com- 
 menced ? The serous membrane, viz. : the periton- 
 aeum, usually suffers from local inflammation which 
 results in adhesion, and thus a cyst is formed which 
 contains the effused pus until ulceration is effected 
 into the rectum, and the matter passed off per anum ; 
 or the coats of the bladder are perforated and the 
 pus escapes with the urine, or an opening is made 
 between the vagina and bladder, or between the 
 uterus, vagina, and rectum ; or lastly, and least 
 frequently, a perforation is made through the cyst 
 into the cavity of the abdomen, and fatal peritonitis 
 is induced. 
 
 What is the prognosis of abscess in the uterus ? 
 Mostly, unless the abscess open mto the cavity of the 
 peritonaeum, life may be preserved, though the pa- 
 tient's health may remain a long time impaired. 
 
 TREATMENT OF ACUTE METRITIS. 
 
 What treatment is appropriate to acute metritis ? 
 One strictly antiphlogistic, as venesection, saline ca- 
 thartics, antimonials, local blood-letting, low diet, 
 perfect rest, and some active revulsives, as fomenta- 
 tions, blisters, &c., &c. 
 
 What is to be said respecting the use of cold or 
 astringents ? That though useful in some stages of 
 the disease, they afe entirely inadmissible in rheuma- 
 tic or gouty constitutions. 
 
 If the inflammation terminate in induration, how 
 is it to be treated ? Attempts are to be made to 
 discuss it by the use of remedies believed to act pow- 
 erfully as discutients, as small and repeated doses of 
 mercury, in the form of calomel, blue pill, or corro- 
 sive sublimate. By many the cicuta has been thought 
 to act in this w^ay, and latterly the Lugol's solution 
 of iodine, in doses of from eight to ten drops, 
 three times a day, has had some reputation for this 
 purpose. 
 
370 PHYSIOLOGY AND PATHOLOGY 
 
 Is it necessary to confine the patient to her bed for 
 the discussion of the induration ? Freedom from ex- 
 citement should be secured to her, but often she may 
 be permitted to move about while under treatment, 
 provided the heavy organ be supported upon a pessary. 
 
 What train of symptoms would indicate the termi- 
 nation in suppuration ? A continuance of the pain, 
 with constitutional irritation, together with a sense of 
 throbbing in the part. 
 
 What particular portion of the uterus is most liable 
 to inflammation ? That part which dips into the va- 
 gina, or the neck and mouth of the uterus. 
 
 What are some of thQ numerous causes of inflamma- 
 tion of this part of the uterus? 1. Extension of in- 
 flammation from the mucous membrane of the vagina — 
 hence it is often connected with vaginitis. 2. It is 
 sometimes caused by the os tincne dropping down into, 
 and becoming strangulated in the orifice of a flat pes- 
 sary ; mechanical shocks, as violence in coition, &c. 
 
 What symptoms usually accompany inflammation of 
 the neck of the uterus ? They are similar to those of 
 mild metritis, as pain in the back, heat and weight in 
 the pelvis, &c. 
 
 What evidence can we have that the inflammation is 
 confined to the neck, and does not involve the body ? 
 The neck is found tumid, and the body not so, when 
 examined by the touch. 
 
 What are some of the terminations of inflamma- 
 tion of the neck of the uterus ? In resolution, in in- 
 duration, in scirrhus, in ulceration both simple and ma- 
 lignant. 
 
 ULCERATION OF THE UTERUS. 
 
 How are we to distinguish simple from syphilitic ul- 
 ceration of this part? Simple ulceration is said to have 
 smooth regularly defined edges, while those of the spe- 
 cific character have irregular margins. 
 
 What varieties of simple ulcerations may affect the 
 neck ? 1. Simple ulceration of the mucous membrane, 
 
OF THE HUMAN FEMALE. 371 
 
 resembling an abrasion of the mucous surface. 2. One 
 in which there are deposites of small patches of lymph, 
 as aphthae, &c. 
 
 How is the corroding ulcer to be distinguished from 
 either of these varieties ? By the fact that it digs out 
 the internal surface of the mouth and neck of the 
 uterus and is constantly extending by the process of 
 ulcerative absorption. 
 
 Can simple ulcerations always be recognized by the 
 touch ? They cannot ; it is rarely safe to rely upon 
 the touch for a knowledge of their character. 
 
 BEST MODE OF RECOGNITION— SPECULUM. 
 
 How then are they to be recognized ? By means 
 of a speculum or well adjusted tube, passed so adroitly 
 into the vagina, as to enable the eye of the practitioner 
 to see the part affected, and thus derive more accu- 
 rate knowledge respecting it. 
 
 AYhat variety of speculums are there, and of what 
 materials are they composed ? They are made of glass, 
 or of some of the metals. Some are complete tubes, 
 either cylindrical, or somewhat conical — consisting of 
 a single piece — such are composed of glass, pewter, or 
 the mixed metals. Others are so divided that they 
 operate with handles upon a hinge, and resemble a tube 
 cleft longitudinally, with a pivot so adjusted that the 
 two extremities of the blades can be more or less wide- 
 ly separated. Others are so constructed as to consist 
 of three equal blades, so adapted as to move upon 
 each other, and thus to be passed into the vagina while 
 folded up, and afterwards expanded, to bring the ori- 
 fice of the uterus into view. 
 
 WhTch variety of those now in use is probably best 
 adapted to most purposes for which the instrument is 
 required ? The quadrivalve instrument, which is so 
 constructed that it enters the vagina in a small com- 
 pass, yet it is capable of great expansion when neces- 
 sary, by compressing the two handles. 
 
 How is the speculum to be introduced ? When no 
 
372 PHYSIOLOGY AND PATHOLOGY 
 
 great precision in the examination is requisite, the pa- 
 tient may be placed on her left side, close to the edge 
 of the bed — or what is to be preferred, she may be 
 placed on her back, with her feet resting at the end 
 of the bed, and the breech brought down to her heels. 
 If, however any careful investigation of the condition 
 of the OS tincse is necessary, it becomes almost indis- 
 pensable that the hips should be brought upon the edge 
 of the bed, elevated by a pillow or some suitable pad- 
 ding, while the feet are extended upon chairs or suit- 
 able supports outside of the bed. 'The patient's limbs 
 should be properly covered with drawers, and over all 
 should be placed a sheet or blanket, having in the 
 central seam an orifice ripped sufiiciently large to 
 receive the instrument as far as to the handles. The 
 examinator is then to be seated or stationed between 
 the knees of the patient, while the instrument, well 
 lubricated, is to be passed by one hand through the 
 orifice, as far as to the handles or base. The vulva 
 is also to be well lubricated by the other hand, one or 
 two fingers of which are to be passed into the orifice 
 of the vagina, to press back the perin^eum. As soon 
 as the posterior commissure of the vulva is put sufii- 
 ciently upon the stretch, the point of the instrument 
 should be carried down upon the back of these fingers, 
 which should thus form a plane, along which the em- 
 bout, or rounded w^ooden extremity of the speculum, 
 can be guided over the posterior surface of the vagina. 
 This done, the fingers are to be withdrawn, and that 
 hand called to aid the other in cautiously passing the 
 speculum onwards in the axis of the vagina to the 
 cul-de-sac behind the uterus. The handles may then 
 be carefully pressed towards each other, when the 
 emboutj becoming disengaged, is forced out by the 
 spring contrived for the purpose, and thus leaves the 
 upper portion of the vagina accessible to the eye of 
 the examinator. 
 
 What kind of light is best adapted to the purpose 
 of such examinations? Clear daylight is to be pre- 
 
OF THE HUMAN FEMALE. 3T3 
 
 ferred : but a bright moveable ligbt, such as a free 
 burning lamp or candle will mostly answer the pur- 
 pose very well. 
 
 What obstructions may prevent the ready discovery 
 of the state of the parts ? A greater or less quantity 
 of tenacious mucus, or even coagulated blood, may 
 be attached to the surface of the os tincse. This 
 must be wiped off by a mop made of fine sponge or 
 charpie, or washed away by a detergent injection. . 
 
 TREATMENT OF ULCERS OF THE OS TINCiE. 
 
 What is the proper treatment of ulcers of the os 
 tincae? Depletory, while any marked inflammatory 
 action exists — then astringents, and for the mucous 
 ulcerations the nitrate of silver, either in substance 
 on a port caustique, or in proper solution, and applied 
 by means of a camel's hair pencil. 
 
 Is it essential that the patient should be kept at 
 rest during the treatment ? If possible, the patient 
 should be kept at rest, and pressure should as much 
 as possible be taken from the uterus. Where, however, 
 quietness is impracticable, the patient should have the 
 ulcerated surface of the uterus isolated from the mu- 
 cous membrane of the vagina, by the use of a properly 
 adjusted pessary. The dressings or washings can 
 then be applied with better effect. 
 
 Are dressings to the os tinc^e of easy application ? 
 They can rarely be properly applied unless through 
 the speculum, previously introduced, to bring the af- 
 fected part into view. 
 
 Is it important that an accurate distinction be made 
 between pure inflammation of a part, and irritation 
 and disorders of function merely ? It is highly im- 
 portant, as the therapeutic indications are essentially 
 different in many of these cases. 
 
 MALIGNANT ULCERATIONS OF THE UTERUS. 
 Wliat is meant by the term phagedenic or corrosive 
 ulcer of the mouth or neck of the womb ? That va- 
 32 
 
874 PHYPTOLOGY AND PATHOLOGY 
 
 riety of ulcers which is constantly extending by the 
 progress of ulcerative absorption. 
 
 Is it proper to regard this as always malignant and 
 incurable ? It is mostly sufficiently malignant in its 
 character to produce serious, and generally fatal in- 
 roads upon the constitution, but it is sometimes amen- 
 able to appropriate remedies. 
 
 In what class of females does it usually occur ? In 
 those of a lymphatic temperament, and who have 
 passed the menstruating period of life in most, but 
 not in all cases. 
 
 Is its existence generally recognized early after its 
 commencement ? As it is usually not attended with 
 very severe pain, the patient ascribes the discharge 
 which attends it to too frequent a menstruation, or if 
 she be passed this period of life, she thinks menstrua- 
 tion has returned. 
 
 What sensations are usually experienced by these 
 who have this disease ? Principally a sense of weight, 
 bearing down, as occurs in prolapsus or other displace- 
 ment. 
 
 DIAGNOSIS OF MALIGNANT ULCER. 
 
 What condition of the uterus, &c., is to be recog- 
 nized by the finger in the touch in such cases ? The 
 circumference of the neck is found enlarged, and the 
 orifice very considerably so — it seems to be infundi- 
 bulated or dug out — sometimes the fingers will pass 
 readily to the internal os uteri. 
 
 Is the body of the uterus moveable or fixed in these 
 cases ? It is usually quite free and moveable — some- 
 times it is a little engorged. The neck only or the 
 internal surface being implicated. 
 
 Can an accurate diagnosis be obtained by the touch 
 alone ? No, the sense of sight through the medium 
 of the speculum becomes necessary to recognise to the 
 fullest extent the alterations which have taken place. 
 
 What influence does this affection exert upon the 
 constitution of the patient? Although it is usually 
 
OF THE HUMAN FEMALE. 375 
 
 attended with very little pain, yet sooner or later the 
 patient becomes reduced to a state of great feeble- 
 ness and prostration. The absorption of the vitiated 
 secretion produces hectic fever, great emaciation, fol- 
 lowed by edema, &c. 
 
 What parts l3ecome subsequently involved in the 
 erosive process which is going on ? The bladder, or 
 rectum, or both, become opened so that the urine es- 
 capes by the vagina ; or in the event of the rectum 
 being ulcerated, the feces pass by the same route. 
 
 TREATMENT OF MALIGNANT ULCERS OF THE UTERUS. 
 
 What precautionary measures are to be adopted to 
 prevent an aggravation or rapid extension of the dis- 
 ease ? The constant use of detergent injections into 
 the vagina, and perhaps into the uterus itself, with 
 a view to remove as effectually as possible all the mat- 
 ter as fast as secreted. 
 
 What local medicines may be used ? Those of an as- 
 tringent character have generally been thought pro- 
 per, after a due ablution of the surfaces with bland 
 mucilages, or simple warm water ; thus the sulphate 
 or acetate of zinc, in the proportion of one, two, or 
 three grains to the ounce of water, may be thrown up 
 by a syringe, or carried upon charpie, through the 
 speculum by some suitable instrument. The solution, 
 or solid nitrate of silver and various other escharotics 
 have also been used in such cases. 
 
 Is it proper to rely upon local treatment alone ? It 
 will be highly important to attend to all the hygienic 
 measures which improve the general health. 
 
 In regard to the use of injections into the cavity 
 of the uterus, how, and by what means should they 
 be introduced? Unless there be a reliable nurse in 
 attendance the practitioner should always apply them, 
 and that if possible two or three times a day. The 
 mucilage of flaxseed, slippery elm, pith of sassafras, 
 starch or barley, should be carefully strained, and 
 then conveyed through a gum elastic catheter, the 
 
376 PHYSIOLOGY AND PATHOLOGY 
 
 eyelet end of which should be first carefully introduced 
 upon the point of the finger into the cavity of the 
 uterus, and so retained by the hand of the patient or 
 a proper assistant, that it be not driven forcibly 
 against the walls of the uterus when adapting the pipe 
 of the syringe to it : or a silver tube curved into the 
 proper shape may be substituted, and to this the sy- 
 ringe when charged may be so fitted as to pass up the 
 whole contents into the cavity of the uterus. This 
 operation with whatever kind of instrument, should be 
 conducted with great care, as not only the instrument 
 improperly introduced may do much injury, but there 
 is some danger of forcing the fluids along the fallopian 
 tubes into the cavity of the peritonaeum, and thus 
 causing fatal peritonitis. 
 
 CANCER OF THE UTERUS. 
 
 Is cancer of the uterus a very common disease ? 
 In this country it is believed really to be one of very 
 rare occurrence, though there are many aifections of 
 the uterus which are ascribed to cancer, and yet are 
 not carcinomatous. 
 
 What portion of the uterus is most liable to be at- 
 tacked with cancer ? The neck. 
 
 What is the usual mode of attack of cancer ? The 
 parts become the seat of irregular induration of a 
 scirrhous character, being more nodulated, harder and 
 more dense and painful than simple induration ; one 
 lip is mostly sensibly larger than the other. 
 
 What is usually observed in regard to the vagina in 
 these cases ? That it is more or less shortened, and 
 sometimes adherent to adjacent parts. The same may 
 be said of the uterus, which is usually found im- 
 moveable, being bound down to the blader, or rectum, 
 or both. 
 
 What is subsequently observed in respect to the 
 march of the disease? Sooner or later, corrosive ul- 
 ceration with hemorrhage from the surface which is 
 sometimes studded by a fungus growth takes place. 
 
OF THE HUMAN FEMALE. 377 
 
 The patient also experiences deep seated lancinating 
 pain, (which is generally, though not uniformly pa- 
 thognomonic of cancer,) and after a time the ner- 
 vous system suffers severely, while sooner or later 
 the aspect of the patient changes : she loses the 
 solidity of muscular and cellular tissue, she may pre- 
 viously have possessed, and substitutes for it a straw 
 colored surface, with more or less edema of the whole 
 cellular membrane, 
 
 TREATMENT OF CANCER OF THE UTERUS. 
 
 What should be the treatment of cancer of the ute- 
 rus ? At the very incipient stage, it should be anti- 
 phlogistic ; after it has made some progress, we can 
 do no more than palliate by keeping the system con- 
 stantly under the influence of cicuta, hyosciamus, &c., 
 though sooner or later, we are generally compelled to 
 use opium in some form or preparation, in gradually 
 increasing doses, to keep up a degree of narcotism. 
 By these means, the action of the disease is sometimes 
 arrested in its early stage, and its development re- 
 tarded for a greater or less length of time. When 
 ulceration occurs, the same care should be taken to 
 wash away the vitiated secretions. 
 
 What is to be said respecting the propriety of am- 
 putating the neck of the uterus ? Although this ope- 
 ration has been frequently practised in Europe, in 
 cases of real or supposed cancer, the recorded results 
 are not sufficiently favorable in cases of true carci- 
 noma as to gain our approbation for the practice. 
 The diagnosis of the disease while strictly confined to 
 the inferior portion of the neck, is not sufficiently clear 
 to justify an indiscriminate resort to it ; and further, 
 when it has become clearly developed, the parts above 
 the reach of the knife are so often invaded by the 
 same disease, that little or no benefit could arise 
 from the cutting away of a portion only of the dis- 
 ease. 
 
 32* 
 
378 PHYSIOLOGY AND PATHOLOGY 
 
 CAULIFLOWER EXCRESCENCE OF THE UTERUS. 
 
 What other morbid formations are liable to take 
 place in or about the uterus ? Cauliflower excres- 
 cence, fibrous tumors, polypi, moles, and osteo-sarco- 
 matous tumors. 
 
 What is the nature of cauliflower excrescence ? It 
 appears to be composed of a tissue of vessels bound 
 together by slight attachments of cellular membrane, 
 and covered by a smooth but very fragile envolope of 
 the same character ; to the touch it feels like a fungus 
 or cauliflower, whence the English name. When ex- 
 posed to the eye, it displays a bright arterial color. 
 
 What is its general texture ? Very slight, it is 
 ruptured by slight pressure, the touch of a finger, or 
 the point of a syringe, or even the contractions of 
 the vagina, or pressure of the perinaeum upon it ; 
 hence it readily pours out a great deal of serum and 
 very often some blood, and thus drains the patient. 
 In some instances, its texture is more firai. 
 
 What proofs have we, that it consists almost en- 
 tirely of vessels of the most delicate texture ? Im- 
 mediately after death it is found completely collapsed, 
 with scarcely a vestige of its character w^hile living, 
 and when strangulated by a ligature, the same thing 
 is observed. When the ligature comes away, there 
 is usually only a half putrid membranous mass de- 
 tached by it. 
 
 What is its usual point of origin ? The neck or 
 orifice, though sometimes the cavity of the body of the 
 uterus. 
 
 What period of life is most incident to it ? Though 
 of rare occurrence, it may attack at any period of 
 married or single life. 
 
 What influence does it exert upon the health of the 
 patient ? The constant drainage to which she becomes 
 subject, sooner or later, renders her anemic, gives her a 
 pallid, or straw colored appearance : it is also usually 
 
OF THE HUMAN FEMALE. 379 
 
 accompanied by more or less edema, and other evi- 
 dences of debility. 
 
 With what other diseases may this cauliflower excres- 
 cence be confounded ? With polypus, and the fungus 
 which sometimes springs from a cancerous base in the 
 uterus. 
 
 What is the prognosis of cauliflower excrescence ? 
 It is generally unfavorable. 
 
 What treatment has been proposed and adopted for 
 it ? Astringents of various kinds ; and in using these 
 to avoid the rupture of the surface of the tumor it 
 is proposed to have the patient's hips elevated, and 
 then pour the fluid into the vagina from a suitable 
 vessel. 
 
 TREATMENT OF CAULIFLOWER EXCRESCENCE 
 OF THE UTERUS. 
 
 Has any surgical treatment ever been resorted to, 
 for its removal ? The ligature has been applied to its 
 base for that purpose, and its removal has thus been 
 accomplished. The os uteri has also been ablated. 
 
 What should be applied to the base of the tumor 
 after removal, to prevent its return ? The nitrate of 
 silver, or what Churchill has regarded better, the 
 butter of antimony, through a speculum. 
 
 PHYSOMETRA. 
 
 What do you mean by the term physometra ? Tym- 
 panitis uteri, or a distension of the uterus by a quan- 
 tity of air supposed to be secreted within its cavity. 
 
 Does the mucous membrane of the vagina probably 
 ever secrete air also ? It is believed that it sometimes 
 does, as some females have these discharges of air per 
 vaginam only when in the unimprcgnated state, and 
 others when pregnant. 
 
 Is it ever attended with any serious consequences ? 
 Not when it passes off" readily, which it does do some- 
 times with considerable noise ; but when it is confined 
 within the cavity of the uterus, the patient suffers 
 more or less from distension. 
 
380 PHYSIOLOGY AND PATHOLOGY 
 
 Upon what condition of the system, does it depend? 
 Some suppose it dependent upon a low degree of in- 
 flammation of the mucous membrane ; others ascribe 
 it to some peculiar condition of the nervous system, 
 which presides over the secretory processes. 
 
 How is the distension of the uterus from this cause, 
 to he distinguished from pregnancy? By percussion, 
 auscultation, and ballottement : 1. Percussion pro- 
 duces a resonance which cannot be perceived in preg- 
 nancy. 2. Auscultation in this case, cannot detect 
 the sound of the fetal heart, &c. 3. Ballottement, 
 cannot recognise the existence of a body moveable in 
 a fluid, within the cavity of the uterus. 
 
 TREATMENT OF PHYSOMETRA. 
 
 What treatment is to be used in these cases ? 
 There is no specific remedy known for this affection : if 
 the air do not pass *off" under contraction of the ute- 
 rus, or by the shock of the abdominal muscles, by 
 coughing, or otherwise, it may be necessary to dilate, 
 or perforate the os uteri, and allow the air to pass 
 through a catheter, or canula ; after which, it has 
 been proposed to apply to the inner surface of the 
 uterus, solution of nitrate of silver, or some prepara- 
 tion of iodine, &c., with the view to alter the con- 
 dition of the surface which gives rise to this secretion : 
 particular regard should be had to the healthy condi- 
 tion of the general system. 
 
 HYDROMETRA. 
 
 What do you mean by the term hydrometra? 
 Dropsy of the uterus, from an accumulation of 
 serous, albuminous, or muco-purulent fluid, within its 
 cavity. 
 
 Is this condition easily diagnosticated ? It is not, 
 being easily confounded with pregnancy, — having a 
 similarity of sympathetic signs, though the stomach 
 is said usually to sympathize less than in pregnancy. 
 
 What physical examination is best adapted to clear 
 
OF THE HUMAN FEMALE* 381 
 
 the diagnosis ? Ballottement, by which the uterus is 
 found to contain a fluid, but having nothing moveable 
 suspended within it. Auscultation, moreover, detects 
 no sounds of the fetal heart. 
 
 What treatment is proper for hydrops uteri, or hy- 
 drometra ? A general diuretic treatment might be 
 somewhat useful, but it is mostly necessary to perfo- 
 rate the uterus, by a stilet or catheter in its orifice, 
 or pass a trochar and canula into some part of the 
 neck which can be reached by the vagina. 
 
 Should we regard dropsy of the uterus, as a dan- 
 gerous complaint ? It should be so considered, but 
 chiefly from the morbid action going on in the inner 
 surface of the uterus, and its liability to ulceration 
 through its walls into the cavity of the abdomen. 
 
 DISEASES INCIDENT TO PREGNANCY. 
 
 Do the sympathetic or secondary disturbances of 
 the system during pregnancy, sometimes amount to 
 disease ? Yes, and are entitled to be called the 
 diseases of pregnancy. 
 
 Into how many classes may these diseases be 
 divided ? Into local and general. 
 
 In what way are the local diseases induced ? By 
 pressure and sympathy. 
 
 What are some of the consequences induced by en- 
 largement of the uterus ? Pressure on the neck of 
 the bladder, which prevents a free discharge of urine, 
 and often causes distension. 
 
 What consequences may result from this distension? 
 Retroversion of the uterus, inflammation of the blad- 
 der, &c. 
 
 Does the bladder suff*er more or less during the 
 later, than in the earlier stages of pregnancy ? Ge- 
 nerally it sufl'ers less in the later stages, because it is 
 then flattened out over the surface of the uterus. 
 
 Can it therefore retain much urine ? No — but a 
 small quantity in general, though it sometimes be- 
 comes enormously distended. 
 
382 PHYSIOLOGY AND PATHOLOGY 
 
 What are some of the consequences of the pressure 
 of the developed uterus ? Pain in the right side, 
 similating liver complaint. 
 
 Upon what depends the pain frequently felt in one 
 or both of the iliac regions, as the uterus becomes 
 enlarged ? Probably upon the stretching of the round 
 ligaments. 
 
 Which of the round ligaments is the shorter ? The 
 right one. 
 
 Towards which side of the abdomen does the uterus 
 usually incline as it becomes developed? Towards 
 the right side. 
 
 How is this inclination accounted for ? First, by 
 the shortness of the right round ligament, and se- 
 condly, by the presence of the rectum on the left side 
 of the spine usually. 
 
 • Does the pressure of the fundus of the uterus up- 
 wards, produce any inconvenience to the stomach ? 
 It frequently causes dyspeptic symptoms. 
 
 What are some of the effects of pressure upon the 
 bowels ? Displacements through several . natural 
 openings in some instances — hence hernia in certain 
 periods of pregnancy. 
 
 How are we to account for ventral hernia in preg- 
 nancy ? Pressure of the uterus causes separation of 
 the fibres of the abdominal muscles, and the escape of 
 the bowel between them. 
 
 What kind of displacement of the bladder is apt to 
 result from pressure of the uterus upon it ? Hernia 
 into the vagina, or less frequently into the crural 
 ring. 
 
 What are some of the effects of the pressure of the 
 uterus upon the great blood vessels ? Congestions 
 of the inferior vessels, hemorrhoids, varicose veins, 
 &c. 
 
 How is the edema, to which some women are sub- 
 ject, to be accounted for ? By pressure of the uterus 
 upon the veins and lymphatics. v 
 
 Is this pressure apt to affect the labia ? It some- 
 
OF THE HUMAN FEMALE. ciH'i 
 
 times causes great distension and swelling with enor- 
 mcwis serous effusion in the cellular membrane of the 
 labia. 
 
 Does pressure of the uterus exert any unfavorable 
 influence on the nerves of the lower part of the 
 body ? Pressure on the crural and obturator nerves, 
 often causes cramps, spasms, and neuralgic pains. 
 
 What are the local sympathetic diseases of preg- 
 nancy ? Irritation of the uterus and adjacent parts. 
 
 Is the excitement into which the uterus is thrown, 
 usually to be regarded as a healthy action ? In the 
 natural state of society it is so ; but in civilized life, 
 this irritation often induces disease. 
 
 Does the vagina ever become sympathetically af- 
 fected ? It becomes the seat of a sensation of full- 
 ness, heat, and often a leucorrhoeal discharge. 
 
 Does leucorrhoea ever thus become a symptom of 
 pregnancy ? In some doubtful cases this state of the 
 vagina may aid in forming a diagnosis. 
 
 Do the glands of the vagina ever secrete very pro- 
 fusely during pregnancy ? Sometimes the discharge 
 is very copious, and is occasionally thrown out very 
 suddenly. 
 
 From what other parts at this time may a co- 
 pious and sudden discharge take place ? Probably 
 from between the uterus and decidua, between the 
 decidua and chorion, or between the chorion and 
 amnion. 
 
 What abnormal formation upon the ovum may give 
 rise to this discharge ? Hydatids. 
 
 What peculiarly distressing sympathetic irritation 
 is sometimes brought on in the vngina or vulva by 
 pregnancy ? An inflammatory affection, resembling 
 aphthae, called pruritis vulvae. 
 
 What effect has the pressure of the uterus ante- 
 riorly upon the skin ? It sometimes greatly distends 
 it and renders it painful. 
 
 Do the abdominal muscles participate much in the 
 consequences of this pressure ? They are often put 
 
384 PHYSIOLOGY AND PATHOLOGY 
 
 upon the stretclij and are occasionally thrown intc 
 spasm and pain. ^ 
 
 In what pregnancy are these symptoms the most 
 distressing ? Usually, though not always, in the 
 first. 
 
 What sympathetic effect has pregnancy upon the 
 stomach ? It mostly becomes disturbed, the patient 
 being distressed with nausea and vomiting. 
 
 Is the stomach always afflicted thus by pregnancy ? 
 Not invariably. 
 
 What kind of sensation is it which women expe- 
 rience at the stomach, or epigastric region ? A sense 
 of sinking ; sometimes of fullness, nausea, sometimes 
 resulting in vomiting. 
 
 What circumstance aggravates this nausea of the 
 stomach ? Motion ; it usually comes on the moment 
 of rising from bed. 
 
 What is this disturbance usually called ? Morning 
 sickness. 
 
 Is it confined to the morning alone ? It sometimes 
 lasts the whole day. 
 
 Does it always commence in the morning ? It 
 sometimes comes on in the evening, the patient being 
 quite free from it at other times of the day. 
 
 Is this morning sickness a popular sign of preg- 
 nancy ? It is by some persons regarded as an inva- 
 riable or infallible sign. 
 
 Do the olfactory and gustatory nerves become very 
 susceptible with this affection of the stomach ? Both 
 the smell and taste seem to be affected with this irri- 
 tability of the stomach. 
 
 Is the stomach affected by moral causes? It is 
 rendered worse by depressing, and better by exciting 
 moral causes. 
 
 Does any serious consequence ever result from this 
 irritation of the stomach ? Sometimes it results in 
 confirmed dyspepsia. 
 
 What then happens ? Flatulence, cardialgia, py- 
 rosis, gastrodynia, and salivation. 
 
OF THE HUMAN FEMALE. 385 
 
 In what way is the appetite depraved ? The 
 patient is apt to have fastidious tastes, longings ; 
 desires for outre articles, as slate pencils, char- 
 coal, &c. 
 
 Is it necessary that this should be indulged? 
 Ko — we should not encourage such morbid propen- 
 sities. 
 
 What is the popular notion respecting this ? That 
 these longings, if not gratified, will result in some 
 defect or deformity of the child. 
 
 Is it necessary always to withhold the object de- 
 sired ? The patient may be indulged in every rea- 
 sonable desire without impropriety. 
 
 Do these inconveniences always occur ? No — 
 some women are better during pregnancy than any 
 other time. 
 
 How long do the annoyances alluded to generally 
 exist ? Some patients sufier only a month, some 
 three or four. 
 
 When are they usually most severe ? During the 
 second and third months. 
 
 When does the distress usually begin ? Imme- 
 diately after the suspension of the menstruation. 
 
 Is gastritis ever a consequence of this sympathetic 
 irritation ? Occasionally this occurs. 
 
 What is the pathological condition of the stomach 
 in pregnant women ? Usually it is not inflamed, 
 but mostly in a state of irritation, or rather, accord- 
 ing to some, of sedation. 
 
 Is there any indisposition produced by another 
 cause, similar to the sickness of pregnancy ? Sea 
 sickness^ in which also there is irritation, or sedation 
 of the nerves of the stomach. 
 
 From what may we infer that the stomach is not 
 inflamed ? It is relieved by taking food, and espe- 
 cially by stimuli, cordials, &c. 
 
 Is it mostly accompanied by any sympathetic reac- 
 tion ? There is usually no sympathetic fever. 
 
 Is ordinary sickness of the stomach in pregnancy 
 
mb PHYSIOLOGY AND PATHOLOGY 
 
 Tisually productive of unpleasant consequences ? 
 Mostly without any bad consequences, however long 
 the sickness may continue. 
 
 What affords temporary relief-? Lying down, fresh 
 air, moral excitement, &c. 
 
 Does the liver become implicated in the consequen- 
 ces of pregnancy ? It often becomes the seat of pain, 
 and is also sometimes functionally deranged. 
 
 What evidence have we of hepatic derangement ? 
 The urine is high colored, bowels are torpid, skin 
 sallow, and sometimes the patient becomes jaun- 
 diced. 
 
 Is there any other peculiarity about the skin in 
 some cases of pregnancy ? It becomes covered by 
 brown or yellow spots called maculae. 
 
 Where do these spots usually appear ? Upon the 
 face and neck. 
 
 Do they present any bad omen ? No — they 
 are of little consequence, and usually go off after 
 delivery. 
 
 Upon what visceral derangement do they seem to 
 depend ? Upon the hepatic affection. 
 
 What part of the glandular system is apt to sympa- 
 thise with the gravid uterus ? The salivary glands 
 sometimes become greatly excited. 
 
 Do the gums become inflamed ? Not necessarily. 
 
 What is the character of the salivary discharge ? 
 Thick and ropy, sometimes very abundant. 
 
 How are the mammary glands affected? They 
 almost always become enlarged, slightly painful, 
 and they occasionally secrete milk very early in preg- 
 nancy. 
 
 What name is given to a tumefaction, which some- 
 times extends much beyond the ordinary excitement ? 
 Mastodynia. 
 
 Suppose the mammae after having been distended, 
 should become shrunken and flattened, what indica- 
 tion would it present ? That the development of the 
 ovum had become suspended. 
 
OF THE HUMAN FEMALE. 887 
 
 What other sympathies are involved in pregnancy ? 
 Those of a general nature are, first, excitements of 
 the cerebro-spinal axis ; and secondly, those of the 
 vascular system. 
 
 How are the brain and the mental faculties affected ? 
 The brain becomes more impressible, and the mind 
 more susceptible in most cases. 
 
 Does the pregnancy ever cause much depression of 
 the faculties ? The patient sometimes becomes des- 
 pondent, and thinks every thing is wrong. 
 
 Does the opposite state of things ever occur ? In 
 some cases the sense of smell and taste becomes more 
 acute, and the mind much more active and effec- 
 tive. 
 
 Is the vascular system necessarily excited at the 
 same time ? The vascular system is not necessarily 
 correspondingly excited in such cases. 
 
 Is the excitement of the cerebrum ever attended by 
 mania ? In some cases, though it rarely comes on till 
 after delivery. 
 
 What are some of the consequen*ces of this excite- 
 ment of the brain and spinal marrow ? Hysteric con- 
 vulsions. 
 
 Does a moderate degree of this stimulation of the 
 nervous system ever produce a favorable result ? In 
 some cases the patient is able to use her muscles more 
 freely than when unimpregnated. 
 
 What disturbances are produced in the lungs, or 
 thorax by this nervous excitement? Dyspnoea; some- 
 times palpitation and spasmodic cough. 
 
 What effect has this nervous stimulation upon the 
 uterus itself? It increases its sensibility, and ren- 
 ders it often extremely sensitive to the touch. 
 
 What influence has it upon the muscular fibres of 
 the uterus ? It often causes irregular contractions, 
 somewhat resembling labor. 
 
 What effect has this excitation upon the general 
 sensibilities of the patient ? She sometimes has ner- 
 vous chills, a kind of universal tremor. 
 
388 PHYSIOLOGY and pathology 
 
 "When are these sensations experienced ? Some- 
 times at the very commencement of pregnancy. 
 
 Are they liable to produce much muscular move- 
 ment ? In some cases they amount to regular hys- 
 teria. 
 
 Do some patiefits experience a condition opposite 
 to this ? They become faint even during sleep. 
 
 Does this condition of the uterus ever excite any 
 disturbance of the cephalic nerves ? Some females 
 suffer much from otalgia, odontalgia, cephalalgia, &c. 
 
 Is toothache very common in pregnancy ? With 
 some females it is, and some ladies lose a tooth at 
 every pregnancy, in consequence of the recurrence of 
 odontalgia. 
 
 It has been said that some females become better, 
 more able to make exertion, &c., during pregnancy ; 
 are any patients in an opposite condition ? Some wo- 
 men become very feeble, and unable to walk, during 
 the greater part of pregnancy, until after delivery. 
 
 PLETHORA. 
 
 We have spoken now of the nervous excitability as 
 a consequence of pregnancy, — what are occasionally 
 its effects upon the vascular system ? Most young 
 women become more developed, their vessels enlarge, 
 and carry more blood ; the whole body, pelvis, &c., be- 
 come increased in size. 
 
 Is this a natural and salutary consequence of preg- 
 nancy ? It should be so regarded. 
 
 How is this change brought about? By a pletho- 
 ric condition of the blood vessels. 
 
 Under what circumstances does this plethora become 
 an evil ? In civilized life, females who live luxuriantly, 
 and do not use much physical exertion become subject 
 to local congestions. 
 
 What then, is the best remedy for the natural ple- 
 thora of pregnancy ? Free exercise and temperate 
 living. 
 
 What sympathetic disturbance is a usual preventive 
 
OF THE HUMAN FEMALE. 389 
 
 of plethora ? Nausea and vomiting, as in the morn- 
 ing sickness. 
 
 After what period of pregnancy does plethora usually 
 exist most conspicuously ? The fourth month, and 
 later when the stomach usually has become more 
 tranquil. 
 
 What kind of pulse is presented in this plethora ? 
 It is not frequent ; rather slow and full, indicating 
 congestion. 
 
 What is the condition of the veins ? They are com- 
 monly very full. 
 
 What are some of the consequences of this plethora ? 
 Sense of general fullness — headache, particularly on 
 lying down. 
 
 How is the respiration aifected ? It is oppressed, 
 and there is usually a difficulty in taking a deep inspi- 
 ration. 
 
 What is the condition of the heart, in this general 
 plethora ? It labors irregularly and with difficulty ; 
 there is palpitation combined with oppression. 
 
 CONSEQUENCES OF EXCESSIVE PLETHORA. 
 
 What is the consequence of the congestion of the 
 portal system ? Distress in the epigastric region, and 
 aggravation of the dyspeptic symptoms where they 
 co-exist. 
 
 What effect has plethora upon the viscera at the 
 lower part of the abdomen ? Sensation of weight 
 and distress, especially at the usual menstrual pe- 
 riod. 
 
 What evil consequences may arise from plethora in 
 the uterus? Hemorrhage from the cervix, or from 
 the inner surface of the uterus, from detachment of 
 the placenta. 
 
 Is it of importance to attend to these symptoms ? 
 They sometimes become exceedingly dangerous and 
 should be carefully watched. 
 
 Does this plethora ever cause effusions of blood in 
 any other part than the uterus ? Hsemoptisis, ha^mc- 
 33* 
 
390 PHYSIOLOGY AND PATHOLOGY 
 
 tamesis, sanguineous apoplexy of brain or lungs, and 
 melanosis, may result from it. 
 
 What other evil may happen from extreme turges- 
 cence of the blood vessels in the brain ? Convulsions. 
 
 What other species of efiusion may result from this 
 plethoric condition of the vascular system ? Serous 
 effusions upon the brain, into the thorax, the abdo- 
 domen and the general cellular tissue, &c. 
 
 What effect have these effusions upon the excited 
 condition of the nervous system ? They aggravate 
 the irritability of the nervous system. 
 
 How are the bowels sometimes affected by it? They 
 sometimes pour off the water or serum of the blood in 
 large amounts. 
 
 What is the general condition of the blood, in a 
 pregnant female ? It is usually altered ; has more 
 coagulable lymph or buff upon it when drawn. 
 
 Is this the result of inflammatory action, during 
 pregnancy ? It is not necessarily dependent upon in- 
 flammatory action. 
 
 Is this plethoric condition never attended by fever ? 
 In some cases, it is combined with fever and inflam- 
 matory action. 
 
 FEVER FROM NERVOUS IRRITATION. 
 
 How should we regard a little febrile condition of 
 the patient if she have no plethora ? It is not to be 
 looked upon as a serious affair. It is usually remedied 
 by cooling medicines, and generally goes off after de- 
 livery. 
 
 What is it apparently the result of? Nervous 
 excitability; it is not apt to be followed by debihty. 
 
 What are the symptoms of this nervous fever? 
 Dry skin, small pulse, &c. 
 
 BEST REMEDY FOR IT. 
 
 What means are best calculated to relieve this irri- 
 tability of pregnancy ? Cold bath, sponging with cold 
 water. 
 
OP THE HUMAN FEMALE. 391 
 
 What might we regard as suitable temporary reme- 
 dies ? Mild anodynes; particularly those of an anti- 
 spasmodic character, as assafoetida, ether, &c. 
 
 Why not use the narcotic anodynes, as camphor, 
 and opium, &c. ? When the system becomes habi- 
 tuated to the use of them, the irritability is usually 
 increased ? 
 
 Is it safe to deplete very much, during pregnancy ? 
 Too much depletion induces debility, and conse- 
 quently increases irritation. 
 
 MILD TREATMENT MOST PROPER IN PREGNANCY. 
 
 Should the treatment of pregnant women generally 
 be mild or active ? The treatment should be mild in 
 most cases. 
 
 Should it be preventive or hygienic, rather than 
 corrective or medical ? It should be rather prophy- 
 lactic and hygienic — the professional counsellor should 
 give proper attention to suitable exercise of body and 
 mind, rather than medicine in most cases. 
 
 What general rules should be laid down. In refer- 
 ence to diet ? It should be light, easy of digestion ; 
 chiefly vegetable. 
 
 Suppose the patient is dyspeptic, and subject to fla- 
 tulence ? Allow her some light animal food, and mild 
 condiments. 
 
 What rule should be observed in regard to her 
 drinks? They should be simple, and in moderate 
 quantities. 
 
 What ill consequences may arise from drinking 
 large quantities even of water ? In the opinion of 
 some, it is apt to increase plethora. 
 
 What popular prejudice exists in regard to the 
 amount of diet, required by pregnant women ? That 
 they require more food while pregnant, and that it 
 should be richer and better than usual. 
 
 How far should this idea be favored ? Though it is in 
 general, fair to suppose that a woman in this situation 
 
892 PHYSIOLOGY AND PATHOLOGY 
 
 would require more, yet due prudence is requisite in 
 the indulgence of a very strong appetite. 
 
 After the period of morning sickness has passed, 
 what should she do to remove plethora ? She should 
 use as much exercise as may be consistent with her 
 physical ability. 
 
 EXERCISE DURINa PREGNANCY. 
 
 What are some of the good effects of exercise ? 
 When taken regularly and in moderation, it excites 
 secretion, and prevents dyspepsia, increases strength 
 and removes irritability. 
 
 Suppose the patient be too feeble to walk, what 
 kind of exercise can she substitute for it ? Riding, 
 sailing, &c. 
 
 What are some of the disadvantages of too much 
 exercise ? Pain, fatigue, spasms, abortion or prema- 
 ture labor. 
 
 Suppose your patient was already very plethoric, 
 would you oblige her to use exertion to wear it off? 
 This plethora should first be reduced by proper 
 direct means before she be recommended to use 
 exertion. 
 
 What treatment of a general nature, is proper 
 to allay the great irritability of some pregnant 
 women ? General bathing, using merely the cold 
 bath. 
 
 Suppose the cold bath is followed by a sense of 
 chilliness, what should be substituted ? It should be 
 tepid, or warm, followed by moderate friction upon 
 the skin. 
 
 What peculiar advantages does the warm bath 
 offer at the later stages of pregnancy ? It is very 
 useful to promote the relaxation of the system. 
 
 What consequences might occur if the bath were 
 too hot ? Labor might be brought on, especially if 
 the woman be plethoric. 
 
 VENESECTION, &c. 
 
 What are some of the more distinct means of 
 
OF THE HUMAN FEMALE. 393 
 
 reducing plethora ? Venesection is the most effi- 
 cient. 
 
 How do pregnant women usually bear bleeding ? 
 Very well — most of them think they require it, and 
 to many of them it is almost indispensable. 
 
 Is it better to bleed freely and rarely, if you bleed 
 at all, than to bleed a little, and often ? Bleed freely, 
 and empty the turgid vessels. 
 
 After a free bleeding, whereby a plethoric state is 
 removed, what are the best measures for preventing 
 its return ? Free exercise, bathing, aperient medi- 
 cines, mild diaphoretics, &c. 
 
 How would you treat a local inflammation, as pleu- 
 ritis, hepatitis, &c., during pregnancy ? By free 
 bleeding, and after the reduction of the inflammation, 
 an early use of opiates. 
 
 Why resort to opiates? To prevent the strong 
 liability to premature uterine contractions. 
 
 What unfavorable influence may irritation of the 
 bowels exert upon the uterus ? It is very likely to 
 bring on contractions, and false pains. 
 
 What treatment is proper in the febrile state of the 
 system accompanied by nervous chills, and debility ? 
 Here omit venesection, but administer instead, spirits 
 of nitre, and mild diaphoretics. 
 
 What should be done during the apyrexia ? Mild 
 tonics should be given. 
 
 What advice should be given the patient, when she 
 experiences difiiculty in urinating in consequence of 
 the pressure of the uterus ? To bear forward, or to 
 place herself on her knees, and if necessary, press the 
 uterus upward, when it rests upon the pubes. 
 
 Suppose this means will not aff"ord her the neces- 
 sary relief, what should be done ? Introduce the 
 catheter, and allow the urine to escape through it. 
 
 CATHETERISM. 
 What precautions are to be taken, in the introduc- 
 tion of the instrument under such circumstances ? 
 
394 PHYSIOLOGY AND PATHOLOGY 
 
 Bear in mmd, that as the bladder is compressed by 
 the uterine tumor, it is usually carried so high up as 
 to put the urethra upon the stretch, and fix it parallel 
 with the posterior surface of the symphysis pubes, 
 and that the bladder itself is pressed forward over the 
 symphysis. Consequently, the point of the catheter, 
 is to be carried along parallel with the symphysis 
 until it gets above it ; the handle is then to be de- 
 pressed, in order to carry the point of the instrument 
 into the cavity of the bladder. 
 
 What evil consequences may result from the long 
 retention of the urine ? Paralysis of the bladder, or 
 its rupture and the death of the patient. 
 
 What useful mechanical measure may be resorted 
 to, to obviate or remove the pressure of the uterus 
 upon the bladder ? A broad bandage applied in front 
 of the lower part of the abdomen and carried round to 
 the back, or even across the shoulders. 
 
 When the uterus presses upon the rectum, and 
 causes a tenesmus, how should it be relieved ? By 
 pressing the uterus upward. 
 
 APERIENTS, &c. 
 
 What means should be used to remove the im- 
 pacted feces from the rectum ? If oleaginous in- 
 jections do not succeed, the mass must be removed 
 by a finger or a spoon-handle, or some similar in- 
 strument. 
 
 How is the pain which is often felt in the abdo- 
 minal muscles, the skin, &c., to be relieved ? By 
 rubbing them with oleaginous and anodyne mixtures. 
 
 Supposing much of the abdominal pain to depend 
 upon the existence of flatus in the intestines, what 
 should be done to relieve it ? Remove the flatus by 
 some carminative or gently stimulating laxative, or 
 antispasmodic. 
 
 If the intestines become inflamed, how may they be 
 treated ? By cups, leeches, &c., to the sides of the 
 
OF THE HUMAN FEMALE. 395 
 
 abdomen ; and the other modes of treatment consi- 
 dered proper in ordinary cases. 
 
 What other cause may give rise to pain in some 
 portion of the abdomen ? Either of the varieties of 
 hernia, if they become strangulated, or the bowel 
 inflamed. 
 
 HOW TO TREAT HERNIA. 
 
 What is the proper mode of treating hernia ? Ee- 
 duce it and keep it supported by a proper truss or 
 bandage, which presses upon the opening only — pro- 
 perly adjusted adhesive straps often answer this 
 purpose very well. 
 
 What is the most usual kind of vesical hernia? 
 Into the vagina, although it has been known to take 
 place into the abdominal or the crural ring. 
 
 How is it to be relieved ? By supporting the su- 
 perincumbent uterus by a proper bandage. 
 
 CAUTION ABOUT DRESS, &c. 
 
 What caution should pregnant women observe in 
 regard to dress ? It should be such as to make no 
 pressure on the abdomen ; they should abandon the 
 use of corsets, or have them so constructed as not to 
 compress the body. 
 
 How should the hemorrhoids of pregnant women be 
 treated ? By laxatives, leeches, cold poultices, &c. 
 They should be speedily returned within the sphinc- 
 ter, whenever they become prolapsed. 
 
 What is the proper treatment for varices ? Bleed- 
 ing and skilful bandaging. 
 
 Can all patients who are troubled with varices bear 
 to have their limbs firmly bandaged ? In some cases 
 bandages which compress the limbs cause a sense of 
 extreme suffocation. 
 
 What other exciting cause besides pressure is liable 
 to produce anasarca, varices, &c., in pregnant women? 
 General plethora. 
 
 What serious evil may be apprehended from great 
 
396 PHYSIOLOGY AND PATHOLOGY 
 
 distension of the lower extremities by anasarca? 
 Gangrene and sloughing. 
 
 What surgical treatment does it sometimes require ? 
 Evacuation by puncturing. 
 
 TREATMENT OF SYMPATHETIC VAGINITIS AND PRU- 
 RITIS VULV^, IRRITATION OF THE BLADDER, DIAR- 
 RHCEA, &c. 
 
 How is the sympathic vaginitis of pregnant women 
 to be treated ? When the patient is plethoric, by 
 free general bleeding, then followed, if necessary, by 
 leeching and cold astringent washes, and alterative 
 injections of nitrate of silver, of alum, &c.^ 
 
 PRURITIS VULViE. 
 
 What means should be resorted to for the relief of 
 pruritis vulvae ? General bleeding, if plethoric, and 
 then mucilaginous injections, well charged with bo- 
 rax, and occasionally with laudanum, or better still, 
 the aqueous solutions of opium. 
 
 Under what circumstances would the sulphate 
 of zinc or nitrate of silver be useful ? After the 
 removal of the plethora. 
 
 How strong a solution of the nitrate of silver should 
 be used ? Two, three, or four grains to the ounce of 
 water. 
 
 IRRITATION OF THE BLADDER, BOWELS, STOMACH, &c. 
 
 How should we treat irritation of the bladder ? By 
 the use of bland diuretics. 
 
 What treatment is most proper for the diarrhoea 
 of pregnant women ? As it is mostly the result of, 
 or accompanied by, inflammatory action, it should 
 be treated by depletion, mild laxatives, regulated 
 diet, &c. 
 
 When might astringents be used ? After the in- 
 flammation has been cured. 
 
 Should the remedies applied to the stomach for 
 morning sickness be curative or palliative only ? Pal- 
 
OF THE HUMAN FEMALE. 397 
 
 liatlve only — thus, let the patient eat before she rises ; 
 let her take her cup of coffee and a piece of bread 
 in bed, or instantly after rising. Her food should 
 be solid mostly; she should not indulge much in 
 liquids. 
 
 What should she do if she becomes again sick after 
 eating ? Lie down at once, or go directly out and 
 walk in the open air. 
 
 What temporary medicines may she take to relieve 
 the vomiting, when it is urgent ? Lime water and 
 milk, and other antacids. Hot drinks, as catnip tea, 
 infusions of cloves, nutmegs, mace, &c. 
 
 Suppose more active measures be necessary, what 
 other articles may be administered ? Spirits of tur- 
 pentine in small doses, and wine in moderate quanti- 
 ties : the aromatic sulphuric acid may be adminis- 
 tered, and in some urgent cases, sinapisms may be 
 applied over the region of the stomach. 
 
 What notice should we take of her longings, if her 
 sickness be urgent ? They should be gratified to 
 avoid irritability, unless she desires improper and 
 outr^ articles. 
 
 What organ should we regard as the primary seat 
 of irritation of the stomach ? The uterus ; and 
 hence none other than mild palliative measures can 
 ^ e useful. 
 
 If the liver become torpid and jaundice occur, how 
 rust it be treated ? By mild alteratives, a gentle 
 mercurial course, and especially the proper use of 
 alkalies. 
 
 Suppose the secretions from any organ become very 
 a'^ indant during pregnancy, how should they be man- 
 a^od ? Great care should be taken not to arrest them 
 suddenly. 
 
 Suppose the patient suffered from mastodynia ? 
 Care should be taken not to remove it at once by the 
 application of cold, for fear of causing a metastasis. 
 It should be moderated by warm application, leeches, 
 &c., if necessary. 
 
 34 
 
398 PHYSIOLOGY AND PATHOLOGY 
 
 What kind of plaster is very useful, and usually 
 sufficient to relieve it ? The Diachylon or soap 
 plaster. 
 
 What other means often succeed ? Frictions with 
 anodyne liniments. 
 
 Is it important to distinguish neuralgia of a part 
 from inflammation ? It is : and the treatment should 
 be conducted accordingly. 
 
 What kind of anodynes are best, if the pain be 
 purely nervous ? Camphor, hyosciamus, ether, assa- 
 foetida, &c., but not opium. 
 
 How should we treat the pains in the chest in 
 pregnant women ? With cups, leeches, &c., if in- 
 iiammation exist ; but if it be merely neuralgic, pal- 
 liate with assafoetida, camphor, &c., carefully with- 
 holding opium, if possible. 
 
 Suppose there is pain in the abdomen, with indica- 
 tions for bleeding, what subsequent treatment should 
 be used ? In such cases, after proper sanguineous 
 depletion, give opiates by the stomach, or in enemata, 
 to prevent the contractions of the uterus. 
 
 How should we treat a severe cephalalgia or 
 otalgia ? By leeches, laxatives, &c., upon general 
 principles, and after excitement is allayed, give ano- 
 dynes. 
 
 Suppose the woman have severe tooth ache, what 
 objection would there be to the extraction of the 
 tooth ? Any sudden and powerful shock, as that of 
 extraction of teeth, might bring on contractions of 
 the uterus, and result in premature delivery. It is 
 therefore better, as soon as it is admissible, to give 
 anodynes. 
 
 CARE TO BE TAKEN OF THE MAMM^. 
 
 What care should be taken of the mammae of preg- 
 nant females ? The condition of the mammary 
 glands should be enquired into in the latter periods 
 of gestation, and especial regard should be had to the 
 state of the nipple. 
 
OF THE HUMAN FEMALE. 390 
 
 What are some of the conditions to which the nip- 
 ples are subject ? In many females, primips espe- 
 cially, the central portions of the nipples are so um- 
 bilicated as to be scarcely visible : in some there is a 
 sulcus running across the disc of the efferent ex- 
 tremities of the gland, so that the two halves of it are 
 introverted. 
 
 What consequences are likely to arise from this 
 condition ? First : The conversion of the true skin 
 which should cover and protect the end of the nip- 
 ples, into a thin epithelial secreting surface on 
 which the nervous papilloe are much exposed, and 
 which evince an exalted sensibility whenever touched, 
 and especially when subjected to the suction by the 
 child. 
 
 What treatment should be adopted to correct this 
 condition, if possible, before the breast is brought 
 into use ? By some judicious means, as by the gen- 
 tle application of a breast pipe, to be exhausted by 
 the mouth of the patient, or by a gum elastic bag or 
 air-pump, till the nipple becomes elongated and the 
 efferent ducts are brought into parallel lines. 
 
 Does this plan succeed effectually in a short time ? 
 In the majority of cases it requires great perse- 
 verance, inasmuch as in most, the nipple has to ac- 
 quire a development in the right direction before its 
 permanency can be relied upon. 
 
 What may be said of astringent or moderately 
 stimulating washes in those cases ? Judiciously ap- 
 plied, in moderately active potions, they will often 
 contribute to the hardening of the investment of the 
 lactiferous ducts, and prepare them for the use of the 
 child after its birth. 
 
 Is there any other condition to which the nipple 
 of the primiparous or multiparous female is subject, 
 that is unfavorable to comfort of the mother or child 
 when needed for nursing ? The nipple is sometimes 
 chapped, fissured or sulcated more or less deeply, the 
 substance between the different sulci resembling tho 
 
400 PHYSIOLOGY AND PATHOLOGY 
 
 granules of a ripe blackberry, and in some instanceg 
 broken out nearly as easily. The sulci are mostly 
 the seat of an exalted sensibility whenever the nipple 
 suiFers from the least irritation. 
 
 HEMORRHAGES FROM THE UTERUS DURING PREGNANCY. 
 
 How are hemorrhages from the uterus during preg- 
 nancy classified ? Into avoidable or accidental and 
 unavoidable. 
 
 What is meant by accidental or avoidable hemor- 
 rhage ? That which occurs at any period of preg- 
 nancy from an accidental detachment of the placenta 
 when it is situated at a portion of the uterus, the 
 development of which is proportionate to that of the 
 placenta itself, as about the bod}^ or fundus of the 
 organ. 
 
 UNAVOIDABLE HEMORRHAGE— PLACENTA-PR^VIA. 
 
 What do you mean by unavoidable hemorrhage ? 
 It is that which inevitably occurs from the detachment 
 of some portion of, or the entire placenta from the 
 uterus, in consequence of its being situated at a part 
 which is developed more rapidly than the placenta 
 itself. 
 
 Is the hemorrhage necessarily constant in this 
 case ? It may be arrested temporarily by the pro- 
 cess of coagulation, but it is subject to constant re- 
 currence. 
 
 What are the means of diagnosis in these cases ? 
 Examination per vaginam, by which you can feel the 
 fibrous structure of the placenta over the os uteri. 
 
 How much of the hand should be introduced into 
 the vagina for this purpose ? In order fully to appre- 
 ciate the existence of placenta prsevia, it is mostly 
 necessary to pass in the entire hand. 
 
 HOW MANAGED. 
 How are you to proceed to arrest the hemorrhage in 
 this case ? It has been prooosed to place the patient 
 
OF THE HUMAN FEMALE. 401 
 
 in a recumbent posture with her hips elevated, keep her 
 circulation as much reduced as may be consistent with 
 her health, and then resort to such medical means as 
 favor coagulation of the blood. 
 
 Are you ever to resort to version for the purpose 
 of eiFecting delivery before term ? This has been pro- 
 posed, and directions given to force open the os uteri 
 for this purpose, but we regard it as highly improper. 
 We think a better method would be (if any be called 
 for,) to perforate the placenta, allow the liquor amnii 
 to escape and the uterus to contract upon the fetus, 
 &c., as in cases of premature artificial delivery, when 
 the pelvis is known to be too small for delivery at 
 term. 
 
 What means have you of arresting the hemorrhage 
 mechanically ? The tampon, which may be cautiously 
 applied, and continued until complete dilation occurs, 
 and the uterus expels it, the coagula, the placenta and 
 the fetus from its cavity. 
 
 Should you keep down the force of the circulation, 
 favor the coagulation of blood, by absolute rest, by 
 the use of tampon, &c., even though you have to 
 continue this plan for some months ? We think this 
 would be the appropriate plan of treatment. 
 
 Suppose you find hemorrlnwge coming on at the full 
 period of gestation, should you palliate during the 
 first stage of labour ? Yes ; never introduce the 
 hand till the os uteri is dilated or dilatable. 
 
 How are you to proceed, as soon as the second 
 stage of labor commences ? Pass up a hand, punc- 
 ture the ovum, facilitate as fast as possible the de- 
 livery of the child, and as soon as it is born, place 
 the other hand on the fundus of the uterus, and ensure 
 its complete contraction. 
 
 May not the pressure of the head or breech or 
 body of the child in the os uteri, arrest for a time the 
 hemorrhage ? It will sometimes do so. 
 
 Suppose the pains are slow, and the head is above 
 the superior strait? Turn and deliver, or give 
 34* 
 
402 PHYSIOLOGY AND PATHOLOGY 
 
 ergot, and as soon as the head is within reach, apply 
 the forceps. Treat the third stage according to 
 established usage. 
 
 In cases of placenta praevia, as soon as the os uteri 
 is dilated, what are you to do ? Pass your fingers, 
 and then whole hand, between the placenta and sur- 
 face of the uterus, seize the breech, knees, feet, and 
 deliver footling. 
 
 What other practice has been proposed by some of 
 the German physicians in such cases ? To let the 
 child alone, fill the vagina with a tampon, made of 
 strips of bandage, portions of which can be removed 
 as the head or presenting part is protruded through 
 the uterus ; and when it is fairly within reach, use 
 forceps, blunt hook, or other authorized means for 
 expediting the delivery. 
 
 RETROVERSION OF THE UTERUS IN PREGNANCY. 
 
 What do you mean by retroversion of the uterus ? 
 That in which the fundus of the uterus is thrown 
 down into the hollow of the sacrum, while the os tincse 
 is carried up behind the pubes. 
 
 Is pregnancy ever complicated by this accident to 
 the uterus ? Numerous instances have occurred of 
 this variety of displaceiHent of the uterus after it had 
 begun to gestate with a matured and fecundated 
 ovum. 
 
 During what period of gestation may this condition 
 of the uterus take place ? During the first three 
 months only, since after this period it is too late to 
 change its position in this direction. 
 
 At what time are you to expect that labor will 
 take place in this case ? Generally before the sixth 
 month. 
 
 Have any women laboring under this accident ever 
 reached the full term of gestation ? Very few, if any 
 instances are recorded, except perhaps some which 
 have been mentioned by Dr. Merriman, an English 
 accoucheur and author. 
 
OF THE HUMAN FEMALE. 403 
 
 What are the inconveniences and dangers arising 
 from this accident ? Retention of urine and feces 
 from pressure ; more or less paralysis also of the 
 lower extremities ; inflammation and sloughing of the 
 bladder, rectum, and uterus. 
 
 How may retroversion of the gravid uterus hazard 
 the life both of mother and fetus ? By the fatal 
 pressure which the developing organ may exert upon 
 the bladder in front and the rectum behind, causing 
 inflammation and sloughing of either or both, but 
 particularly the former viscus. The embryo or fetus 
 may also have its vitality destroyed by the resistance 
 off'ered to its circulation and development in conse- 
 quence of the close confinement of the uterus in the 
 cavity of the pelvis. 
 
 What are the usual causes of retroversion ? Vio- 
 lent straining, as in jumping, falling, &c. Efl'orts at 
 defecation while constipated ; too great a distension 
 of the bladder ; the superincumbent pressure of im- 
 pacted feces in the colon, &c. 
 
 What are the symptoms of retroversion of the 
 uterus? Constant bearing down sensation, great dif- 
 ficulty, or utter impracticability of evacuating the 
 bowels or bladder, &c. 
 
 What is the most prominent symptom, and also the 
 most dangerous one ? Retention of urine, and dis- 
 tension to the immediate danger of rupture of the 
 bladder is the earliest urgent symptom, though when 
 in some cases the urine can be evacuated artificially, 
 and the bowels accommodate themselves to the aid of 
 art, the condition of developing uterus and ovum be- 
 comes the subject of great concern. 
 
 As many of these rational signs are fallacious, 
 how are we to determine the existence of the re- 
 troversion of the uterus ? By the introduction 
 of the finger into the vagina, and discovering that 
 the OS tincye is closely forced up behind the pubes, 
 while the body is thrown backwards into the hollow 
 
404 PHYSIOLOGY AND PATHOLOGY 
 
 of the sacrum, and the vagina thereby very much 
 shortened. 
 
 What are the indications for treatment ? Reduc- 
 tion or restoration, if possible ; but if the uterus be 
 so far developed as not to admit of being replaced, 
 we must palliate by artificially evacuating the blad- 
 der and bowels ; if the enlargement of the uterus 
 produce serious inconvenience, it will be necessary to 
 induce abortion, by rupturing the membranes if 
 possible, by a stilet passed into the os tincse ; but if not, 
 by a puncture through the substance of the uterus, 
 either directly through the vagina, or through the 
 recto-vaginal septum. 
 
 ANTEVERSION AND HERNIA OF THE UTERUS IN PREG- 
 NANCY. 
 
 What other displacements of the uterus may com- 
 plicate pregnancy ? Anteversion of the uterus, and 
 hernia of the uterus. 
 
 What consequences to pregnancy may happen from 
 either of these conditions ? Little inconvenience can 
 happen to pregnancy from anteversion of the uterus, 
 as it is usually rectified in proportion as it becomes 
 developed ; but with regard to hernia of the organ, 
 this sort of displacement would entail serious conse- 
 quences upon gravidity. 
 
 ABORTION AND PREMATURE DELIVERY. 
 
 What is to be understood by the term abortion in 
 obstetric language ? It signifies the separation of an 
 ovum from the mother's organs previous to the com- 
 pletion of its development. 
 
 To within what period of gestation do we limit 
 the term abortion ? Till the end of the sixth 
 month. 
 
 What do we call the expulsion of an ovum at 
 any time between the end of the sixth, and the end 
 of the ninth month of gestation ? Premature delivery. 
 
 How many varieties or modes of abortion are 
 
OF THE HUMAN FEMALE. 405 
 
 there ? Two : one in which the ovum is detached 
 merely, and the other, in which it is not only de- 
 tached, but expelled. 
 
 Upon w^hat conditions may abortion depend ? 
 First : Those peculiar to the mother. Second : Those 
 peculiar to the child. 
 
 What are the various causes of abortion ? Some 
 depend upon the state of the system generally, some 
 upon the state of the uterus itself. 
 
 What condition of the general system of the mother 
 favors abortion ? Any extremes of health, as plethora, 
 asthenia, great irritability of the nervous system, &c. 
 Syphilis, and other severe constitutional irritation, 
 accidental diarrhoea, active catharsis caused by drastic 
 purgatives, &c. 
 
 What condition of the uterus is favorable to, or pre- 
 disposes to this accident ? Plethora ; the menstrual 
 nisus ; irritability of its fibre, &c. 
 
 Does the female necessarily abort when subjected 
 to the influence of these predisposing causes ? No : 
 it usually requires the aid of an exciting cause to 
 effect the abortion. 
 
 What may be regarded as exciting causes ? Mecha- 
 nical irritants, great muscular effort, nauseating, or 
 peculiar odors ; the smell of segars the odor of flow- 
 ers, &c., under some circumstances produce this effect. 
 
 Is the production of abortion always within the 
 power of the mother ? Not always ; some women are 
 unable to produce it, however they wickedly attempt 
 it, by jumping, standing, taking active medicines, &c. 
 
 What is the most certain mode of effecting abortion ? 
 By rupturing the membranes, and allowing the fluids 
 to escape. 
 
 How are you to explain the action of the causes of 
 abortion ? They must produce first organic irritation 
 in the blood vessels of the uterus, and this must extend 
 to the muscular tissue of the organ. 
 
 What distinction are you to make between irritation 
 of the blood vessels, and that of the muscular fibres of 
 
406 PHYSIOLOGY AND PATHOLOGY 
 
 the uterus ? It has been explained thus, according to 
 the theory of Bichat : irritation of the blood vessels 
 involves merely the organic life ; irritation of the ute- 
 rine fibre involves the animal life — hence when irrita- 
 tion of the blood vessels occurs, there is not necessa- 
 rily any contraction, but when irritation of the uterine 
 or muscular fibre occurs, there will be contractions, 
 and perhaps also expulsion. This however is to be 
 understood as a speculation. 
 
 Will contraction of the uterine fibres arrest hem- 
 orrhage so long as the ovum is retained ? No : if the 
 ovum be detached, it is usually a cause of hemorrhagic 
 irritation. 
 
 Suppose however you have a partial detachment of 
 the ovum, can the hemorrhage be arrested before the 
 ovum be expelled ? It may in consequence of the co- 
 agulation of blood in the orifices of the vessels, provided 
 the surface of the detachment be not too large. 
 
 SYMPTOMS OF ABORTION. 
 
 What are the symptoms of abortion? Sense of 
 weight, and pain in the pubic and sacral regions, 
 more or less muco-sanguineous secretion escaping from 
 the vulva, &c. 
 
 Can you diagnosticate between abortion and dys- 
 menorrhoea, during the first three months of supposed 
 pregnancy ? Not with any confidence, even in some 
 cases after the mass within the uterus has been extruded. 
 
 What are usually regarded as the diagnostic signs 
 of abortion ? Regular, intermitting pain in the back ; 
 hemorrhage to some extent ; more or less watery dis- 
 charge ; strong bearing down, expulsive pains : most 
 or all of these, except the watery discharge are met 
 with in dysmenorrhoea. 
 
 Does abortion always become complete when once 
 begun ? Not always ; the ovum may sometimes be 
 preserved in a state of vitality for some length of time, 
 though its development may not increase. 
 
 What consequences result from abortion ? They 
 
OF THE HUMAN FEMALE. 407 
 
 arc very various ; some women recover well and enjoy 
 even better health after one abortion, but others suffer 
 ill health, during a part or all the remainder of their 
 lives, especially when the death of the ovum has been 
 caused by mechanical violence. 
 
 How do you prevent abortion ? Diminish the mor- 
 bid irritability, by removing the cause. If plethoric, 
 bleed, &c. If too much reduced give nutritious food, 
 tonics, &c. Keep the patient quiet. 
 
 What are habitual abortions ? A recurrence of abor- 
 tions at every pregnancy. 
 
 PREVENTIVE TREATMENT IN CASES DISPOSED TO 
 ABORTION. 
 
 How are you to arrest a tendency to abortion ? 
 By a general antiphlogistic and revulsive plan of treat- 
 ment, which diminishes the force of the blood upon 
 the inner surface of the uterus, &c. 
 
 Blisters to the back, &c., are often useful in such 
 cases. Amongst the internal remedies are the sugar 
 of lead, digitalis, &c., to diminish the force of the cir- 
 culation. 
 
 What valuable mechanical means have we at hand, 
 for the arrest of the hemorrhage? The tampon, for 
 the purpose of arresting the flow of the blood through 
 the vagina. 
 
 What is the best article for the tampon or plug ? 
 
 Strips of bandage, or better still, a piece of sponge, 
 cut into an oblong shape, and so introduced as to 
 allow of its expansion within the vagina. 
 
 How far may the use of the tampon involve the safety 
 of the ovum ? It has been supposed dangerous to it, 
 but this can rarely if ever happen, provided it be pro- 
 perly introduced, and judiciously managed. 
 
 What precautions are first to be had recourse to ? 
 Beduce first of all, the force of the general circulation, 
 by vascular depletion, then allay the pain by opiates. 
 
 May the ovum be detaclied from the surface of the 
 uterus ? It may become detached, after the symp- 
 toms have continued a short time. 
 
408 PHYSIOLOGY AND PATHOLOGY 
 
 WHAT TO DO IF OVUM IS DETACHED. 
 
 How are you to act when you discover this fact ? 
 Encourage its complete expulsion. 
 
 Suppose you find the ovum lodged in the orifice of 
 the uterus, what should you do ? Remove it, or facili- 
 tate its detachment. 
 
 Should you give large doses of opium in this parti- 
 cular state of things ? If any, merely sufficient to 
 allay the nervous irritation, not enough to paralyse 
 the uterine contractions. 
 
 Should you always make an examination per va- 
 ginam, in case of supposed detachment ? Yes, always, 
 carefully. 
 
 HoAv should you proceed to eifect the complete re- 
 moval of the ovum in such cases ? By the finger, by 
 Dewees' hook, or better still by Bond's abortion forceps. 
 
 Does the hemorrhage usually cease speedily, after 
 the removal of the ovum ? It speedily in most cases 
 becomes reduced to a mere lochial discharge, which 
 usually subsides in a very few da^^s. 
 
 Upon what does uterine hemorrhage depend, during 
 or immediately after labor, or for some time before 
 labor begins ? Upon detachment of some portion of 
 the placenta. 
 
 Where is the placenta usually attached ? About the 
 fundus, or one of the sides of the uterus, near one of 
 the fallopian tubes. 
 
 What are the consequences of the detachment of 
 the placenta, to both mother and child ? Both are 
 endangered by it ; the mother suffers from the direct 
 loss of blood, and the fetus from imperfect hematosis. 
 Should any lesion of the placenta occur, the fetus 
 suffers from direct loss of blood, while the mother may 
 escape accident. 
 
 Is the detached portion of the placenta ever re- 
 united? It is probably never re-united in such way 
 as that the function can be carried on in the part once 
 detached. 
 
OF THE HUMAN FEMALE. 409 
 
 What becomes interposed between the placenta and 
 the internal surface of the uterus ? A coagulum of 
 blood, which may become organized and adherent both 
 to the uterus and placenta. 
 
 HYDATIDS IN THE UTERUS. 
 
 What is supposed to be the origin of hydatid form- 
 ations, which sometimes distend the uterus ? At one 
 time they were supposed to spring from mucous sur- 
 face, and hence, originate in the lining membrane of 
 the uterus. At present the prevailing opinion is that 
 they depend upon the serous membranes for their 
 nutrition, and it has been observed, that they are 
 rarely or ever found, except in some way or other, 
 connected with pregnancy. In such cases, they are 
 usually first developed upon the surface of the ovum. 
 
 What influence do they exert over the development 
 of the ovum itself? When numerous, they interfere 
 with the nutrition of the ovum, which then blights, so 
 that upon extrusion there is little appearance of the 
 original ovum. 
 
 What are the symptoms of hydatids in the uterus ? 
 They considerably resemble those of ordinary preg- 
 nancy, and hence, cannot be satisfactorily diagnosti- 
 cated, until they begin to be extruded. Women af- 
 fected with hydatid formations in the uterus, are rather 
 more liable to have occasional or constant bloody 
 serous discharges from the uterus, for a greater or 
 less length of time, before expulsion takes place. In 
 the early months, the diagnosis is very obscure, but 
 when the uterus is greatly distended, physical explo- 
 ration and ballottement, prove the non-existence of a 
 fetus in utero. 
 
 What opinions have been entertained, respecting the 
 dependence of hydroraetraupon hydatids ? Dr. Denman 
 regarded dropsy of the uterus, as a very large hydatid. 
 
 Suppose the existence of hydatids be suspected, 
 or even satisfactorily made out, what plan of treat- 
 ment ought to be adopted ? As a general rule 
 35 
 
410 PHYSIOLOGY AND PATHOLOGY 
 
 it will be proper to palliate any disturbances which 
 may occur, and then wait until symptoms of labor 
 come on, when if the extrusion of the mass or masses 
 be tardy, administer ergot sufficent to excite the expul- 
 sive action of the uterus. 
 
 EXTRA-UTERINE PREGNANCY. 
 
 What is the second class of pregnancies usually 
 adopted by obstetric writers ? Irregular, abnormal, 
 or extra-uterine pregnancy. 
 
 Of how many varieties does it consist ? 1st. Of 
 Ovarian pregnancy. 2d. Of ventral or abdominal 
 pregnancy. 3d. Of tubal pregnancy. 4th. Of inter- 
 stitial pregnancy. 
 
 What is meant by the term ovarian pregnancy ? 
 That in which the embryo becomes developed in the 
 ovary. 
 
 What by ventral or abdominal pregnancy ? That 
 in which the ovule or embryo becomes deposited in 
 the cavity of the abdomen and developed there. 
 
 What by tubal pregnancy ? That in vfhich the 
 embryo becomes developed in the tube. 
 
 What are we to understand by interstitial preg- 
 nancy ? That in which the ovule has in some way or 
 other become situated between the layers of muscular 
 fibres in the uterus, and there acquires a degree of 
 development. 
 
 Have we any precise knowledge of the causes of 
 these different varieties of extra-uterine pregnancy ? 
 We have no precise knowledge of the causes — our ideas 
 are merely speculative on this subject. It has been 
 ascertained by experiment that if the fallopian tube 
 be obstructed by ligature, or by excision of a portion 
 of it, after impregnation and before the ovule has 
 passed through its canal, it becomes unable to arrive 
 at the uterus, and it may be somewhat developed in the 
 ovary or tube as a consequence, &c. 
 
 Does the development of the fetus go on in the 
 
OF THE nUMAN FEMALE. 411 
 
 body, or at the surface of an ovary? At the surface, 
 and rarely, if ever, in the body. 
 
 What then are the investments of the embryo? 
 Amnion, chorion, and peritonaeum, and probably ad- 
 ventitious membranes. 
 
 Upon what does abdominal pregnancy probably de- 
 pend ? Upon irregular action of the tubes ; the 
 morsus diaboli not embracing or retaining the ovum. 
 
 What is the process by which the ovum forms a 
 nidus in which to be developed ? Its presence in the 
 cavity of the peritonasum probably excites inflamma- 
 tion and an effusion of coagulable lymph, which sur- 
 rounds the ovum, as the decidua would in the cavity 
 of the uterus. 
 
 Upon what does tubal pregnancy possibly depend ? 
 Upon stricture of the tube, preventing the passage of 
 the ovum into the cavity of the uterus. 
 
 What in this case are the investments of the em- 
 bryo ? Amnion, chorion, and parietes of the tube. 
 
 Can interstitial pregnancies be satisfactorily ac- 
 counted for ? Not at all, unless under the supposi- 
 tion that when the ovum reaches the parietes of the 
 uterus in the tubes, it is arrested at that point and 
 ulcerates its way into the substance of the walls of 
 the organ. 
 
 For what length of time may the ovum continue to 
 develop, in these cases of extra-uterine pregnancy ? 
 For one or two months, though in some cases much 
 longer. 
 
 What usually becomes of it after that time ? It 
 usually dies, becomes encysted in its own membranes, 
 then gradually converted into a sebaceous matter, and 
 looks as though it had been kept in spirits. 
 
 Is it subject to decomposition while thus encysted? 
 It rarely becomes decomposed unless the cavity of the 
 cyst is exposed to atmospheric air. 
 
 Are the placenta and cord mostly found appended to 
 the embryo in these cases ? In all cases where there 
 is any degree of general development. 
 
412 PHYSIOLOGY AND PATHOLOGY 
 
 What substitutes the decidua ? Coagulable lymph. 
 
 What is the condition of the cavity of the uterus 
 in these cases ? It is always furnished with a decidua. 
 
 Does this decidua remain in the uterus as long as 
 the embryo remains in the pelvis or abdomen ? Not 
 usually — it is sometimes thrown off in a few months. 
 
 Do any inconveniences result to the mother in those 
 ca'&es in which the fetus lives and continues to be de- 
 veloped ? Serious consequences usually ensue ; irri- 
 tation, inflammation, suppuration, ulceration, and 
 sloughing, are all liable to take place ; sometimes to 
 an extent to cause the death of the mother. 
 
 What kind of accident may accompany the rupture 
 of the cyst, and cause the immediate death of the 
 mother ? Profuse hemorrhage. 
 
 If death do not happen from this cause what may 
 produce it more tardily ? Peritongeal inflammation. 
 
 Do any instances occur, in which the fetus becomes 
 considerably developed, without causing fatal irrita- 
 tion ? There are instances on record in which the wo- 
 man has carried such a fetus many years. 
 
 What then usually happens about the end of the 
 ninth month ? A parturient effort takes place, and 
 sometimes the decidua and some coagula are thrown 
 off; uterine action then subsides. 
 
 Does the patient ever recover after such parturient 
 efforts ? Some women live many years after such an 
 event. 
 
 Is it possible for them to have a true pregnancy 
 while they are carrying the product of extra-uterine con- 
 ception ? Some cases of this kind are on record, and 
 there is no reason why pregnancy should not recur 
 after the decidua has been discharged from the cavity 
 of the uterus ? 
 
 What is the more common result ? Irritation, fol- 
 lowed by inflammation and abscess, opening exter- 
 nally, as at the umbilicus, groin, pcrinseum, or into 
 the intestines. 
 
 What are the symj)toms of extra- uterine pregnancy ? 
 
OF THE HUMAN FEMALE. 413 
 
 They are very irregular, and differ somewhat from 
 those of normal or uterine pregnancy. 
 
 What takes place in regard to the catamenia ? It 
 mostly returns at the usual period of quickening, and 
 then continues regular, especially if the decidua have 
 been thrown off. 
 
 What is the condition of the mammae ? They mostly 
 become flattened after having been partially de- 
 veloped. 
 
 Is there any difference in the time at which the 
 fetus is felt ? If it acquires any muscular develop- 
 ment, it is felt earlier than in natural pi'egnancy. 
 
 Is the ovary liable to take on an effort at abnormal 
 generation ? Yes — it has been known to contain hair, 
 teeth, &c., which were probably the result of abnor- 
 mal generation. 
 
 What other instances are known which lend support 
 to the doctrine of emboitment or encasement of germs? 
 The fact recorded (in Coxe's Med. Museum, vol. ii. 
 No. 2. — Sept. and Oct. 1805,) in which a fetus was 
 found within the abdomen of a boy, fourteen years 
 old ; and the case related by Velpeau, where the ru- 
 diments of a fetus were engrafted on the testicle of 
 a male, &c. Blundell saw an " imperfectly developed 
 fetus, about the size of six or seven months, and 
 which was taken from a boy, where it lay in a sac in 
 communication with the child's duodenum, the buy 
 being pregnant." 
 
 TREATMENT IN EXTRA-UTERINE PREGNANCY. 
 
 What are the indications for treatment of extra- 
 uterine pregnancies ? Generally palliative, to relieve 
 or remove irritation as much as possible. 
 
 What is to be done when the cyst is ruptured ? 
 Support the patient's strength by tonics, cordials, &;c. 
 
 Suppose an abscess should form and point exter- 
 nally ? Apply fomentations, poultices, &c. 
 
 Would it be advisable to open an abscess, if it could 
 be reached by an incision ? By good authority, it is 
 35* 
 
414 THE OVUM, EMBRYO AND FETUS 
 
 thought that it would be best to make a free inci- 
 sion, to evacuate the contents of the abscess, and thus 
 remove the irritation. 
 
 Would it be proper to favor the removal of the con- 
 tents of the abscess bj injecting it with cleansing 
 washes ? This would probably greatly facilitate the 
 restoration of the patient's health. 
 
 Is the placenta mostly adherent to some part of 
 parieties of the abscess ? It is usually attached 
 strongly to some portion of the wall of the sac. 
 
 How is it to be separated ? By washing away the 
 debris, as fast as it sloughs. 
 
 Would gastrotomy be advisable in the early stage 
 of abdominal pregnancy ? The opinion is entertained 
 by some that it would be safer for the mother that it 
 be done, and thus protect her against subsequent irri- 
 tation. 
 
 THE OVUM, EMBRYO, AND FETUS LIABLE TO ACCIDENTS 
 WHILE IN UTERO. 
 
 Is the ovum, the embryo, or the fetus liable to any 
 accidents while in utero ? The product of conception 
 has been observed to be incident to various accidents, 
 resulting in modification by excess, or diminution of 
 parts, or disarrangement of the various organs. These 
 accidents have been classed under the general epi- 
 thet of monstrosity. Thus the ovum has become one 
 immense hydatid, or a number of the cells of the pla- 
 centa have taken on this modified action, and there 
 has resulted a congeries of cells filled with fluid, va- 
 ried in size, w^hich congeries has been called by Ma- 
 dame Boivin, Hydatideengrappe, or grape-like hyda- 
 tids. The influence of this accident to the placenta 
 upon the embryo has been various — sometimes blight- 
 ing its growth very perceptibly, so that when the con- 
 tents of the uterus were thrown ofl", it has been found 
 imperfect and shrivelled, or in some cases it could not 
 be seen at all, having probably died and been dis- 
 solved in some of the fluids. In other instances the 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 415 
 
 "wliole ovum has been converted into a solid substance 
 resembling, when cut open after being thrown off, a 
 firm clot of blood. Such discharged masses have re- 
 ceived the popular name of moles. Again the con- 
 tents of a gravid uterus may undergo changes which 
 result in the defect of development, and when thrown 
 off at various periods of the gestation, are found to 
 hold but faint resemblance to the normal product of 
 conception in the human female. Besides this, it oc- 
 casionally happens that two ova fecundated at the 
 same time, and passing into the uterus in a healthy 
 condition, by some accident become so fused together 
 at different points, as in some cases to appear as one 
 child with two heads, or with four arms, or with four 
 legs, or with two apparently perfect persons fastened 
 to each other at some small point which enabled each 
 to obey, to some extent, its own instincts, as was illus- 
 trated in the case of Ritta and Christina, reported by 
 European writers, as well as the case of the " Siamese 
 Twins" seen in America by very many citizens but a 
 few years since. Although there have been numerous 
 instances of various kinds of monstrosity reported at 
 different periods through a long series of years, we are 
 not aware that there has been any systematic account 
 or classification of these departures from the ordinary 
 laws of formation, since between the years 1832 and 
 1837, when Isidore Geoffrey Saint Ililaire, publislicd 
 his very interesting and instructive Histoire Gdnerale 
 et Particuliere des Anomalies de ['Organisation chez 
 L'Homme et les Animaux ; Ouvrage Comprenant des 
 Recherches surles Caracteres,la Classification, I'lnflu- 
 ence Physiologique et Pathologique, les Rapports Q6- 
 n^raux, les Lois et les Causes des Monstruositds, des 
 Vari^tds et des Vices de Conformation, ou Traite de 
 Teratologic — a work which all medical men should 
 read. Dr. Meigs has also collected the history of 
 a few cases which have occurred in this country. 
 In the winter of 1850-1, I)r. Pemberton Thorn, a 
 pupil of the Philadelphia Obstetric Institute, while 
 
416 THE OVUM, EMBRYO AND FETUS 
 
 attending upon one of the patients, found her with 
 four feet offering at the vulva, which when de- 
 livered were discovered to belong to two female 
 children, who had been subjected to this process of 
 fusion to such extent as to have the two heads and 
 two thoraxes united apparently into one, so that there 
 was but one face, two perfect and two imperfect ears ; 
 four well developed thoracic members, two distinct 
 abdomens, each with its umbilical cord, placenta and 
 pelvic members. 
 
 The injection, dissection, anatomical preparations 
 and the description were performed by the dex- 
 trous hands of Dr. John Neill, the curator of the 
 College, and the artistic representations were executed 
 under his supervision. 
 
 What are the description and illustration of this 
 subject as published in No. 2, of Quarterly Summary 
 of the Transactions of the College of Physicians of 
 Philadelphia, from January to April inclusive, 1851 ? 
 
 No. 46, Skeleton of a double-bodied monster, and 
 No. 47, Alimentary canal, respiratory organs, &c., 
 of the same, presented by Dr. Warrington. 
 
 In the dissection and preparation of the specimen, 
 the following peculiarities were observed. 
 
 Exterior, — The general appearance is that of two 
 children, having a thorax in common, with a single " 
 head. By referring to the accompanying drawing, it 
 will be seen that the head is apparently single, and 
 that the face presents no peculiarity but a fissure of 
 the lower lip in the median line. On the back of the 
 head, which w^as very wide, there was a symmetrical 
 double ear, the meatus of which was imperforate. 
 
 The thorax was single, common to the two bodies. 
 Upon its exterior were four nipples, two of which 
 are seen in the drawing, the other two were in the 
 same position on the corresponding part of the 
 thorax. There were four upper extremities, all of 
 w^hich were perfect, equally developed, and natural 
 in their positions. 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 417 
 
 Below the umbilicus the separation was complete. 
 The lower part of each body was perfect. The lower 
 extremities were of the same size and appearance. 
 
 The cord was very thick, and consisted of two 
 umbilical veins, which were of the same size, and 
 four umbilical arteries, one of which was very large, 
 and the other very small. At a distance of two inches 
 from the placenta, which was double, the cord bifurcat- 
 ed, each part entering its own placenta. See fig. 143. 
 
 Fig. 143. 
 
 Alimentary canal, — The mouth was a single cav- 
 
418 
 
 THE OVUM, EMBRYO AND FETUS 
 
 ity, containing two tongues, separated posteriorly by 
 an irregular mass covered with skin, which was pro- 
 bably a rudimentary cheek or lip. The fauces and 
 upper part of each pharynx were distinct; each 
 contained a uvula and two tonsils. The pharynges 
 communicated, and, from the funnel-shaped cavity 
 formed by their junction, there proceeded a single 
 oesophagus. 
 
 The oesophagus terminated in a stomach containing 
 a single cavity, though its shape was such as to give 
 the idea that two stomachs had been fused by their 
 lesser curvatures. The antrum pylori is plainly seen 
 on either side in fig. 144, in which T, represents 
 
 the tongues; ^, trachea; L, lungs ; H, rudimentary 
 heart ; S, stomach ; E, intestine ; J, bifurcation ; C, 
 colon. 
 
 From the pylorus there extended a single intesti- 
 nal canal which, at u distance of two feet from the 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 419 
 
 storaacli, divided into two distinct tubes, each about 
 fifteen inches in length. These had all the charac- 
 ters of the small intestine, and terminated regularly 
 at the ileo-colic valve. The large intestine was com- 
 pletely double, there being one for each child ; each 
 was perfect from the coecum to the anus, not except- 
 ing the appendix vermiforis, and contained the usual 
 amount of meconium. 
 
 The liver was single, large, and symmetrical.; it 
 contained two lobes of about the same size, and a 
 single gall-bladder. The spleen and two well- formed 
 kidneys were found in each trunk. The genitals, 
 which were female, were perfectly developed both ex- 
 ternally and internally in each pelvis. 
 
 Organs of Respiration. — The larynx opened in the 
 usual position in each pharynx, and the trachea and 
 bronchial tubes were regularly developed for each 
 body. The lungs were four in number; those be- 
 longing to the right child had a large vessel entering 
 directly at the apex. 
 
 Circulation. — There were two hearts ; one was 
 rudimentary and situated between the lungs of the 
 left child ; it was conical in its shape, consisted of but 
 one single cavity, and from its base there proceeded 
 a single vessel. The other was developed irregularly, 
 (fig. 145 ;) it was situated under the sternum, to which 
 are articulated the right ribs of the right child, and 
 the left ribs of the left child. From the base of this 
 heart there arose an aorta for each child, which oc- 
 cupied its usual position on the vertebral column. 
 The larger arterial branches were regularly given off, 
 with the exception of the umbilical arteries of the 
 right child, one of which was very large and appeared 
 to be the continuation of the primitive iliac ; the other 
 was exceedingly small. 
 
 The ascending vena cava of the left child did not 
 pass through the liver, but, after being joined by the 
 descending vena cava, the common trunk thus formed 
 passed behind the heart, emptying into the right 
 
420 
 
 THE OVUM, EMERY AND FETUS 
 
 auricle. The ascending vena cava of the right child 
 did not seem to exist below the liver, but the blood- 
 vessels from the lower extremities opened into the 
 portal vein, which was large proportionally. The 
 pulmonary artery communicated with each aorta. 
 See fig. 145, in which H, represents the heart ; A, 
 
 Fig. 145. 
 
 pulmonary artery ; aor, aorta ; Y C, ascending vena 
 cava of right body ; P, portal vein ; U, umbilical 
 veins ; u a, umbilical arteries ; L, liver ; D V C, 
 descending vena cava of left body ; A V 0, ascend- 
 ing vena cava of left bod}^ 
 
 Skeleton. — The skeleton measured thirteen inches 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 421 
 
 after it had been prepared and dried. The head 
 measured four inches in its occipito-mental diameter, 
 and three and a half inches in its bi-parietal. The 
 anterior and superior surface of the head was single ; 
 the duplication commenced at the base of the cranium. 
 The bones of the face are those of a single head, 
 with the exception of an effort at a double forma- 
 tion of the inferior maxillary bone and of the palate 
 processes of the superior maxillary. The frontal and 
 parietal bones were those of a single head, but there 
 were two occipital bones ; to the condyloid processes 
 of each were articulated the atlas of each vertebral 
 column. There were four temporal and two imper- 
 fect sphenoid bones. See fig. 146, in which P, 
 represents the parietal bone ; W, w^ormian bones ; 
 0, occipital bones ; T, temporal bones ; L, lateral 
 portion of the occiput. 
 
 Fig. 146. 
 
 Below the head, the skeleton was completely dou- 
 ble. The thorax was a single cavity having two 
 sterna, to which the ribs and clavicles were articu- 
 lated in a very peculiar manner. The right ribs 
 and clavicle of the right skeleton, and the left ribs 
 and clavicle of the left skeleton, articulated with the 
 80 
 
422 THE OVUM, EMBRYO AND FETUS 
 
 anterior sternum. The left ribs and clavicle of the 
 right skeleton, and the right ribs and clavicle of the 
 left skeleton, articulated with the posterior sternum. 
 
 In other respects, the bones of each skeleton were 
 developed and articulated as usual. See 
 
 Fig. 147. 
 
 DU. WEST'S CASE OF MONSTROSITY. 
 
 What is the description and illustration given by 
 Dr. Francis West, Jr., of Philadelphia, of an anence- 
 phalous fetus born under his care, and reported by 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 423 
 
 him in vol. i. of the Medical Examiner ? In the fol- 
 lowing brief and imperfect sketch, I have attempted 
 only to delineate the more characteristic features of 
 this interesting specimen of monstrosity, leaving to 
 others to explain the causes of their occurrence, and 
 to fix their precise value and importance. It is a per- 
 fect specimen of what has been thought by the learned 
 author of the article " Anencephalous," in the Ameri- 
 can Cyclopaedia of Pract. Med. and Surgery, to be 
 the rarest form of this kind of abnormal deviation, 
 and the only one to which the term can be appro- 
 priately applied — " So seldom does it occur," he adds, 
 " that only a few cases of it are to be found on re- 
 cord." — Some remarkable peculiarities of external 
 configuration and structure exist along with the entire 
 absence of the cerebro-spinal axis, which give to the 
 specimen before us increased value and curiosity. By 
 some very essential and radical vice of formation, the 
 human fetus may become so materially degraded in the 
 scale of being, as very closely to approximate, in some 
 prominent points, the lower order of animals ; and I 
 may state that its peculiar configuration and structure 
 would not by any possibility have permitted it to as- 
 sume the erect position, supposing it capable of main- 
 taining an independent existence. In obedience then 
 to this necessity, which I think will be perfectly ap- 
 parent from what follows, it has been represented, 
 in the accompanying drawing, in the horizontal posi- 
 tion, and not with the view of adding grotesqueness 
 to its other singularities. This anencephalous fetus 
 possesses all the characters belonging to the varieties, 
 " Anencephalus " and " Derencephalus " in Geoffroy 
 St. Hilaire's classification of monsters. The cranial 
 bones which have been thought always to exist, though 
 sometimes only in a rudimentary condition in fetuses 
 of this kind, are here entirely absent. The basilar 
 process of the occipital bone is united with the bodies 
 of the dorsal vertebrae, the intervening cervical ones 
 i ivinaj no existence ; these vertebrse and those be- 
 
424 
 
 THE OVUM, EMBRYO AND FETUS 
 
 low them to the termination of the column, are " cleft 
 posteriorly and enlarged by spina bifida, with their 
 lateral halves much inflected outwards and separated 
 from each other." This condition of the vertebrae 
 
 Fig. 148. 
 
 leaves a large chasm in the back, about 14 lines wide, 
 covered only by the membranous semi-circular sac, 
 represented in the draAving. The whole face with 
 each individual organ of sense is much enlarged, and 
 presents a most unnatural expression of countenance. 
 The direction of the eyes as well as tlie whole face, 
 in consequence of the excessive posterior inclination 
 of the base of the cranium, is immediately upwards, 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 425 
 
 even more so than is shown in the drawing, when the 
 fetus is held in the erect position, which therefore 
 must have been attended by their total uselessness. 
 To the whole margin of the chasm in the back, which 
 at the angle formed by the junction of the basilar 
 portion of the skull to the dorsal vertebrae becomes a 
 triangular cavity of some depth, is attached the sac 
 above mentioned, which is continued forwards on 
 either side along the edge of the oblique plane formed 
 by the base of the cranium and the bones of the face. 
 This sac which was filled with fluid was ruptured dur- 
 ing labor ; it enclosed the membranous cornua, to be 
 seen in the drawing, and which alone occupied all the 
 space upon which should have rested the cerebral 
 mass. Along the margin of this bag throughout its 
 whole extent from the orbits to its termination at the 
 sacrum, is an abundant growth of very dark hair, at 
 some points more than half an inch long, — which ar- 
 rangement gives the idea of the scalp having been drawn 
 over the back, and countenances the notion that the 
 head with its contents or something answering to 
 them, were to have been developed upon the back, 
 which displays to all appearance the attempt to form 
 there a lodgment for them. The above impression is 
 very strongly forced upon us by a posterior view of 
 these parts as they exist in the preparation, which 
 could not be given in the drawing. Portions of the 
 membranes of the medulla spinalis, forming elongated 
 circular sacs, containing a little thin fluid, existed 
 upon and in close contact with the depression along 
 the bodies of the vertebrae. The upper and lower ex- 
 tremities present remarkable peculiarities which de- 
 serve special attention in our observations and reflec- 
 tions upon the character and destination of this much 
 deformed being. The clavicles do not exist at all : 
 and the scapulae in actual contact with the sides of 
 the face, are attached to the fore-part and sides of 
 the thorax, instead of posteriorly, with their long dia- 
 meters perpendicular to, instead of parallel with the 
 36* 
 
426 THE OVUM, EMBRYO AND FETUS 
 
 axis of the body ; the arms and fore-arms are of un- 
 usual length and very loosely articulated at the carpo- 
 radial articulation ; the deltoid muscles are extraordi- 
 narily developed, and the skin of these, as well as 
 that of the lower extremities has much hair growing 
 upon it; the lower extremities are also very long and 
 muscular, and present the same peculiarity of direc- 
 tion as the upper ones at their union with the body. 
 The articulations at the ankles are very loose and ad- 
 mit without the least violence the touching of the 
 metatarsus and the spine of the tibia as the foot rests 
 upon a plane surface. Whole length of fetus from 
 heel to base of cranium, 11 inches; from anus to base 
 of cranium, 5 inches ; from external malleolus to tro- 
 chanter, 6 inches ; length of femur, 3 inches and 6 
 lines ; length of tibia, 2 inches and 9 lines ; length 
 of foot, 2 inches and 3 lines ; length of whole arm, 8 
 inches ; length of humerus, 3 inches and 3 lines ; 
 length of fore-arm, 4 inches and 9 lines. The nerves 
 of the extremities are fully developed, and ramify 
 through the parts to which they are respectively sent. 
 On tracing up these nerves they were found suddenly 
 to terminate at the vertebrae and had no connexion 
 with the spinal membranes spoken of. This fact is of 
 importance to those who contend that the nerves are 
 formed at the periphery of the body and are de- 
 veloped towards the central masses, with which they 
 afterwards unite. One or two ganglions of the sym- 
 pathetic nerve were discovered in the thorax, and its 
 dissection was not further pursued. The umbilical 
 cord is about IJ inches in diameter, and contains the 
 entire liver, which is closely adherent to its sides, with 
 a large portion of the great and small intestines. 
 The other organs of the abdomen are natural and in 
 situ, and so are those contained in the thoracic cavity. 
 It was desired to pursue particularly the dissection of 
 the nerves of animal life, but as this would materially 
 have destroyed the preparation, the examination was 
 reluctantly given up, and it is hoped without the sa- 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 427 
 
 crifice of much information. The parents are natives 
 of Lincolnshire, England, and were married in June 
 last, exactly six months before the woman aborted 
 with this monstrous fetus. The father is about 25, 
 and the mother 28 years of age ; they are perfectly 
 •healthy and well formed. They arrived at a hotel in 
 this city much fatigued by a forced journey which 
 they had made from Cincinnati, and the mother was 
 very soon after taken sick. I reached her just after 
 the w^aters had been discharged, and found, on exami- 
 nation, the chin of the child presenting at the inferior 
 strait : a very few pains sufficed to deliver it. The 
 umbilical cord and placenta were much diseased, and 
 of the latter small pieces continued to come away 
 for several days, producing each time alarming he- 
 morrhage, which jeoparded the life of the woman. 
 She ultimately, however, recovered perfectly, and left 
 the city 
 
 Is the welfare of the fetus ever compromised by the 
 accident of having the cord encircle the neck, one or 
 more times ? Fetuses at birth are sometimes found 
 dead. Under such circumstances, though probably not 
 so much from the fact that the cord by its pressure 
 interrupts the circulation through the brain, directly, 
 as that it is itself so compressed as to cut off the ne- 
 cessary connexion with the placenta. 
 
 Is the life of the fetus ever endangered by such 
 evolutions in the uterus as tie the cord into close 
 knots ? The life of the fetus is even sometimes de- 
 stroyed by the tension by which the cord is drawn 
 when thus knotted, since in such instances the vessels 
 have been found nearly or quite obliterated. 
 
 Does any inconvenience ever result from the coil- 
 ing of the umbilical cord aroui:)d the limbs of the fe- 
 tus ? Such circumstances have been known to cause 
 atrophy and sometimes even an amputation of the 
 member which it encircled, see figs. 149, and 150. , 
 
 What Irish author has given the fullest account of 
 
428 THE OVUM, EMBRYO AND FETUS 
 
 this spontaneous amputation of the limbs of the fetus 
 in utero ? Probably Dr. Montgomery of Dublin. 
 
 Fig. 149. Fig. 150. 
 
 Is it satisfactorily proved that all the cases of spon- 
 taneous amputation of the fetal members are depend- 
 ant upon the accidental coiling of the umbilical cord 
 around them ? It would be best, before coming to 
 such a conclusion, to consult his entire paper on this 
 subject, and to read attentively the cases he describes, 
 as well as those he refers to as having been collected 
 by Professor Simpson and others. 
 
 Is the fetus subject to any modification of its nor- 
 mal form, ascribable to its position in the uterus ? 
 Many cases occur in which the shape, or the direction 
 of the growth of the lower extremities particularly, 
 appears to be modified by the peculiar position of the 
 fetus in utero, or the influence which the pressure of 
 the uterus may exert upon it. Hence the varieties of 
 bow legs, club feet, &c. 
 
 To what other accidents may the fetus be subjected 
 during its continuance in the cavity of the uterus ? 
 Many, as for example, if the placenta becomes de- 
 tached, the fetus may become atrophied ; or even pu- 
 trescent. The fetus may also be subjected in a greater 
 or less degree, to certain diseases to which the mother is 
 
LIABLE TO ACCIDENTS WHILE IN UTERO. 429 
 
 incident ; the mother may have mild varioloid and the 
 fetus die of confluent small-pox. 
 
 ACCIDENTS TO THE CHILD DURING LABOR. 
 To what accidents is the child liable during the 
 maternal effort at parturition ? They are numerous, 
 depending upon the condition of the uterus in some 
 cases, and upon that of the pelvis, or that of both 
 together, in some other instances. Should the pla- 
 centa be implanted over the orifice of the womb, its 
 separation as the orifice dilates, may not only cut off 
 the means of hematosis for the child, but it may 
 and probably does in some cases give exit to the blood 
 of the fetus, so that it may die of actual hemor- 
 rhage from the placental vessels. If the membranes 
 should be ruptured in the very early stage of the 
 labor, the contractions of the fundus and body of the 
 uterus severe, and its orifice rigid, the fetus, either by 
 direct compression made upon itself, or by the com- 
 pression of the cord or placenta between the uterus 
 and itself, may be greatly prostrated or its life en- 
 tirely destroyed. Again : if the umbilical cord should 
 become prolapsed, and it be not possible to return it 
 to the cavity of the uterus so that the head of the 
 child may descend first, the circulation may become 
 fatally arrested, or the fetus, when born, is with ex- 
 treme difficulty resuscitated. When the pelvis is 
 faulty in its formation, so as to be defective in its 
 amplitude, the brain may be either fatally compressed 
 or its functions so far impaired that they are after- 
 w^ards a long time in recovering, or are always imper- 
 fectly performed, leaving the child susceptible to con- 
 vulsions or imbecility, or other forms of insanity. 
 
 ASTHENIA OF INFANTS AT BIRTH. 
 
 What do you mean by an asthenic condition of the 
 
 child at birth ? That it is feeble, the features are 
 
 shrivelled and narrow, resembling old persons. The 
 
 child is blue, does not respire freely ; its circulation 
 
430 ACCIDENTS TO THE CHILD AT BIRTH. 
 
 is very feeble ; it groans, does not cry, nor seem to 
 make any effort to breathe, or if it breathes, it does 
 so very feebly. 
 
 How should you manage such a condition ? En- 
 deavor to stimulate its respiratory muscles by warm 
 bath, and cold douches alternately ; by dry heat, slight 
 friction with the end of the fingers ; do not fatigue it, 
 but w^ash it with warm alcoholic fluids, then apply 
 warm cloths ; assist its respiration by blowing into its 
 lungs, &c. ; give it barley water, gum water, sugar 
 and water, &c. ; do not let it be fatigued with nurs- 
 ing ; take care not to weary it by dressing ; wrap it 
 in a warm flannel or in cotton wadding, to accumu- 
 late animal heat as much as possible. 
 
 ASPHYXIA OF INFANTS AT BIRTH. 
 
 What do you mean by asphyxia ? A state of ap- 
 parent death, in which the child is perfectly motion- 
 less, and either pale, or livid. 
 
 How many kinds of asphyxia do you recognise ? 
 Two; simple, and congestive asphyxia. 
 
 What are the common causes of this state ? Pres- 
 sure in the passage through the pelvis. Pressure 
 on the cords or the placenta, by arresting the circula- 
 tion, &c. 
 
 Is the brain of much importance during intra- 
 uterine life ? It does not appear to be. The child 
 is like a plant, appearing to have a mere vegetable 
 existence while in utero. 
 
 What causes operate often to produce asphyxia? 
 Compression upon the cord around the child's neck : 
 knots in the cord which may arrest its circulation. 
 The retention of the membranes over the child's head. 
 The floodings of the large quantities of the liquor 
 amnii or blood over the child. Suffocation under the 
 bed clothes, or by the membranes around the head. 
 The respiratory organs clogged with mucus, &c. 
 
 What evidences have we of the state of simple 
 asphyxia ? Pallor, absence of pure blood on the 
 
ACCIDENTS TO THE CHILD AT BIRTH. 431 
 
 surface, absence of respiration. The breast, &c., 
 may have a bluish appearance, but other parts are 
 pallid. 
 
 What evidences have we of the congestive state of 
 asphyxia ? The face is swollen and turgid with blood. 
 There is absence of respiration and circulation ; the 
 whole surface is more or less blue, and the extremi- 
 ties cold. 
 
 Are these two distinct aiFections, or are they pro- 
 bably degrees of the same condition ? It is probable 
 that they are but degrees of the same state. 
 
 How should you treat asphyxia ? Remove all 
 mechanical impediments to the respiration or circula- 
 tion ; place the child free from the cloths, &c., clear 
 all mucus from about its glottis ; assist its respiration, 
 if it be able to swallow, give it a little fluid to wash 
 away the mucus. Keep the child connected with the 
 placenta as long as any circulation exists. Keep the 
 body warm, put it into a basin of warm water ; bring 
 this to the bed and lift the child into it, before the 
 placenta is removed ; then dry it at once by warm 
 cloths ; when it comes out, use free friction in this 
 case, about the respiratory muscles with towel or 
 hand; use brandy, alcohol, or hartshorn liniments, 
 and also stimulating injections ; then dash on some 
 cold spirits, or cold water ; then in a moment wipe it 
 off, and plunge it into the warm bath again, &c. 
 Imitate the process of respiration, by pressing the 
 thorax and abdomen, alternately with the head : 
 sometimes breathe into the lungs, pressing' the larynx 
 slightly against the spine to prevent the air from 
 passing through the esophagus into the stomach, if 
 you cannot soon 'succeed thus, use the tracheal pipe 
 or quill to convey the air into the lungs. 
 
 How must this tube be used ? Pass it along 
 the side of the mouth and throat, over the glot- 
 tis, and then force in a small quantity of your own 
 breath. 
 
 What can be said of the value of galvanism or 
 
432 ACCIDENTS TO THE CHILD AT BIRTH. 
 
 electricity in these cases ? They have not generally 
 succeeded, and the apparatus is rarely at hand. 
 
 Are you speedily to abandon this treatment if your 
 first efforts do not succeed ? By no means ; the 
 efforts must be persisted in for half an hour, an 
 hour, or even more before relinquishing any attempts 
 to resuscitate it ; and after you have succeeded, 
 oblige the nurse to continue frictions over the skin 
 for some time. 
 
 How would you treat the congestive form of the 
 affection ? The same as before, adding some care to 
 diminish the amount of blood in the veins of the child. 
 Therefore, do not tie the cord ; for if the symptoms 
 be urgent cut the vein at least, some say the whole 
 cord, and thus let the blood escape. 
 
 How much blood may you thus take away ? From 
 half an ounce to an ounce. 
 
 TUMORS ON THE SCALP OF INFANTS AT BIRTH. 
 
 Are children ever born with tumors on the scalp ? 
 It not unfrequently happens that tumors of greater 
 or less size are found on the scalp. 
 
 Of what character are they? Generally bloody, 
 and are of the character of ecchymosis. 
 
 How are they formed? Most likely by the ex- 
 cessive pressure made upon the body of the child 
 within the uterus or pelvis, the blood is squeezed 
 out into that portion of the scalp which is not so 
 compressed. 
 
 May these tumors be supposed to be fractures of 
 the cranium ? They may, and sometimes they strongly 
 simulate fractures with depression of a portion of the 
 bone. 
 
 Are fractures of the cranium often met with ? 
 They are not, though the bones are sometimes in- 
 dented by the pelvic bones during the second stage 
 of labor. 
 
 What should you do for the relief of the tumor ? 
 Apply cold lead-water, &c., with a view to discuss it. 
 
SUBJECTS NOT YET TREATED OF. 433 
 
 Should you use frictions ? No : because by so 
 doing you may excite inflammation in the tumor. 
 
 Suppose it is inclined to suppurate, how should 
 you do ? • Poultice it, and promote the formation 
 of pus. 
 
 Should you open it freely ? It should be freely 
 opened, unless as happens in some cases, absorption 
 goes on very rapidly. If opened, it is to be dressed 
 as a simple suppurating wound. 
 
 What other accidents to the child in utero, during 
 the labor for its delivery, and for some time after, its 
 birth, could you. describe, did time and the capacity 
 of this volume permit ? Very many, as hair-lip, cleft 
 palate, deficiency or excess of members or parts, 
 difterent varieties of hernia, exstrophies, atrophies, 
 &c., &c., and in relation to the accidents after birth, 
 as the several diseases of the skin ; the morbus cae- 
 ruleus, or cyanosis neonatorum, and other affections 
 of the vascular system ; the various disorders of the 
 digestive apparatus, &c., all of which may hereafter 
 be disposed of as may be necessary and desirable. 
 
 Has the subject of the diseases of women been ex- 
 hausted in the course of the present inquiries? 
 While those to which women are incident during the 
 menstrual and pregnant conditions have been but 
 cursorily examined and treated of, it is not pretended 
 that thus far even an allusion has been made to those 
 which frequently complicate the puerperal condition, 
 as mammary engorgements, deficient or excessive 
 lactation during the first few days and weeks after 
 delivery — the metritis, the peritonitis, the metro-pe- 
 ritonitis, the phlebitis, the mammary abscess, &c., &c., 
 which are also liable to occur to the puerperal and 
 nursing female. The apology for this apparent omis- 
 sion is to be found in the want of time and space, at 
 present, to do them justice. They may, however, 
 secure their due claims to consideration at a future 
 period. 
 
 37 
 
THE OBSTETRIC INSTITUTE 
 
 ©[F [PMD[k3^[e)l[L[^[K]Q/^9 
 
 TJNDER THE CHAEGE OF 
 
 JOSEPH WARRINGTON, M. D. 
 
 I. DESIGN OF THE OBSTETRIC INSTITUTE. 
 
 1. To furnish Obstetric aid to such indigent females at their 
 own homes, as apply for the benefit of the Philadelphia Dis- 
 pensary, Lying-in Charity and Nurse Society. 
 
 2. To supply practical facilities to gentlemen pursuing the 
 study of medicine, for attaining to present and future useful- 
 ness in their profession, by a close preliminary training, and a 
 subsequent attendance as accoucheur in ordinary, upon those 
 who may require obstetric aid from the Dispensary, &c., &c, 
 
 3. To qualify Nurses for their especial duties in the sick- 
 room, with particular reference to obstetric cases, and to im^ 
 press thera with a due sense of the relation they hold with the 
 Physician, in the management of such patients. 
 
 II. QUALIFICATIONS OF CANDIDATES FOR ADMISSION INTO 
 THE INSTITUTE. 
 
 1. Gentlemen, who produce from a Professor, preceptor, or 
 some other responsible person, a certificate, that they sustain 
 a good moral character, that they are diligent in the study 
 of Medicine, and that they have attended at least one full 
 course of Lectures- included in the Curriculum of a degree- 
 conferring School, are eligible to admission to the instructions 
 and practical advantages of the Institute, — provided they pro- 
 cure their tickets, and regularly enter the class within five days 
 from the commencement of either of the courses of Lectures 
 indicated in page 443 of this announcement. 
 
 2. The principal reserves the right to receive Graduates in 
 Medicine, at later periods of the^ course, whenever the coraplo- 
 
 (435) 
 
436 ANNOUNCEMENT OF 
 
 raent of sixteen pupils has n-ot been made up within the time 
 specified. 
 
 III. ORGANIZATION OF THE INSTITUTE. 
 
 J. WARRINGTON, M. D., Principal. 
 • M. D., Senior Assistant. 
 
 ZZHZII ZZZZZI I Junior Assistants. 
 
 Practising Pupils, — limited to sixty-four per annum ; and, as 
 nearly as possible, sixteen to each course. 
 
 IV. DUTIES OF PUPILS. 
 
 1. To give regular and punctual attendance upon the prac- 
 tical instructions of the Institute. Absence from a lecture 
 will require explanation, since each meeting of the class is re- 
 garded as a professional appointment ; and no pupil can be 
 expected to have the management of actual cases, unless he 
 shall have been present at, and shared in all the practical ex- 
 ercises upon the models to the satisfaction of the Principal. 
 
 2. To make one or more visits to the patients under his care, 
 during the latter periods of pregnancy, to give such instruc- 
 tions in relation to their persons and positions as the nature 
 of the case may require : and promptly to obey a request to 
 attend upon the labor, unaccompanied, except by the Principal 
 or a duly recognised assistant. 
 
 3. To summon to his aid, at as early a period as practicable, 
 an assistant or the Principal, whenever he is embarrassed in 
 reference to the management of the case under his care, espe- 
 cially if the life of the mother or child is involved in the 
 slightest danger. 
 
 4. To inform the Principal in person or by note, of the de- 
 livery, as soon as possible after its occurrence, and furnish a 
 summary account of the condition of the mother and child, at 
 the date of such communication. 
 
 5. To visit his patients daily, or more frequently for at least 
 five days, and then once in two days until after the tenth day 
 from the period of confinement. To embrace every suitable 
 opportunity to make himself acquainted with the actual condi- 
 tron of the puerperal woman and her child, with such other 
 matters as appertain to the professional superintendence of the 
 affairs of the nursery. 
 
 6. To enter, as soon as practicable, under appropriate heads, 
 in the Tabular Feports, the results of his observations, and to 
 write at length a history of the case as observed by him, 
 through its whole progress. 
 
 7. To render to the Principal, in a neat and perspicuous 
 style, the tabular reports, and a minute detail of all the 
 cases which have been under his care, on the alternate 
 
THE OBSTETRIC INSTITUTE. 437 
 
 pages of thesis paper, with a title page after the following 
 manner : 
 
 RECORD OF CASES 
 
 ASSIGNED ME BY DR. WARRINGTON, DURING MY CONNECTION WITH 
 
 THE PHILADELPHIA OBSTETRIC INSTITUTE, 
 
 IN THE MONTHS OF 
 
 , and , 18 
 
 BY 
 
 8. And to return to the Principal, the names of all patients, 
 whom, with his consent, he may decline to attenfd, that they 
 may be distributed to other members of the class. 
 
 V. PRIVILEGES OF PUPILS. 
 
 1. To attend all the lectures given during their period of 
 engagement in the practice of the Institute, besides the in- 
 structions and exercises of their preparatory course. 
 
 2. To receive a Diploma, after the following form : 
 
 €^t (^Mttxit SiistitutB; 
 
 Practical training of Physicians and Nurses in their duties to 
 
 pregnant, parturient, and puerperal Women, and 
 
 their young children : 
 
 BASED UPON 
 
 The Obstetric Department of the Philadelphia Dispensary, — 
 founded in 1786 ; the Philadelphia Lying-in-Charity, — in- 
 corporated in 1832; the Philadelphia Nurse So- 
 ciety, — established in 1839 ; — for supplying ap- 
 propriate Obstetric Aid to indigent fe- 
 males at their own houses. 
 
 That M. D., 
 
 has attended full course of Practical Instructions, 
 
 course of Exercise upon Obstetric Models in my Lecture room, 
 37* 
 
438 ANNOUNCEMENT OF 
 
 and, under my supervision, has had the management of pa- 
 tients, deriving aid from the above Institutions at their own 
 
 houses, during a period of months. 
 
 Joseph Warrington, M. D., Principal. 
 Philadelphia, 18 
 
 The above diploma is granted as an avrard of merit, for the 
 f^xithful discharge of duties assigned by the Principal, and 
 assumed by the pupil. 
 
 It may also be signed and sealed by the President or a Vice 
 President and attested by the Secretary of the Lying-in- 
 Charity, in testimony of the approbation of the Managers of 
 said Charity; Provided, the pupil has obtained the title of 
 M. D. from a legalized Medical School, and has presented to 
 the Principal a clinical report of the cases that have been 
 under his care, satisfactory to the principal and the signing 
 officer. 
 
 It is neatly executed on map paper, covering an area of about 
 15 by 22 incHes, and involves no pecuniary expense on the part 
 of the recipient, except w^hen furnished upon parchment, at a 
 cost of two dollars. 
 
 VI. MANNER IN WHICH THE DIPLOMA IS FORFEITED. 
 
 Neglect of regular attendance upon the preparatory courses 
 of Lectures, or omissions to fulfil the duties to patients as- 
 signed by the Principal and assumed by the pupil, renders the 
 latter liable to have the remaining cases withdrawn, and the 
 Diploma withheld, at the option of the Principal. 
 
 VII. JUNIOR ASSISTANTS. 
 
 {a) Who may become Junior Assista?iis. 
 
 Pupils who have complied with the regulations of the Insti- 
 tute during two terms, consecutive, or nearly so, ma^^ become 
 candidates for the office of Junior Assistant. 
 
 (6) How they a^e chosen. 
 
 Whenever more than two candidates present for Junior As- 
 sistants they shall compete for the office, by a test of their 
 qualifications in the presence of the Principal of the Institute, 
 and two Physicians, nominated by the Managers of the Dis- 
 pensary, or of the Lying-in-Charity. The examination shall 
 be conducted orally and in writing. Two negative votes will 
 reject the candidate. But if the essays be creditable, the fact 
 shaU be publicly announced to the members of the Institute. 
 
 VIII. DUTIES OF THE JUNIOR ASSISTANTS. 
 
 1. Either of them to hold himself in readiness to substitute 
 the practising pupils, in attendance upon patients during their 
 
THE OBSTETRIC INSTITUTE. 439 
 
 absence, to relieve them if the labor be so protracted that they 
 have need of rest, and to aid them in any embarrassment, in 
 the management of cases of simple labor. 
 
 2. To apprise the Senior Assistant, or in his absence, the 
 Principal, of the probable nature of the case, should they dis- 
 cover any thing abnormal in it. 
 
 3. To aid the practising pupil in making distinct notes of the 
 cases, in which they have been associated, and if desired, to 
 fill up such details as may appear to him to have been omitted 
 by the pupil. 
 
 IX. PEIVILEGES OF JUNIOE ASSISTANTS. 
 
 1. The Junior Assistants shall have the privilege of attend- 
 ing all the lectures and exercises upon the models, intended 
 for the instruction of the classes, with whom they are asso- 
 ciated. 
 
 2. The fact of the faithful performance of their duties, may, 
 if desired by them, be inserted on their Diplomas over the sig- 
 nature of the Principal. 
 
 X. SENIOR ASSISTANT. 
 {a) Who may become a Senior Assistant. 
 
 1. Pupils who have received the Diplo^na of this Institute, 
 and satisfactorily discharged the duties of Junior Assistants 
 during two consecutive terms, may become candidates for the 
 ofiice of Senior Assistant. 
 
 (&) How lie is appointed. 
 
 2. If more than one candidate presents for the office of Se- 
 nior Assistant, the concours shall be conducted as in case of 
 Junior Assistants, except that the standard of acquirements 
 shall be of a higher order, in the case of the Senior, than of 
 the Junior Assistant. 
 
 XI. DUTIES OF THE SENIOR ASSISTANT. 
 
 1. To hold himself at all times, ready to respond to a call 
 from a Junior Assistant, either to aid in diagnosis, respect- 
 ing labor, or the presentation, or position of the child, or the 
 necessity of manual or instrumental aid. 
 
 2. To apprise the Principal immediately on the occurrence 
 of any accident, or in his absence, either of the consulting 
 accoucheurs of the Philadelphia Dispensary, whose decisions 
 in the case shall be duly respected. 
 
 • 3. To see that all such cases are fully and regularly re- 
 corded. 
 
 4. To report daily to the Principal the state of the patients, 
 in whom he has been interested. 
 
440 ANNOUNCEMENT OF 
 
 5. To render such assistance in the lecture-room and at 
 the exercises of the practising pupils and Junior Assistants, 
 on the models, as may be necessary. 
 
 6. To attend whenever possible at the place of meeting of 
 the patients, applicants for the benefits of this Institute, and 
 assist in the registry and distribution of them to the practising 
 pupils. 
 
 7. To assist, if required, in the instruction and training of 
 the Nurses under the direction of the Principal and the mana- 
 gers of the Philadelphia Nurse Society. 
 
 8. And to have supervision of the reports of individual 
 cases in which he has been interested, as entered in the record 
 book, and see that the Tabular statements are properly made 
 out. 
 
 XII. PRIVILEGES OF THE SENIOR ASSISTANT. 
 
 1, The Senior Assistant shall have the privilege of control- 
 ling the judgment and actions of the Juniors and practising 
 
 f)upils, in regard to unsettled points of Obstetric practice, un- 
 css his views differ from those of the Principal or the consult- 
 ing accoucheurs of the Philadelphia Dispensary, in which caso 
 either of them shall be the umpire. 
 
 2. The faithful discharge of duty of the Senior Assistant, 
 may be declared upon his Diploma, attested by the Principal. 
 
 XIII. THE PRINCIPAL 
 
 Exercises the entire supervision of all cases under the charge 
 of the Institute, and he alone, or in conjunction with the 
 Managers of the several corporations on which it is based, 
 holds all the Assistants, pupils, nurses and patients, amenable 
 for any omissions of duty, or commission of impropriety. 
 
 XIV. MODE OF TEACHING. 
 
 {a) It is the aim of the Principal to make his instructions 
 to his classes, as demonstrative and practical as possible — 
 hence part of each course is occupied in a brief review of the 
 Anatomy of the female organs of reproduction, the different 
 pelvic viscera, illustrated by diagrams, and wet preparations 
 of the organs removed from the pelvis, as well as the relations 
 which they hold to each other, and to the pelvis within which 
 they are included ; the development of the uterus for the ac- 
 commodation of the ovum ; the study of the pelvis as the 
 canal through which the ovum must pass — leading thus to an 
 examination of its form, axes, diameters, altitudes, planes, &c. 
 
 (5) The mode of actionof the uterine and accessory powerfl 
 in parturient effort, [labor,] — the influences of the os uteri, the 
 vagina and pelvis in changing the direction of the fetus, in 
 course of its expulsion, [mechanism of parturition,] the study 
 
THE OBSTETRIC INSTITUTE. 441 
 
 of the different surfaces of the fetus, and the mode of diagnos- 
 ticating its various presentations and positions at the upper 
 part of the pelvis, — the various deviations, in presentation and 
 position of the fetus, and the mode of rectifying them, are all 
 taught demonstratively and practically upon the models. The 
 Medical and Surgical means to be used in case of tardy, diffi- 
 cult and impracticable parturition ; as well as the various de- 
 tails of duty of the physician and nurse in the chamber of the 
 parturient and puerperal female, and the necessary attention 
 to the infant, are regarded as important items in the course of 
 Instructions. 
 
 The courses are so arranged that by the time the minds of 
 the pupils have been fully impressed with these topics, they 
 have opportunities and occasions to exercise their knowledge, 
 by attendance upon cases which are assigned to their care. 
 To relieve them from the pressure of such responsibility as is 
 incident to the initial practitioner in his entrance upon his 
 duty, each one has the privilege of having associated with 
 him a Junior Assistant of the Institute, who has had the ad- 
 vantage which the experience of two previous terms of prat;- 
 tice has afforded him, and who in turn may demand the aid or 
 experience of the Senior, who is in all cases, expected to no- 
 tify the Principal, or a consulting accoucheur of the Dispen- 
 sary, of any special difficulty. Thus in some instances liable 
 ,to occur, the pupil, Junior and Senior Assistants may be asso- 
 ciated with the Principal, in such cases as require Manual or 
 Instrumental aid. Observations of several years past, have 
 fully demonstrated the advantage which the attainment to, and 
 exercise of the office of Assistants have given to the several 
 successful candidates. Those who have held the relation, have 
 subsequently become well established in Obstetric and general 
 practice in the situations in which they have located. 
 
 (c) The balance of the course of Practical Instructions, if 
 any time be left, is employed in lectures on such diseases of 
 women and children as are likely to engage the attention of 
 an Obstetric practitioner. 
 
 {(]) A portion of each course of the lectures is occupied in 
 instructing in their special and appropriate duties as nurses to 
 the sick, but particularly to obstetric patients, such women as 
 for their intelligence, and apparent suitableness for the perfor- 
 mance of their duties in the Nursery, as after an examination 
 by a committee of Ladies of the Nurse Society, have been re- 
 commended by tliem to the instructions and services of the 
 Principal in carrying out the designs of the Institute. In 
 these instructions the male members of the class participate. 
 
 The attention of gentlemen who reside at a distance from 
 Philadelphia, and who wish to become connected with this In- 
 stitute, is invited to this circumstance, as it is strongly probable 
 
442 ANNOUNCEMENT OF 
 
 that it would advance not only the interests of the Physician, 
 but that of the patients in the district in which he hereafter 
 intends to settle for practice, if, during his stay in this city he 
 could secure the education of one or more nurses, who would 
 be willing to locate in his neighborhood. Each Nurse, upon 
 her having received a course of instruction and faithfully at- 
 tended patients under the direction of the Principal and 
 the Visitors of the Nurse Society, obtains a neat certificate, 
 signed by the Principal and such of the Lady Visitors as are 
 satisfied with her performance. 
 
 XV. FACILITIES FOE IMPARTIllTa OBSTETRIC KNOWLEDGE. 
 
 {a) The Miscellaneous Cabinet. 
 
 Care has been taken to supply the Cabinet with every va- 
 riety of means of illustration which the counsels of friends and 
 pupils at home or abroad could suggest ; and they consist of 
 mannekins, one of full size, for the demonstration of the pro- 
 per positions of the parturient and puerperal female, others re- 
 presenting the abdomen, pelvis, and thighs, — with a number 
 of fetuses and placentae, &c., all manufactured by the best 
 Philadelphia Artists in this department, to the special order 
 of a late Professor of Obstetrics, and the Principal himself. — 
 A great variety of Obstetric Instruments, some of them manu- 
 factured by the late celebrated Botschan, of London, under 
 the supervision of Professor Davis, — as well as by our Artists, 
 are kept for illustration and use. A standing order is in the 
 hands of one of our most extensive Surgical Instrument 
 Makers, to supply the Cabinet with a specimen of every im- 
 provement or new invention of importance in this department. 
 
 (b) ■ The Anatomical Cabinet 
 
 (Contains many specimens, illustrative of the Anatomy, Physi- 
 ology and Pathology of the generative apparatus, including a 
 series of ova and fetuses, from the earliest stage up to the 
 complete intra-uterine development. Constant accessions are 
 being made to this part of the means of illustration, and the 
 Principal avails himself of this opportunity, gratefully to ac- 
 knowledge the kindness of several of his pupils and friends, 
 in presenting to him a number of valuable specimens. He, 
 moreover, cherishes the hope that, either in their private rela- 
 tions, or as members of the Obstetric Society, not only his 
 former, his present, but his future pupils will, as opportunities 
 offer, and inclinations prompt, continue their favors, that 
 thereby the materials for thorough instruction by this species 
 of demonstration, may become complete. 
 
 (c) The Pictorial Cabinet. 
 
 The drawings used in aid of the practical instructions, are 
 
THE OBSTETRIC INSTITUTE. 443 
 
 numerous, and can be so arranged, as, in conjunction with the 
 wet preparations and the models, to make a strong impression 
 upon the understanding of the pupils. They are mostly 
 colored after nature, and hold a definite relation to the size of 
 the adult and fetal subjects. The dimensions of each figure 
 are such, that it can be readily seen from any point of the 
 room occupied by the class. 
 
 XVI. TIME DEVOTED TO LECTUEES. 
 
 1. The regular courses of Practical Instructions in Obstetric 
 Medicine, commence on the 14th of February — 6th of May— 5th 
 of September — and 24th of November,* of each year, provided, 
 that when these dates fall on Sabbath, the first lecture of the 
 course will be given on the following Monday. Each Course 
 continues about 10 weeks, and includes 60 lessons, not only on 
 the great principles of the Science, but the practical details of 
 the Art of Obstetric Medicine — and these, when the pupil is 
 believed to be prepared, are verified by opportunities of ob- 
 serving cases. The members of each class, formed at the com- 
 mencement of the Course, have in regular rotation, the patients 
 of the Dispensary, Lying-in-Charity and Nurse Society as- 
 signed them for their care and attendance, with the aid of the 
 assistants, if necessary, and under the supervision of the Prin- 
 cipal. 
 
 2. The term of engagement in the practice in connection 
 with each course of instruction is about three months — a^d 
 commences on the 16th of April, 16th of July, 16th of October and 
 16th of January, of each year. 
 
 XVII. FEE. 
 
 1. For each pupil, thirty dollars, money current in the banks 
 of Philadelphia, to be paid on entrance to either of the courses 
 of instructions and practice. 
 
 2. The payment of fifty-five dollars upon first entrance, secures 
 to the pupil the privilege of attending two consecutive courses 
 of instructions and practice, by which he may become eligi- 
 ble to promotion to the offices of Junior and Senior Assistants, 
 agreeably to Articles VII. and IX. of this announcement. 
 
 The pupils attaining to these offices, are exempted from 
 any other payment of fees for their connection with the In- 
 stitute. 
 
 XVIII. SUCCESS OF THE INSTITUTE. 
 
 The Obstetric Institute was commenced in June 1837, and 
 since that time the Principal has given four courses each year 
 
 * The daily lessons, since 1847, continue to be given at a quarter before 7, and 
 terminate at a quarter before 8, A. M.— and therefore do not interfere with any 
 other public or private courses in the city. 
 
444 ANNOUNCEMENT OF 
 
 to advanced pupils or recent graduates in Medicine, who had 
 attended under his supervision many hundred Obstetric cases, 
 some of whose histories have been carefully recorded, and in 
 the aggregate supply a considerable amount of material for 
 clinical illustration inr the preparatory courses. In his ardu- 
 ous and responsible enterprise of preparing the Medical Stu- 
 dent for entering upon the practical duties of the accoucheur, 
 through the portals of Obstetric experience, the Principal has 
 been occasionally cheered by concurrent testimonies of many 
 former pupils, distributed throughout various sections of our 
 extended country, respecting the value of these courses of in- 
 struction, as contributing essentially to their success in obtain- 
 ing practice as Physicians. Young gentlemen who are ambi- 
 tious to superadd to the knowledge they may acquire from 
 books and their Professors, the practical advantages which may 
 be obtained by a full compliance with the disciplinary regula- 
 tions of the Obstetric Institute, are not only brought more or 
 less before the notice of thirty-six gentlemen, twelve of whom 
 are Managers of the Philadelphia Dispensary : twenty-four 
 Officers and Directors of the Philadelphia Lying-in-Charity : 
 and twenty-eight Ladies, Visiting Managers of the Nurse So- 
 ciety, who give personal attention to a large number of pa- 
 tients deriving the benefits of the Institute, but by the exer- 
 cise of their daily duties towards the patients under their care, 
 and their almost constant relation with intelligent Nurses, se- 
 lected by, and in . the employment of the Society of Ladies, 
 they are in a marked degree prepared to perform the functions 
 of Physicians, in the neighborhoods in which they settle for 
 practice, with a business-like manner which inspires the confi- 
 dence of their patients in their professional abilities. 
 
 As this plan hererein described, contemplates a succession 
 of elevations in office from that of Pupil up to Senior Assist- 
 ant Obstetric Physician in this Institute, the wish is hereby 
 expressed, and the hope entertained by the Principal, that in 
 the event of his death or resignation, the Boards of Managers 
 of the several co-operative Institutions, which have through the 
 intervention of the present Principal been concentrated upon 
 this school, will elect a successor from amongst those who 
 shall have attained to the stations of Senior Assistant, — and 
 that this election shall proced upon the same ground as that 
 adopted in relation to Junior and Senior Assistants. 
 
 OBSTETRIC SOCIETY 
 
 •In 1843 several members of the class organized themselves 
 into an Association, for mutual improvement in Obstetric Me- 
 dicine. They constituted the Principal their President, with 
 
THE OBSTETRIC INSTITUTE. 445 
 
 whom the Constitution and By-Laws are deposited. A number 
 of interesting and instructive communications have been read 
 at its meetings. 
 
 The plan of the Society is, that it consists of President, Se- 
 cretary, Resident Members, Corresponding or Non-resident 
 Members, Fellows and Honorary Members. 
 
 Gentlemen desirous of connecting themselves with the Ob- 
 stetric Institute, can apply to Dr. Warrington, at his resi- 
 dence. No. 229 Vine Street, Franklin Square, from 2 to 3, or 
 6 to 7, P. M. 
 
 Note. — It is desirable, that the four classes in the year 
 should be as nearly equal in size as possible, since there is 
 nearly the same amount of Clinical practice for each class. It 
 is also desirable, that each class should be in even numbers, 
 since the models and apparatus for practical instruction in the 
 lecture-room are so arranged, as that the members of each class 
 work best in pairs. 
 
 It is suggested, that the courses which commence in Sep- 
 tember and November, are best adapted to the wants of those 
 who resort to Philadelphia principally for Clinical experience, 
 while those of February and May are especially convenient 
 for such gentlemen as have leisure to devote to practical Ob- 
 stetrics, only in the intervals of the first and second courses 
 of instruction in the degree-conferring schools. 
 
 Note. — Dr. Elwood Wilson, 505 Mulberry Street, continues 
 to hold the oflSce of Senior Assistant, a post at which he has 
 arrived through the medium described in the preceding pages 
 of this announcement. 
 
 Note. — Since the establishment of this Institute two thou- 
 sand and one hundred patients have been assigned to the 
 attentions of more than three hundred young gentlemen, who 
 had complied with the disciplinary regulations which govern 
 it. The number of cases has been rapidly increasing during 
 the several years last past; and as the Obstetric department 
 of the Dispensary is coextensive with that of the Lying-in 
 Charity and Nurse Society, extending at present to the supply 
 of applicants for its aid from all the populous portions of 
 Philadelphia and its districts, the limitation of the size of the 
 classes will be withdrawn in proportion to the extension of the 
 operations of thft concern. 
 
BOOKS 
 
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 NO. 87 NORTH SIXTH STREET, PHIL. ADELPHIA. 
 
 Ajtdral's Medical Clinic : 3 vols. 
 
 ■ ■ Diseases of the Encephalon. 
 Diseases of the Abdomen. 
 
 ■ Diseases of the Chest. 
 Abaij 's Practical Manual on Diseases 
 
 of the Heart and Great Vessels. 
 Translated from the French, by 
 Wm. A. Harris, M. D., U. S. N. 
 
 Arktjeus on the Causes and Signs 
 of Acute Diseases, and Schill's Out- 
 lines of Pathological Semeiology. 
 
 Bampfi eld on Curvatures of the Spine. 
 Including all the Forms of Spinal 
 Distortion, Vi^ith additions, by John 
 K. Mitchell, M. D., Professor of the 
 Practice of Medicine in the Jeffer- 
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 Bell's Materia Medica. 
 
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 its Causes and Consequences. 
 
 Christison on Poisons in relation to 
 Medical Jurisprudence, Physiology 
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 Clark on the Sanative Influence of 
 Climate. 
 
 Cooper's, Sir A., Lect. on Surgery. 
 
 CoLLES. — Course of Lectures on Sur- 
 gery, delivered in the Royal (college 
 of Surgeons, by Abraham CoUes, 
 M. D., for thirt^'-four years Profes- 
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 lege. From Notes collected and 
 repeatedly revised by Simon M'- 
 Coy Esq., F. R. C. S. I. 
 
 Colby's Practical Treatise on the 
 Diseases of infants and children. 
 
 Davidson and Hudson on fever. 
 
 Diseases of the Uterus, by Weller, 
 Lisfranc, and Ingleby. 
 
 Epidemics of the Middle Ages, viz. ; 
 the Black Death, and Dancing Ma- 
 nia, from the German of Hecker. 
 
 EvA]yso3ir and Maun sell on the Man- 
 agement and Diseases of Children, 
 edited by D. F. Condie, M. D. 
 
 Fox & Harris on the Human Teeth. 
 A large super-royal octavo volume, 
 with 30 pages of lithographic en- 
 gravings. 
 
 FoRDTCE on Fever. Second Ameri- 
 can edition, with an Introduction. 
 
 Gerhard on the Chest. 
 
 GiBERT on the Changes of the Blood, 
 translated by John H. Dix, M. D. 
 
 Gooch's Midwifery, 8vo. 4th Am. ed. 
 
 GoocH on Diseases of Women and 
 Children, 2nd edition, with engs. 
 
 Graves's System of Clinical Medi- 
 cine, with Notes and Additions by 
 W. W. Gerhard, M. D., 3d Ameri- 
 can ed. revised and greatly enlarged. 
 
 Gross's Pathological Anatomy. A 
 new edition, thoroughly revised and 
 greatly enlarged, illustrated with 
 nearly 250 engs. on wood, and 50 
 figs, colored, on Uthographic plates. 
 
 Harlan's Gannal on Embalming. 
 
 Heberden's Commentaries on the 
 History and Cure of Diseases, 
 
 Holland's Medical Notes and Re- 
 flections. 
 
 Horner's Medical and Topographical 
 Observations upon the Mediterra- 
 nean, and upon Portugal, Spain, 
 and other countries, illustrated with 
 engravings. 
 
 HuNTKR on the Blood, Inflammation, 
 and Gunshot Wounds, with eng's. 
 
 on the Teeth. With eng's. 
 
 (447) 
 
BARRINGTON AND HASWELL's CATALOGUE. 
 
 HuxTER on the Venereal Disease. 
 
 With engravings. 
 
 on the Animal CEconomy. 
 
 's Principles of Surgery. 
 
 — — — 's Life. By Drewry Ottley. 
 
 — — — 's Complete Works, edited by 
 James F. Palmer, Senior Surgeon 
 to the St. George's and St. James's 
 Dispensary, &c. With numerous 
 engravings. 4 vols., 8vo. 
 
 Institutes of Surgery. By Sir C. Bell. 
 
 Latham's Lectures on subjects con- 
 nected vs^ith Clinical Medicine : 
 comprising Dis. of the Heart. 
 
 Latham's Medical Clinic, comprising 
 Semeiology and Auscult. 2d ed. 
 
 Laxcock's Essay on Hysteria. With 
 numerous Illust. and Curious Cases. 
 
 Lkk's Theory and Practice of Mid- 
 wifery. Illust. vv^ith numerous eng's. 
 
 Liston's Elements of Surgery, 4th 
 American from the last London edi- 
 tion, with upwards of 160 illustra- 
 tive Engravings. Edited by Samuel 
 D. Gross, M. D., Professor of Sur- 
 gery, Louisville Medical Institute ; 
 Author of Elements of Pathological 
 Anatomy, &c., &c. 
 
 LiTTKLL on Diseases of the Eye. 
 
 London Dissector, or Guide to Ana- 
 tomy, for the use of Students ; from 
 the last London ed., edited by J. 
 Chaisty, M. D. 
 
 MACAiiTivEr on Inilammation. 
 
 MACROBiif's Introduction to the study 
 of Practical Medicine. 
 
 Marshall's Practical Observations 
 on Diseases of the Heart, Lungs, 
 Stomach, Liver, &c. — Weatherhead 
 on Diseases of the Lungs ; consi- 
 dered especially in relation to the 
 particular Tissues affected, illustra- 
 ting the different kinds of Cough. 
 In 1 vol. 
 
 Millikren's Aphorisms on Insanity 
 
 Minor Surgery ; or, Hints on the 
 Every-day Duties of the Surgeon. 
 Third edition, with numerous ad- 
 ditions. Illustrated by 247 engra- 
 vings. By H. H. Smith, M. D. 
 Assistant Lecturer on Clinical Sur- 
 (448) 
 
 gery in the University of Pennsyl 
 vania, Lecturer on Minor Surgery, 
 Fellow of the College of Physicians, 
 Member of the Philadelphia Medi- 
 cal Society. 
 
 Neill's Outlines of the Arteries, with 
 short Descriptions ; Designed for the 
 Use of Medical Students. 2d edi- 
 tion. Colored engravings. 
 
 Neill's Outlines of the Nerves, with 
 short Descriptions : Designed for 
 the Use of Medical Students. En- 
 gravings, 2d edition. 
 
 Neill's Outlines of the Veins and 
 Lymphatics : Designed for the Use 
 of Medical Students. Col'd. engs. 
 
 Neill's Outlines of the Arteries, 
 Nerves, Veins, and Lymphatics. 3 
 vols, in one, (the complete series.) 
 
 Nunnblex's Treatise on the Nature, 
 Causes, and Treat, of Erysipelas. 
 
 Pettigrew on Superstitions con- 
 nected with the History and Prac- 
 tice of Medicine and Surgery. 
 
 PiLCHER on the Structure, Economy, 
 and Diseases of the Ear. With nu- 
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 Practical Medicine. . Illustrated by 
 Cases on the most important Dis- 
 eases. Edited by J. M. Galt,M. D. 
 
 Schill's OutUnes of Pathological Se- 
 meiology, and Areta)us on the 
 Causes and Signs of Acute Disease. 
 
 ScuDAMORE on the Nature and Cure 
 of Gout and Rheumatism. 
 
 Tamplin's Lectures on the Nature 
 and Treatment of Deformities, with 
 nearly 70 Engravings on wood. 
 
 Thomsox and Twining on Diseases 
 of the Liver and Biliary Passages, 
 and of the Spleen. 
 
 Thomson on Inflammatory Affections 
 of the Internal Organs, and Mal- 
 colmson on Liver Abscess. 
 
 Unherwood on Children. With 
 Notes by Drs. S. Merriman and 
 Marshall Hall and John Bell. 
 
 Willis on Urinary Diseases, and 
 their Treatment. 
 
 Warrington's Obstetric Catechism, 
 150 eng's. and 2347 Ques. & Ans. 
 
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