• V OBSTETEICS. Cazeaux and Taenier EIGHTH AMERICAN EDITION. WITH APPENDIX BY PAUL F. MUNDfi, M.D., AND NEW ILLUSTRATIONS. IN TWO VOLUMES. Plate I. For Explanation see Page 92. CAZEAUX and TARNIER. THE THEORY AND PRACTICE OF OBSTETRICS ; INCLUDING DISEASES OF PREGNANCY AND PARTURITION, OBSTETRICAL OPERATIONS, ETC. By P. CAZEAUX, MEMBER OF THE IMPERIAL ACADEMY OP MEDICINE, ADJUNCT PROFESSOR IN THE FACULTY OF MEDICINE, PARIS, ,KTC. REMODELLED AND REARRANGED, WITH ADDITIONS AND REVISIONS, By S. TARNIER, PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE FACULTY OF MEDICINE, OF PARIS. THE EIGHTH AMERICAN EDITION. Edited and Revised by ROBERT J. HESS, M.D., PHYSICIAN TO THE NORTHERN DISPENSARY, PHILADELPHIA. WITH AN APPENDIX, By PAUL F. MUNDE, M. D., PROFESSOR OF GYNECOLOGY AT THE NEW YORK POLYCLINIC AND AT DARTMOUTH COLLEGE; VICE-PRESIDENT AMERICAN GYNECOLOGICAL SOCIETY, ETC. WITH CHROMOLITHOGRAPHS, LITHOGRAPHS AND OTHER FULL-PAGE PLATES, AND ONE HUNDRED AND SEVENTY-FIVE WOOD ENGRAVINGS. VOLUME I. PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 Walnut Street. 1887. w G COPYRIGHT, 188G, BY P. BLAKISTOX, SON & Co. PREFACE TO THE NEW EDITION. In offering this new American edition of the classical work of Cazeaux and Tarnier to the profession, an apology is scarcely necessary. The previous editions have long since been exhausted, and although references to it in the pages of medical literature are frequent, most of the works upon the science and art of obstetrics which since then have been favorably received by the profession have gleaned much of their worth from its valuable teachings. The student of less elaborate text-books is likely, at the present day, to over- look the foundation principles upon which the science has been built, of which these distinguished authors have been for many years the honored teachers. The present, with slight omissions, embraces all that was originally con- tained in previous American editions. A later French edition, and also an Italian, issued during the past year, the latter with notes by Chiara, Morisani, Tibone, and Porro, have been consulted in its preparation, and we trust it will be found to contain the newest observations in obstetrical science made possible by the advance in every department of knowledge relating thereto. We have been careful to avoid any change in the principles of practice as taught by Cazeaux and Tarnier, deeming the acceptance of them by the profession in the past, and the frequent reference to them by authors of the present, as the most certain test of their value, while the latest contributions of the present time in each department of the science have been carefully and freely introduced, due credit being given, so that this edition will reflect the best practice of the best authorities, and be a complete guide to the student and a source from which the profession may continue to draw rich suggestions in this, the highest branch of the science and art of medicine. ROBERT J. HESS, M.D. I'll! LADELPHIA. 3 I 3oy PREFACE TO THE FRENCH EDITION. THE sixth edition of this work was almost exhausted, when its author, in the full strength of years and talent, was suddenly struck down by the disease which very soon proved fatal. In departing, Cazeaux left a name beloved of physicians and students, and respected by all. The success of his work on obstetrics had greatly contributed to extend his reputation and scientific authority. Inasmuch, therefore, as the stoppage of its publication would deprive the medica 1 public of a work which, for a long time, has justly been ranked first amongst classical books, both Cazeaux's family and his editor concurred in the opinion that a new edition ought to be published. A classical book soon grows old in these days, and it was found im- possible to bring out a new edition without subjecting it to the altera- tions demanded by the progress of science. I was charged with its pre- paration, and accepted the honor of the task with a full appreciation of its difficulties. I had never been Cazeaux's pupil, but his book was the first from which I had studied obstetrics, and I had been accustomed 10 see it in the hands of all my fellow-students, and, at a later period, of my pupils also. Independently, therefore, of my personal observa- tion, I was in a position to become acquainted with its character through others. Thus, together with merited praise, I sometimes also listened to criticisms of its details, and profited by all I heard. I was left at liberty to remodel the work according to my judgment, to make the alterations which seemed to be required, to suppress some passages and to introduce new ones. Out of respect to Cazeaux's memory, it was decided that the printing should be done in two kinds of type ; the larger for the old text, and the smaller for what I had myself written. The reader will readily distinguish what belongs to Cazeaux and what to myself, but the work has been resolved into a homogeneous body without contradictory annotations. This last result could not Viii PREFACE. possibly have been attained without retouching the old text, by which a new direction and meaning has been sometimes given to the original ideas. Should it be desired to know certainly what Cazeaux's opinions were, it will, therefore, be necessary to consult an old edition. Especially have I made it a duty not to change the spirit in which the work had been conceived ; therefore I can say with Cazeaux, that, '• A iur a work has passed through several editions, a preface is hardly needed, for its object is then sufficiently well known. The present is more particularly intended for the use of students of medicine and mid- wife-students, although general practitioners may also, perhaps, gain something by its perusal, for I have endeavored to make it a condensed summary of the leading principles established by the masters of our art, and for that purpose have drawn from all the works published down to the present day. My position in the lying-in hospitals has enabled me to test the value of the doctrines put forth by former authors ; and I have adopted as true all which my daily experience has confirmed, and have rejected unhesitatingly, from whatever source they came, all such as were disproved by the numerous cases brought under my observation, confining myself to quoting, Avithout comment, those whose value I have been unable to determine. "Although this work resembles, in its general arrangement, most of those published on the same subject in France, it differs from them essentially in the main ; for I have adopted almost wholly the views of Professors Nsegele, P. Dubois, and Stoltz, which are uot found clearly expressed in any of our classical books. I have also extracted freely from the learned treatise of Professor Velpeau, whow vast erudition has greatly facilitated my bibliographical researches; trorn the course of my former teacher, Professor Moreau; from the excellent articles of Desormeaux, of Duges, and of Guillemot; from the classical works of England and America, such as those of Burns, Campbell, Merriman, Ramsbotham, Dewees, Meigs, and Rigby ; and from the treatises of Peu, Delamotte, Levret, Smellie, Baudelocque, Gardien, and Capuron. I have also consulted with advantage the manual recently published by my friend, Dr. Jacquemier ; also, the memoirs of Simpson, Tjdor Smith, Depaul, Devilliers, &c. I may be permitted also to express publicly my thanks to M. Coste, for his great kindness in allowing me to study his beautiful collection in the College of France, and to borrow several figures from the magnificent work which he is now publishing. Lastly, it will be seen how highly I value the eminently practical writings of Madame Lachapelle. In a word, I have selected from all sources PREFACE. IX whatever bears the impress of truth. In the sciences of observation, a new work is necessarily enriched by the labors of all antecedent writers ; and therefore, its greatest merit consists in collecting its scattered ma- terials, and forming out of them a body of doctrine, which it illustrates in the clearest and simplest manner possible. Such is the end I have endeavored to attain ; and the medical public, and students especially, must judge whether I have succeeded in the attempt. " But few quotations have been made, though their number might have been greatly increased ; but I wished to avoid the charge made by most students against one of our best classical works. However, I have felt bound to refer to living authors whenever I have introduced a new theory, or any particular procedure, which emanated from them ; and besides, as the professorate may be deemed a mode of publicity, I have respected the right to the original ideas which I have heard emitted by Professor Dubois; and his name will be found scrupulously associated with all the opinions emanating from him. " Notwithstanding a spurious copy published in Belgium, and several translations into foreign languages, the large editions of the work first published were rapidly exhausted. So favorable a reception made it obligatory upon me to neglect nothing which could render this edition worthy of the reputation of its predecessors. I have, therefore, reviewed and corrected all parts of it with scrupulous care." The plan of the present edition has been so greatly modified that it may be regarded as altogether new, the order followed being that which I long- since adopted for my course of lectures, as the most natural and the best. The chapters are grouped into eight principal parts. Part first is devoted to the female organs of generation. The pelvis is first studied by describing separately each of its component parts, afterwards considering them as a whole, and pointing out carefully whatever pecu- liarities it may present as to form, direction, and size ; then we pass immediately to the anatomical description of the external and internal organs of generation. It will be seen that I have here profited by M. Sappey's recent researches in regard to the structure of the ovary, and those of Dr. Iielie (of Nantes) in regard to the structure of the uterus. The physiology of the genital organs is now so intimately connected with their anatomical arrangement that it is impossible to describe them fully without speaking at the same time of their functions. The phenomena which they exhibit at certain periods are also very properly regarded as the preludes of generation, making their preliminary study X PREFACE. indispensable to all who would understand the changes which these organs undergo during the puerperal condition. The genital apparatus of the female having been studied in the non- pregnant condition, we examine, in the second part, those very numerous and important changes which they undergo during gestation, and shall often have occasion to quote the many works of Robin on the uterin* mucous membrane, the decidua, and the placenta. We afterwards ■study the first cause of all of these changes, to wit, the foetus and its appendages, which are traced through the various stages of their devel- opment. From this examination we deduce the signs of pregnancy. Having acquired these preliminary notions, we are in a condition to enter upon the subject of labor in the third part of the work. In the process of parturition we distinguish two orders of phenomena : one purely physiological and expressive of the vital action called into play in order to expel the foetus; the others, purely mechanical, and consti- tuting the mechanism by which this expulsion takes place. We have given great latitude to the description, and especially to the explanation of the mechanism of natural labor, and think that we have succeeded in explaining certain facts which, hitherto, had only been pointed out. New views have also led us to describe six principal stages in the mechanism of all the presentations. After the labor, properly so called, comes the study of the delivery of the after-birth, and of the puerperal state ; this part including afterward the subject of the attentions to be given to the woman during and after labor, as also an article devoted to apparent death of new-born children. I have also greatly extended the pathology of pregnancy, to which the entire fourth part is devoted. Chapters entirely new will be found in it on the diseases of pregnancy, the alterations to which the placenta is subject, and the death of the child during intra-uterine life. Thus, I hope that I have supplied an omission that was to be regretted. In the fifth part, which is devoted to difficult labor, we treat in detail of deformities of the pelvis and all other causes of dystocia, the way in which each operates, their situation in the mother, the child or its appendages, the signs whereby their presence may be detected, the indications which they present, and the means of remedying them. In the study of the accidents which are liable to complicate labor, I have profited by all the works published of late years, and in the account of hemorrhage, puerperal convulsions, and the indications which they present, will be found some new considerations. To fill up properly PREFACE. XI the outline which we had traced, it became necessary to treat carefully of artificial delivery of the after-birth, and the accidents to which it is liable. I have introduced a sixth part, devoted to obstetrical therapeutics, which includes two chapters only : the first being devoted to ergot, and the second to the effect of a debilitating regimen and a certain course of medication upon the development of the child during intra-uterine life. The seventh part comprises a discussion of the use of anaesthetics in labor, an account of the use of the tampon and of all the obstetrical operations, rendered in a degree of detail proportioned to the interest which attaches to them. The eighth and last part, is exclusively devoted to the hygiene of the child from birth to the period of weaning. It would be impossible to point out all the additions which are scattered through the work, but they are very many. Everywhere have I accorded to the views of Professors Depaul and Pajot, as also to the views of all contemporaneous authors, the prominence which they deserve. I hope therefore that this book, which is, so to speak, a new one, will be found to represent all the most important knowledge which we possess pertaining to the obstetric art. TARNIER. CONTENTS OF VOLUME I. PART I. OF THE FEMALE ORGANS OF GENERATION. PAOE CHAPTER I. — Of the Pelvis, 33 Article I. — Of the Bones of the Pelvis, ..... 34 \ 1. The Sacrum, .......... 34 §2. Coccyx, 36 § 3. Coxal Bones, or Ossa Innominata, ...... 37 Article II. — Articulations of the Pelvis, 39 § 1. Articulation of the Pubis, . 40 § 2. Sacro-Iliac Articulations, . 41 \ 3. Sacro-Coccygeal Articulation, ...... 42 \ 4. Sacro-Vertebral Symphysis, . 43 \ 5. Sub-Pubic Membrane, 44 Article III. — Of the Pelvis in general, 44 <} 1. External Surface, ......... 44 2 2. Internal Surface, . .44 \ 3. Superior Strait, ......... 47 \ 4. Inferior Strait, 40 \ 5. Cavity of the Pelvis, 51 I 6. Base of the Pelvis 53 \ 7. Differences of the Pelvis, 53 I 8. Uses of the Pelvis, 54 Article IV. — Of the Pelvis covered by the Soft Parts, ... 54 •CHAPTER II. — Of the External Organs of Generation, ... 57 Article I. — The Mons Veneris, ....... 5S Article II. — The Vulva . .58 Labia Majora, .... .... 58 Labia Minora, 59 Clitoris, . 60 Vestibule, 61 xiii XIV CONTENTS. PAGE Urethra, 51 Hymen, . .62 Carunculae Myrtiformes, 63 Fossa Navicularis, ......... 63 Article III. — Secretory Apparatus of the External Genital Organs, . 64 Sudoriparous Glands, ........ 64 Sebaceous Glands 64 Mucous Glands, 61 Vulvo-Vaginal Gland, 65 A&ticle IV. — The Perineum, 67 Perineal Floor 07 Perineal Body, 67 CHAPTER III. — Internal Organs of Generation, .... 68 Article I. — The Vagina, 68 Article II. — The Uterus, 71 \ 1. External Surface of the Uterus, 73 Body of the Uterus 73 Neck of the Uterus, 74 | 2. Internal Surface of the Uterus, 76 Cavity of the Body, 76 Cavity of the Neck, 77 | 3. Structure of the Uterus, 78 Peculiar Tissue, ......... 78 Peritoneal Membrane, ....... 78 Mucous Membrane, . 79 \ 4. Ligaments of the Uterus 82 Broad Ligaments, . . ..... 82 Bodies of Rosenmliller, 82 Round Ligaments, 84 Article III. — The Fallopian Tubes 85 Article IV. — The Ovaries, 86 \ 1. Structure of the Ovaries, ....... 88 \ 2. Ovarian Vesicles, ......... 90 \ 3. Human Ovule, .' 90 CHAPTER IV. — Ovulation and Menstruation, 93 Article I. — Modifications of the Ovarian Vesicles, .... 93 The Corpus Luteum 96 Article II. — Menstruation, 103 CHAPTER V.— The Breasts 115 Human Milk 117 CONTENTS. XV PART II. OF PREGNANCY. CHAPTER I. — Conception, CHAPTER II. — Changes in the Maternal Organism, Article I. — Changes in the Uterus, . § 1. Changes in the Body of the Uterus, \ 2. Changes in the Neck, | 3. Changes of Structure, ..... 1. Serous Layer, ...... 2. Mucous Layer, ..... 3. Middle Layer, ...... a. Mad. Boivin's Structure, . b. Deville's Structure, .... c. M. Helie's Structure, 4. Vascular Apparatus, ..... Article II. — Properties of the Uterus (Changes of), . Sensibility of the Uterus, ..... Irritability, ....... Contractility, . ' . Retractility, ....... Article III. — Changes in the Parts adjacent to the Uterus, Article IV. — Changes in the Breasts, Article V. — Anatomical and Functional Changes in some concerned in Generation, ..... § 1. Digestion, ....... \ 2. Circulation, . . .... \ 3. Urine, Kyesteine, . \ 4. Osteophytes of the Cranial Bones, . \ 5. Pigmentary Deposits, ..... Parts not page 119 1 25 125 125 130 13G 130 137 137 138 139 142 145 148 148 148 149 151 152 155 156 157 157 160 161 166 166 CHAPTER III. — Of the Decidua, 167 Old Theory, Present Theory, 167 171 CHAPTER IV. — Or the Human Ovum after Fecundation, . . . 179 Article I. — Changes which the Ovule undergoes in the Fallopian Tube, 180 Disappearance of the Germinal Vesicle, 180 XVI CONTENTS. Condensation of the Vitellus, . Polar Globules, Vitelline Nucleus and Segmentation of the Vitellus, Article III. — Of the Foetal Appendages, 2 1. The Allantoid Vesicle, | 2. Umbilical Vesicle, .... 2 3. The Amnion, 2 4. Waters of the Amnion, (Liquor Amnii), ? 5. Chorion, ...... Article IV. — Organs of Connection, 2 i. Placenta, . 2 2. Umbilical Cord, CHAPTER V.— Of tub F 596 Causes, 598 Treatment, 60] LIST OF COLORED PLATES AND OTHER FULL PAGE ILLUSTRATIONS. PAGF Plate I. (Colored.) Median perpendicular section of pelvis from front to back, showing both pelvic spaces and the relations of the female pelvic organs to each other Frontispiece. Plate II. Figures of Uterus at twentieth or twenty-fifth day of gestation, half size 174 Peate III. Figures showing the human ovum, natural size, thirtieth to thirty- fifth day .210 Plate IV. (Colored.) Diagram illustrating the foetal circulation (Flint) . . 232 Plate V. (Colored.) Figures showing section of frozen body of a woman during the period of expulsion. The engagement of the head. Commencing expulsion of the head, and the relations of the muscular floor of tlie pelvis to the presentation at the last stage of parturition ..... 325 Peate VI. Four figures illustrating occipital, face, brow, and antero-frontal presentation (Olshausen) 347 Plate VII. Four figures representing the different stages of spontaneous expulsion, and one figure showing labor with the body bent double . . 371 Plate VIII. Six figures showing flexions and retroversions of the uterus . 713 Plate IX. (Colored.) Two figures, an ovarian tumor complicating labor. Longitudinal rupture of the cervix 74.'! Plate X. (Colored.) The blood-vessels of the pelvis seen from t lie front . . 1025 Plate XI. Vertical and transverse sections of pelvic organs, showing exuda- tion in cellular tissue, Douglas's pouch, right and left broad ligaments, etc. 1145 Plate XII. External genital organs, showing difference between those of the virgin, nulliparous and parous women, and prolapse of anterior wall (cysto- cele), and of posterior wall (rectocele), with laceration of perinaeum. (Drawn from life) . . . . . . . . . . .1177 LIST OF WOOD-CUT ILLUSTRATIONS. PAGE Anterior surface of sacrum 35 Posterior " " " 35 " " " coccyx 36 Anterior " " " " 36 External surface of the os innominatum 37 rnternal " " " " " 38 Horizontal section through the articulation of the pubis 40 Posterior view of the articulation of the pubis 40 Pelvis with its ligaments ; the anterior portion removed 42 IVK is with its ligaments, posterior view 42 The plane and axis of the superior strait and of the inferior strait . . .48 Diameters of the pelvis 48 The plane and axis of the inferior strait 50 Diameters of the pelvis • .51 The pelvic excavation 52 Pelvis with soft parts seen from above 55 Position of the pelvis and the direction of its axis during labor .... 57 External genital parts 58 The hvmen in the form of a crescent 62 • * " " " " circle 62 Urethral follicles 65 Vulvo-vaginal gland ............ 66 Muscles of the female perineum 67 The internal genital organs i 1 Relative position of the pelvic viscera 73 Differences in the uterine neck and external orifice 75 Cavity of the uterus and the Fallopian tubes 76 Three sections of the virgin uterus 77 Mucous membrane and tissue of the uterus 80 Bodies of Rosenmuller 83 Uterus and Fallopian tubes 84 Ovary of female after puberty 87 Section of ovary 89 Ovule or Graafian vesicle 90 Nun-fecundated human ovule 91 Ovary and Graafian vesicle at highest degree of development .... 94 Ovary and ruptured vesicle 94 Uterus laid open ..... 96 Ovary laid open longitudinally 97 Corpus luteum (sixth month of pregnancy) 100 Lobules of a mammary gland .......... 116 Mammary gland of human female. ......... 117 Section of neck of the uterus . . . 132 (A) Gradual dilatation of the neck of uterus during pregnancy .... 133 |: » " u u u a it .... 133 ( " " " " " it tt .... 133 Muscular fibres of the uterus 138 Muscular fibres on anterior face of womb 140 Disposition of the muscular fibres on posterior face of womb .... 141 Intercrossing of the uterine fibres 141 xx iv the ov LIST OF ILLUSTRATIONS. Second plane of the anterior muscular layer . Internal muscular layer The nipple, sebaceous tubercles, and areola Section of womb The decidua after the arrival of the ovum The layer of albumen The vitelline membrane Fecundated ovum Ovule shortly after its arrival in the womb . The blastoderm " " (in profile) ..... Section of more developed ovum .... Origin and first traces of the amnios The amniotic hoods ....... Amnios almost completed, and the origin of the allantois Rapid progress of the allantois .... The allantois spread over the whole internal surface of Placenta with separate cotyledons .... The internal or foetal surface of the placenta The external or uterine surface of the placenta Representing, how the villi of the chorion ramify Fragment of the villi of the chorion A case described by Benckiser Diameters of the foetal skull ..... Position of child in the womb .... " twins " .... Form of the bag of waters . The head in the occipito-iliac position . The head in the same position but more flexed The head in various degrees of extension Disengagement of the head ..... Mechanism of face presentations .... Position of head when forward rotation of chin takes p Three diagrams showing method of converting face into Presentation of the breech ..... The same after internal rotation .... The delivery of the breech ..... Another illustration of the same .... The same, disengagement of the head . The same, the occiput behind First position of right shoulder with arm hanging dow The same position during the descent Position after rotation ...... The same position, delivery more advanced . Bifurcation of the Fallopian tube .... Contraction of the sacro-pubic diameter of the pelvis The superior strait in the figure eight pelvis . Sinking in of the anterolateral walls of the pelvis Pelvis deformed by rachitis ..... " " by osteomalacia .... The oblique-oval pelvis ...... Skeleton deformed by rachitis " " by flexure of the vertebral column Baudelocque's callipers ...... ice ver tex presentations xxv PAGE 14.", 144 156 168 169 181 181 181 182 183 183 184 184 185 185 186 1ST 195 196 196 202 204 209 220 223 270 295 317 319 322 ;>-2r> 338 .",4(1 347 352 353 353 354 356 .">">7 369 369 370 370 , 600 . 621 , 621 . 623 . 629 . 629 . 630 . 650 . 650 . 654 XXVi LIST OF ILLUSTRATIONS. PAGE Hue vet's pelvimeter , . , . .657 Mensuration of the symphysis pubis ......... 658 Huevet's pelvimeter as a pair of callipers 659 A simple pair of callipers 660 Mode of using the finger 664 Tumor complicating labor . ... . . . . . . . .' 70'.) Section of a fibrous tumor ........... 722 Vaginal cystocele ............. 729 Right posterior occipito-iliac position complicated by the cord .... 829 The left occipito-iliac position 841 " posterior tnento-iliac position ......... 852 Oval shaped tumors between the thighs 861 Illustrating Jacquemier's case of twins 865 Hour-glass contraction of womb 873 Mode of dilating the strictured part of womb 873 " breaking up the adhesions of the placenta 878 Pushing up the head into the left iliac fossa 941 Version by drawing down the feet 942 Delivery of the posterior arm . .......... 945 Mode of flexing the head 951 " rotating the face 951 I'sim; the blunt hook in breech positions 955 Introduction of the hand in second position of the right shoulder . . . . 956 Mode of seizing the feet in the same position 956 " second position of left shoulder . . . . 957 The male branch of the forceps 961 The female branch 961 The forceps locked 961 Tarnier's forceps ........ .... 963 Wells' axis-traction attachment applied to Elliot's forceps .... 963 Simpson's forceps 964 Hodge's forceps 964 Introduction of first branch of forceps .... .... 967 " second branch 968 The forceps applied and locked .......... 969 Forceps applied on the child's head 972 Application of the forceps in right posterior occipito-iliac position . . . '.'73 Forceps applied and locked in the left transverse occipital-iliac position . . 976 " " '' " " anterior mento-iliac position . . . 981 The same in the mentoposterior position 981 Application of forceps when the head is retained, only 984 Using the lever to pull down the occiput 996 Method of dilating the os uteri 1012 (A) Intra-uterine dilator 1017 (B) " " " 1017 (C) " " " 1017 Smellie's scissors closed 1041 Tin- same opened 1 041 Mode of using Smellie's scissors 1041 Cephalotome closed 1042 The same opened 1042 Incising the cranium with the cephalotome .... ... 1042 The embryotomy or cephalotribe forceps (Baudelocque's) .... 1045 Lusk's cephalotribe 1045 LIST OF ILLUSTRATIONS. XXV11 PAGE The same applied and locked 1046 The cranioclast 1054 Mode of using the blunt hook 1059 Binder for compression of the mammae ........ 1078 " " " " 1078 "* " " " 1078 Position of hands in palpation of the abdomen (Munde) 1101 " " " at the beginning of the examination of the pelvic excavation (Pinard) ..... 1105 The hands exploring the excavation — the right hand arrested by the brow on the right side (Pinard) ........... HOG Position of the hands and direction of the pressure in external version, when the position is oblique (Pinard) .......... 1113 Position of the hands and direction of the pressure in external version, when the position is longitudinal (Pinard) 1114 Munde' s placental curette. Length of instrument, 16 /r ; width of loop, \" . 1137 Showing degrees of partial laceration (Munde) 1159 " ' " complete laceration (Munde') 1159 Wire twister (Munde") 1161 Sim's shield, 1161 " Crutch " for bending wire sutures, ... ..... 1161 CAZEAVX AND TARJVIER. THE THEORY AND PRACTICE OP OBSTETKICS. PART I. OF THE FEMALE ORGANS OF GENERATION rpHE female organs subservient to generation are: the ovaries, the prin- X cipal function of which is the secretion of the ovule or female germ ; the Fallopian tubes, designed to receive the ovule, and conduct it into the cavity of the uterus ; the uterus, a kind of receptacle, whose office it is to contain the fecundated germ during its period of development, and to expel it immediately afterward ; finally, the vagina, a membranous canal extending from the neck of the uterus to the external genital parts. Most of these organs are situated within a large cavity, the walls of which are composed of bones and soft parts ; the cavity is termed the cavity of the pelvis, or pelvic cavity. On account of the importance of the pelvis as an organ both of protection and transmission, we shall, with it, begin the study of the organs of generation. CHAPTER I. OF THE PELVIS. The bnsin, in Latin, pelvis, is a large, irregular, bony cavity, a sort of curved canal, which terminates the trunk interiorly, and sustains it by its posterior part. It is placed directly upon the lower extremities, which afford it points of support, and to which, in the erect posture, it transmits the weight of the upper portions of the body. Its position in an adult of ordinary stature is, in general, about the central part of the whole trunk. In the infant at term, and more especially during the intra-uterine life, it is much below this point; and at a certain period of foetal existence, when the lower extremities resemble as yet but little nipples, it even occupies the inferior portion of the body. Especially should the accoucheur study « 33 34 FEMALE ORGANS OF GENERATION. the pelvis in it? totality and in its relations with the great function which it subserves. Now as the best way of understanding a whole is to decom- pose it, and study separately its constituent parts, we shall proceed at once to consider individually the bones which enter into the composition of the pelvis. ARTICLE I. BONES OF THE PELVIS. The bones which together constitute the pelvis are: the sacrum, ant the coccyx, both placed behind and on the median line, and the ossa innominata or coxal bones. These last are in pairs, being situated at the sides and articulating with each other in front. § 1. Of the Sacrum. This is a symmetrical, triangular bone, which is curved forward at ita lower part, and is placed at the posterior part of the pelvis, where it appears like a wedge, forced in between the two ossa innominata, immediately below the vertebral column, and directly above the coccyx. It is traversed longi- tudinally by the sacral canal (a continuation of the vertebral canal), and. relatively to the axis of the body, it is directed from above downwards, and from before backwards; hence the column represented by it forms an obtuse angle with the lumbar vertebrce, being salient in front, and receding behind. This point is called the promontory, or the sacro-vertebral angle. Besides this direction, the sacrum is curved upon itself from behind for- wards, so as to present an anterior concavity, the hollow of the sacrum : this curvature is generally much more marked in the female than in the male. Anatomists describe the bone as having two faces, two borders, a base, and an apex. 1. The spinal, or posterior face, is convex, rough, and very irregular, pre- senting on the median line three, four, or five prominences, the longest of which are above, and continuous with the ridge formed by the series of spinous processes of the vertebra? ; lower down, the sacral canal is terminated as a triangular gutter, being bounded laterally by two tubercles, caPled the cornua of the sacrum; upon each side of, and close to the median line, a large furrow exists, at the bottom of which the four posterior sacral foramina are seen, communicating with the vertebral canal, and serving to transmit the nerves of the same name. Outside of these foramina Ave find a series of elevations, apparently analogous to the transverse processes of the vertebra?; and above them two irregular fossa?, into which the pos- terior sacro-iliac ligaments are inserted. 2. The pelvic, or anterior face, is smooth and concave, and is traversed by four prominent transverse lines, the remnants of the sutures between the different pieces that composed the bone in early infancy, and which served to separate some superficial, transverse, and quadrilateral grooves found there, from each other. Sometimes the first of these prominent lines OF THE PELVIS. 35 is so well marked as to be mistaken, when practising the touch, for the sacro-vertebral angle. The anterior sacral foramina, four in number, are found nearer the lateral margins; they communicate with the sacral canal, and transmit the anterior branches of the nerves of the same name. Beyond the foramina is an unequal surface for the attachment of the pyramidal muscles. 3. The borders of the sacrum may be divided into two portions. 1. Tht superior, being very thick, presents, on its anterior half, a semilunar articular facet for joining with the coxal bone, and on its posterior part an excavation, and some rough projections for the attachment of the sacro- iliac ligaments. The other, or inferior portion, is quite thin, and is occupied by the insertion of the sacro-sciatic ligaments. 4. The base is directed upwardly and a little in front, and has its greatest diameter transversely. An oval facet, more or less inclined backwards, surmounts it at the middle, whereby the bone is articulated with the last lumbar vertebra. Upon each side is seen a smooth surface, which is con- cave transversely, and convex from before backwards. These surfaces incline forwards and are continuous with the iliac fossa?, being covered, in the recent subject, by the anterior sacro-iliac ligaments. They are sepa- rated from the anterior face of the sacrum by a rounded border, which forms, as we shall hereafter learn, the posterior part of the superior strait. The two surfaces constitute the %vings of the sacrum. Behind, are found the upper orifice of the sacral canal, and the two articular processes of the first piece of the sacrum. 5. The apex of the sacrum is- directed downwards, and a little back- wards; presenting an oval facet for the articulation of the coccyx. 6. The sacral canal, hollowed out in the thickness of the bone, is the termination of the vertebral canal ; being triangular and broad superiorly, it becomes narrow and flattened at its inferior part, where it degenerates into a gutter, that is converted into a canal by the ligaments. This lodges the sacral nerves, and communicates both with the anterior and the pos- terior sacral foramina. A--:, Anterior snrfai :e of the sacrum. Posterior surface of (lie sacrum. Fto. 1. A. Ala or wings of the sacrum. B. Articular processes. C. Anterior sacral foramina. E. rotate •»f attachment of the ri<;lit pyramidal musclo. Fin 2. A Ridge formed by the spinous pi occsses. 1!. Posterior sacral foramina. V>. Articular processes. The sacrum, although quite thick, is a very light and spongy bone. Besides, it is pierced by a great number of foramina, and traversed by -i central cavity, which serve to diminish its weight still more. 36 FEMALE ORGANS OF GENERATION. It is formed of five principal pieces (false sacral vertebra?), sometimes of six, and in one case, seven •were observed (Pauw). In Soemmering's cabinet are tbree specimens which present but four pieces. The development of the sacrum is analogous to that of the vertebrae, and takes place from thirty-four or thirty-five points of ossification, arranged in the following manner: 1. Five of them, placed one over the other, occupy the anterior and middle parts. 2. In each of the interspaces which separate these, two small osseous lamina? are developed some time after birth, which seem to form their articular surfaces. 3. Ten are situated in front and upon each side of the latter, that is, one for each lateral portion of the four or five primitive bones. 4. And behind them six others are developed, between which: 5. There appear three or four that correspond with the spinous processes, or their lamina?; and 6. Lastly, there is one upon each side above the iliac surface, for the articular facet. § 2. The Coccyx. This name is given to an assemblage of three or four, occasionally five little bones, united with each other on the median line of the body, and apparently suspended at the point of the sacrum, of which, indeed, they appear to be only a movable appendage, continuing its line of curvature forwards. Fio. 3. Fio. 4. A. A Posterior surface of the coccyx. Anterior surface of the coccyx. Fio. 3. A. Cornua of the coccyx. B. Apex. Fio. 4. A. Cornua of the coccyx. B. Apex. M. Cruveilhier declares that he has known it, in some cases, to form a right angle or even an acute one with the sacrum. As a whole, the coccyx represents a triangular and symmetrical bone. 1. Its spinal, or posterior face, is convex and irregular, and is only separated from the skin by the posterior sacro-coccygeal ligament. 2. Its pelvic, or anterior face, is smooth and slightly concave, and lies in contact with the termination of the rectum, which rests upon it. Like the preceding bone, it is marked by certain transverse grooves, corresponding with the intervals which had, for a long period, separated its different pieces. 3. Its two lateral borders are quite irregular, and are occupied by the attachments of the anterior sacro-sciatic ligaments, and the ischio-coccygeal muscles. 4. Its slightly concave base presents, above, an oval surface, which articulates with the apex of the sacrum, and behind, two little tubercles called the cornua of the coccyx. 5. The. apex is rounded, irregular, and sometimes bifurcated, affording attachment to the levator ani muscle. The coccyx is developed from four or five centres of ossificate >n, that is, one for each of its parts. of the pelvis. 37 § 3. The Coxal Bone, Haunch Bone, or Os Innominatum. This is a non-symmetrical, quadrilateral bone, curved upon itself, as if twisted in two different directions, contracted in its middle, and of a verv irregular figure. The pair occupy the lateral and anterior parts of the pelvis. It presents an internal and external face, and four borders, for our consideration. 1. The external, or femoral surface, is turned outwards, backwards, and downwards, at its superior part, while inferiorly, it looks forward. At its superior and posterior portion is seen an unequal, narrow, and convex surface, affording origin to the gluteus maximus muscle, and ter- minated below by a slightly elevated circular ridge, called the superior curved line. Beneath this, there is a larger surface, which is concave behind, narrowed in front for the insertion of the gluteus medius muscle, and bounded by a slight ridge below, called the inferior curved line; still lower, there is a third extensive and convex surface, serving for the attach- ment of the gluteus minimus muscle. All that portion of the femoral face just described forms a large fossa, alternately concave and convex, bearing the name of the external iliac fossa. Towards the front, the external face presents the cotyloid cavity or the acetabulum, at its superior part; and a little more in advance and below, the sub-pubic, or obturator foramen. This opening is triangular, with rounded angles; its long diameter is inclined downwards and outwards, and its circumference is sharp and irregular, presenting above a groove, directed obliquely from behind forwards and from without inwards, through which the obturator vessels and nerves pass out. A fibrous membrane that subtends the foramen is attached to its periphery, except in the immediate vicinity of the groove. Upon the upper side of the obturator foramen, between it and the median line, there is a concave or nearly plane surface for the origin of several muscles. External surface of the os innominatum. A. External iliac fossa. B. Crest of the ilium. C. Anterior superior spine of the ilium. 1). Anterior in- ferior spine of the ilium. K. Horizontal branch of the pubis. K. Posterior superior spine of the ilium 0. Posterior inferior spine of the ilium. 11. Cotyloid cavity. I. Ischium. K. Sub-pubicor obturator foramen M. Iscliiopubic ramus. C. Descending branch of the pubis. 38 F EM ALE ORGANS OF GENERATION. Fio. 6. 2. The abdominal, or internal face, is directed forwards at its uppei part. and backwards at the lower. It may be divided into two portions, the superior of which is characterized by a large excavation, called the internal Hide fossa, by a semilunar articular surface found just behind this fossa, and called the auricular facet, and still more posteriorly, by some rugosities, analogous to those found on the articular faces of the sacrum. The superior portion is terminated below by a large, rounded, and con- cave line, which separates it from the other moiety. The latter, or inferior portion, presents behind a nearly triangular plane surface, which corre- sponds to the cotyloid cavity and to the body of the ischium; near its middle, we find the obturator foramen, and in front, the internal face of the pubis and of the ischio-pubic ramus. 3. Borders. These are four in number. The posterior one has a very irregular shape, being oblique from above down- wards, and from without inwards. The posterior superior spinous process is found at its junction with the superior border. This prominent, well-marked eminence is separated by a rough margin from another though less voluminous one, called the posterior inferior spinous process. Below this last apophysis, the student will observe a very deep notch, which con- tributes to the formation of the great sciatic foramen, and is terminated below by a triangular, pointed projection, bearing the title of the spine of the ischium. This pro- cess is more or less prominent in different individuals, and is sometimes directed in- wards. A groove is seen just beneath it, in which the tendon of the obturator in- ternus muscle plays; this groove is a part of the lesser sciatic notch ; and lastly, this border terminates at the tuberosity of the ischium. The anterior border is concave, oblique above, and nearly horizontal in front. The anterior superior spinous process is formed by its union with the superior border. A considerable depression exists under this apophysis, which separates it from another one, called the anterior inferior spinous process. Then we find a groove just under this elevation, for the gliding of the conjoint tendon of the psoas magnus and the iliacus internus muscles; which groove is bounded, in front and below, by the ilio-pectineal eminence. And lastly, the border is terminated by a triangular horizontal surface, which is directed downwards and forwards, and is broader externally than internally, and by the spine and angle of the pubis. The superior border or crest of the ilium is thick, convex, and inclined outwauls, excepting at its posterior part, where it looks slightly inwards— Internal surface of the right os innomiimtum. A. Internal iliac fossa. B. Anterior superior spinous procesu of the ilium. C. Crest of the ilium. D. Posterior superior spinous process of the ilium. K. Posterior inferior spinous process of the ilium. F. Articular surface. U Spine of the ischium. H. Tuberosity of the ischium. I. Sub-pubic or obturator foramen. K. Ischio-pubic ramus. M. Ilio-pectineal eminence. N. Spine of the pubis. OF THE PELVIS 39 being twisted, in its course, somewhat like an italic/. Anatomists have subdivided it into the external and internal lips, and the inlervening space. The anterior superior spinous process bounds it in front, and the posterior superior one behind. The inferior border is shorter than either of the others; it presents, how- ever, three parts for study. There is an oval surface above, for articulating with its fellow of the opposite side, forming the symphysis; below, it is terminated by the tuberosity of the ischium, and in the middle, we find the ischio-pubic ramus; this is a sharp ridge, formed superiorly by the descend- ing branch of the pubis, and inferiorly by the ascending portion of the ischium. The coxal bone is developed from the principal centres of ossification, which appear at the same time in the iliac fossa, the tuberosity of the ischium, and in the pubis. Owing to this mode of growth, it has been customary to divide the os innominatum into three portions: the superior one, styled the ilium, forms, in a great measure, the contour and prominence of the hip; t\\& pubis, being anterior, supports the genital organs; and the inferior one, which sustains the body when seated, is named the ischium. Several years after birth, an osseous lamina resting upon the superior border of the bone, is developed to form the iliac crest, whilst a similar layer embraces the tuberosity of the ischium, and extends to its ramus ; at the same time, a third centre of ossification appears for the anterior inferior spinous process of the ilium, and a fourth forms the angle of the pubis. ARTICLE II. ARTICULATIONS OF THE PELVIS. [The four bones just described are united by four articulations peculiar to the pelvis ; one in front for the two pubic bones, two behind for the iliac bones and the sacrum, and that of the coccyx with the sacrum. All these articulations are usually termed symphyses ; thus the articulation of the two pubic bones is styled the pubic symphysis, the junction of the iliac bone with the sacrum is called the sacro- iliac symphysis, and the connection of the sacrum and coccyx the sacro-coccygeal symphysis. It should be observed, however, that the symphyses or am phi arthroses are characterized by fiat articular surfaces, united by a layer of fibrous tissue which allows a bending motion without any sliding of the bones upon each other. Now this sliding motion exists in the pelvic articulations of the female. It is, there- fore, a mistake to classify them amongst the amphiarthroses, and only by an abuse of language can they continue to be called symphyses. Lenoir's researches prove that some anatomists were near the truth in considering them as arthrodia. In twenty-two female subjects between the ages of eighteen and thirty-five years, Lenoir found that the four pelvic articulations are formed by the ('(intact of sur- faces covered with cartilage and lined with synovial membranes; they present, therefore, all the characteristics of arthrodia, and have a simple, sliding motion. To the four articulations proper, of the pelvis, it is well to add in this connection, the articulation of the sacrum with the spinal column. Here we have really on« of the amphiarthroses or symphyses. The description of the sub-pubic ligament completes the history of the liga- mentous connections of the pelvis. J 40 FEMALE ORGANS OF GENERATION. § 1. Articulation of the Pubis. This articulation is formed by the approximation of the oval surfaces occupying the upper part of the lower border of the coxal bones. These surfaces are slightly convex and unequal, and are covered with a cartila- ginous lamina which fills up the inequalities. The convex shape and the direction of their faces are such, that they only come into contact for an inconsiderable extent at their internal or posterior part, and hence they leave above, in front, and below, an open space, which is the more con- siderable, in proportion to the distance from the centre of the joint. The articulating surface of the two cartilages is a little facet, about six or eight lines in its vertical diameter, by two or three in its transverse one. This facet is smooth, and furnished with a synovial membrane, which is the more lubricated Avith synovia .as the female approaches the period of labor. A considerable thickness of the interpubic ligament fills up the interval which exists between the other points of these articular surfaces. This interpubic ligament is formed of a very dense fibrous substance. It has the form of a wedge, with the point forced down between the bones and the sides adhering to the rough surfaces fronting the articulation. Two planes of fibres are discoverable in it; the deeper ones, which pass from one iliac bone to the other, and are shorter in proportion to their depth, are crossed, and disposed in several layers. They constitute the interpubic liga- ment properly so called. The others, which are more superficial, are parallel, and pass obliquely from within outwards and from above down- wards. Beginning at the upper part of the articulation they spread in descending, until they are finally divided into two bundles, which become lost in front of the branches of the pubic arch by mingling with the peri- osteum of the bones and the tendons of the muscles inserted in the vicinity. These form the anterior pubic ligament. The uppermost portion of the anterior pubic ligament seems to take its origin in the fibrous cord Avhich is inserted on the spine of the pubis, and which cushions, so to speak, the upper edge of that bone, in such a way as to efface its inequalities. It constitutes the superior pubic ligament. Lastly, at its lowest part, the anterior pubic ligament assumes the form of a thick triangular bundle occupying the summit of the pubic arch, and fixed by its lateral edges to the upper and internal part of the two branches thereof. This ligament, called the triangular, or sub-pubic ligament, pre- Fio. 7. Fin. 8. Hoi izontal section through the articulation of the pubis. Posterior view of the articulation of the pubis. Fig. 7. A. Synovial Diembrane. B. Articular cartilages. C. Inter-pubic ligament. D. Section oft lie bones Fig. 8. A. Posterior projecting pad. 15. Sub-pubic ligament. C. Section of horizontal branch of pubis !). Section of ischiopab 5 " ramus. OF THE PELVIS. 41 senl3 a rounded base, which completes the arch of the pubes by giving it a regular curve calculated to facilitate the exit of the foetus. Thus, we have three anterior pubic ligaments, a superior pubic and a 3ub-pubic ligament, all of them representing a spreading out of the inter- osseous ligament. Behind the S) r mphysis, the fibro-cartilaginous substance forms a sort of projecting pad, which occupies the middle part only, and disappears from above downwards. Finally, the ligamentous arrangement of the articulation is completed by the posterior pubic ligament, composed of fibres extending transversely from one pubis to the other, above the projection just noticed. This liga- ment, which is very thin, and of moderate strength, forms the posterior lining of the synovial membrane. § 2. Sacroiliac Articulations. This articulation is formed by the junction of the semilunar facets, which were pointed out in describing the border of the sacrum and the internal face of the ossa ilia. Both these facets are covered with a diarthrodial cartilage, which is closely adapted to the inequalities they present; that, however, which per- tains to the sacrum, being always much thicker than the layer which belongs to the iliac bones. The latter is so thin, that its existence has been denied. These cartilages are covered with a synovial membrane, which secretes quite abundantly a viscid and transparent synovia. But, when the female has passed the prime of life, this fluid often concretes, and becomes disposed in isolated flakes upon the articular surfaces, — a fact which has caused its true nature to be misunderstood. A very limited sliding motion is all of which this articulation is suscep- tible. The bones are held together by the following ligaments : 1. The posterior, or great sacro-sciatic ligament, is found at the posterior inferior pai-t of the pelvis. It is triangular, thin, flattened, and narrower in the middle than at the extremities. It arises by a large base from the posterior inferior spinous process of the ilium, the sacro-spinous ligament, the last of the posterior tubercles of the sacrum, and from the inferior part of the margin of this bone and border of the coccyx, and running outwards, downwards, and a little forwards, is inserted into the tuberosity of the ischium. Its fibres are arranged in such a way, that the internal ones cross the external about their middle. 2. The lesser sacro-sciatic ligament is smaller than the preceding, though nearly of the same form, and situated more in front. Within, it is broad, being partially confounded with the other, but arising a little more ante- riorly upon the sides of the sacrum and coccyx; thence, it passes forwards and outwards to be inserted into the spine of the ischium. The sacro-sciatic ligaments convert the two sciatic notches into foramina. They not only serve to unite the sacrum to the ilium, but also contribute tc the formation of the parietes of the pelvis. 3. The posterior sacro-ilkic ligament is a collection of yellow, elastic, fibrous bundles, intermixed with fatty pellets, which fill up the rough 12 FEMALE ORGANS OF GENERATION. Pelvis with its ligaments; the anterior portion remold. A. Internal iliac fossa. B. Section of the bones. C. Origin of the great sacro-sciatic ligament. D. Great sacro-sciatic ligament. E. Lesser sacro-sciatic ligament. F. Great sacro-sciatic foramen. G. Last lumbar vertebra. II. Ilio-lumbar ligament. I. Sacro- veitebral ligament. Fig. 10. Pelvis with its ligaments. Posterior view. A. Great sacro sciatic foramen, through which is seen the horizontal branch of the pubis. B. Great sacro-sciatic ligament. C. Tuberosity of the ischium. D. Posterior 6acro-iliac ligament. E. Posterior superior spinous process of the ilium. F. Inferior »acro-iliac ligament. excavation observed behind the cartilaginous surfaces; very short, numerous, and interlacing in every direc- tion, they become almost in- timately blended with lit* sacrum and coxal bones. On account of their strength, they greatly consolidate this articulation. 4. The anterior sacro-Mat ligament is a simple fibrous lamina, extended transverse- ly from the sacrum to the os innominatum. It is rather an expansion of the perios- teum of the pelvis than a true ligameut. 5. The superior sacro-iliac ligament is a very thick fas- ciculus, passing transversely from the base of the sacrum to the coxal bone. 6. The inferior sacro-iliac ligament (vertical sacro-iliac of M. Cruveilhier) arises from the posterior superior spinous process of the ilium, and is inserted just below the third sacral foramen into the tubercle found at the termi- nation of the border of the sacrum; and behind, into the great sacro-sciatic liga- ment. § 3. Sacro-coccygeal Articulation. This articulation, which for a long time was supposed to resemble those between the bodies of the vertebrae, differs from them materially in being a true arthrodia. It is formed by the opposition of the oval surface of the point of the sacrum to that of the base of the coccyx; the middle of the former is projecting, and corresponds to a depression in the centre of the latter. The long diameter of the articular face of the coccyx is directed transversely. The cartilages covering these surfaces aie rather thinner at the centre than at the circumference. They are provided in the adult female with a synovial membrane, which is supposed by M. Lenoir to be only developed by the movements of the coccyx upon the sacrum, since he has failed to meet with it in subjects under eighteen years of age. OF THE PELVIS. 43 1. The anterior sacro-coccygeal ligament consists of a few parallel fibres, which descend from the anterior part of the sacrum to the corresponding face of the coccyx. 2. The posterior sacro-coccygeal ligament is flat, triangular, broader above than below, and of a dark color. Arising from the margin of the inferior orifice of the sacral canal, it descends to, and is lost upon, the whole posterior surface of the coccyx. It also aids in completing the canal behind. In investigating upon the dead body the anatomical arrangement to which the motion of the coccyx on the sacrum is due, it was ascertained by M. Lenoir that the motion takes place almost as frequently in the sacro- coccygeal articulation, as in that of the second piece of the coccyx witli the third. Sometimes it happens simultaneously in both, whilst in few cases only does it occur in the connection of the second piece with the third, or of the third with the fourth. These inter-coccygeal articulations are similarly constructed. In all cases, in fact, in which the points of motion of the coccyx were changed, M. Lenoir discovered a more or less complete anchylosis of the articulation between the sacrum and coccyx, and of those between the bones of the coccyx itself, at points above and below the one which preserved its mobility. Then, also, wherever situated, the movable articulation was constructed as follows: 1. Of articular surfaces irregular in form but corresponding exactly, which were incrusted with diarthrodial cartilages and provided with a synovial membrane. 2. Of lax peripheral ligaments formed at the expense of the layers of fibrous substance covering the bones of the coccyx. 3. Lastly, motion was possible in every direction. It is to be observed that ossification is more frequent and rapid in the joint between the sacrum and coccyx than in that between the first piece of the coccyx and the second; the third and fourth become fused very early. It is therefore easy to understand how the great mobility of the sacro-coccygeal articulations renders luxation possible in labor, whilst in cases of anchylosis, either fracture or a sudden separation of the united bones might occur. During pregnancy, the ligaments of the pelvic articulations become so softened and swelled by imbibition of fluid, as to render the mobility of the articular surfaces very evident. This softening is very considerable in some cases, and may make walking, or even standing, impossible. (See Diseases of Pregnancy.) § 4. Sacro-vertebral Symphysis. This is produced by the junction of the sacrum with the fifth lumbar vertebra. It is a true aniphiarthrosis, as are all the vertebral articulations. It takes place at three different points, viz., between the oval facet, seen at the middle of the base of the sacrum, and the inferior surface of the body of the last vertebra; and at the two articular surfaces found near the entrance of the sacral canal. The modes of connection are, a fibro-cartilage (which is much thicker in 44 FEMALE ORGANS OF GENERATION. front than behind), the termination of the two anterior and posterior verte- bral ligaments, the interspinous ligament, and lastly, the sacro-vertebrai ligament, a short, very strong, fibrous bundle, which descends obliquely from the anterior inferior part of the transverse process of the last vertebra, downwards and outwards, towards the base of the sacrum, where it is inserted. Further, a synovia. 1 membrane is found in the articulation between the; oblique process of the sacrum and those of the vertebrae. To these must also bo added the ilio-lumbar ligament, which passes from the apex of the transverse process of the fifth lumbar vertebra to the thickest portion of the iliac crest; and the ilio-vertebral ligament formed of two fibrous bands, the superior of which arises from the middle and lateral part of the body of the last lumbar vertebra, and the inferior, from the inter-sacro-vertebral space; both are then spread out on the coxal bone. § 5. Obturator Membrane. The obturator membrane still claims a description, in order to finish the history of the ligamentous apparatus of the pelvis. This, as has beeD remarked by M. Cruveilhier, like the sacro-sciatic ligaments already spoken of, is rather an aponeurosis serving to complete the pelvic walls, than a true ligament. These resisting membranes are probably intended to diminish, in the hour of labor, the compression of the mother's soft parts, included between the infant's head and the osseous parietes of the pelvis, as also to favor, by their elasticity, the passage of the head through the pelvic excavation. Obturator membrane. — This membrane subtends the foramen thyroideum, excepting at its superior part, where an opening exists, which converts the groove, intended for the passage of the obturator vessels and nerves, into a complete canal. Being inserted by its external semi-circumference into the corresponding part of the periphery of the obturator foramen, it is attached by its internal half to the posterior face of the ascending ramus of the ischium. Its surfaces afford origins for the two obturator muscles. This membrane is composed of aponeurotic fasciculi, which cross each other in every direction. (Cruveilhier.) ARTICLE III. OF THE PELVIS IN GENERAL. Studied in its general aspect, the pelvis represents a cone, slightly flat- tened from before backwards; the base of which, being above, is at the same time inclined forwards, whilst the apex is directed downwards and a little backwards. § 1. External Surface of the Pelvis. Anatomists have divided this surface into four regions: the anterior of which exhibits, ^n the median line, the front part of the symphysis pubis. OF THE PELVIS. 45 which is directed from above downwards and from befcte backwards, at aD angle with the perpendicular of some 15° to 20° ; next (passing outwards) is a smooth surface, from which several muscles of the thigh arise, then the external obturator fossa, occupied in the recent subject by the muscle of the same name, and finally by the anterior half of the edge of the cotyloid cavity. The posterior, bounded by the hinder part of the iliac crest, presents, on (he median line, the ridge of the sacral spinous processes, the inferior open- ing of the vertebral canal, the union of the sacrum with the coccyx, and the posterior face of this latter bone. The ten posterior sacral foramina, transmitting the nerves of the same name, are found in two deep gutters, on the sides. These grooves prolong the spinal gutters, and are occupied in the recent state by the commence- ment of the sacro-spinal muscles. The lateral regions may each be divided into two parts: one, the superior, is the external iliac fossa; the other, or inferior, offers, behind, the posterior aspect of the sacro-sciatic ligaments, and the plane of the notches or foramina bearing the same name; and, in front, the cotyloid cavity and the external face of the tuberosity of the ischium. § 2. Internal Surface. The internal surface or cavity of the pelvis has been aptly compared to the basin of the ancient barbers. (Vesalius.) In fact, like those vessels, it has a superior part which spreads out freely, and is called the great, the superior, or the abdominal pelvis; and an inferior one, more contracted, bearing the title of the little pelvis, or pelvic excavation. 1. The great pelvis has a very irregular figure, and forms a species of pavilion to the entrance of the pelvis. Its walls are three in number: the anterior one is deficient in the dried skeleton, but in the living state it is supplied by the anterior abdominal muscles; its posterior parietes exhibit a notch in its middle, that is ordinarily filled up by the projection of the last lumbar vertebrae, which are usually left in connection with the pelvis, although in reality not forming any part of it. Two gutters are found on the sides of this eminence, occupied by the psoae muscles; further outwards, the anterior part of the sacro-iliac symphyses appear, which constitute the boundaries between the posterior and lateral regions: these hitter are con- stituted by the internal iliac fossa?, covered by the iliacus interims muscles. 2. The lesser pelvis, or basin. This forms a curved canal, larger in the middle than at its extremities, and slightly bent forward. If all the parts described as appertaining to the great pelvis be removed by the saw, as recommended by Chaussier, a species of ring will remain, whose circum- ference, being narrow in front and much broader behind, will furnish a correct idea of the shape of the pelvis. Four regions are found in this cavity also: The anterior one is concave transversely, and is inclined upwards, having the posterior part of the pubic articulation near its middle: this is generally prominent, assuming the form of a longitudinal pad, which may in some cases project to the extent of from two to three-eighths of an inch. Towards 46 FEMA.LE ORGANS OF GENERATION. the sides a smooth surface appears, and then the internal obturator, or sub- pubic fossa, having, at its upper external part, the inner orifice of the sub- pubic canal, through which the external obturator vessels and nerves pass out from the pelvis. It is not at all uncommon for females to complain during labor of severe cramps in the muscles of the upper internal part of one thigh. These pains result from the pressure made by the child's head upon those nerves, as it glides over this portion of the excavation. The posterior region — constituted by the front face of the sacrum and coccyx — is directed downwards, and is concave from above, downwards. It consequently exhibits those peculiarities already noticed when describing the sacrum. The lateral regions present two quite distinct portions: the anterior one is wholly osseous, corresponding to the back part of the cotyloid cavity, and to the body and tuberosity of the ischium. It is directed from above down- wards, from behind forwards, and from without inwards. The posterior one is formed by the internal face of the greater and lesser sacro-sciatic ligaments, and by the internal aspect of the great and small sciatic notches, converted by them into foramina; it has an opposite direc- tion to the former. One of these foramina is larger and situated higher up than the other, and is of an oval form. The other is triangular, smaller, and more inferior. The pyramidal muscle, the great sciatic nerve, gluteal artery, and the internal pudic vessels and nerves, escape from the pelvis through the great sciatic foramen. The small sciatic hole is filled up by the obturator internus muscle, and the internal pudic vessels and nerves, which re-enter the pelvis in order to supply the perineum. If two vertical sections be made, the one extending on the median line through the sacrum and the pubis, dividing the pelvis into two lateral halves, and the other at right angles to the first, dividing it into anterior and posterior halves, four equal parts or quarters of the pelvis will be thereby produced, which accoucheurs have designated as the anterior and "posterior inclined planes. Desormeaux included only the lateral regions of the excavation, which he divided into two equal parts, in the composition of these planes: according to him, the anterior inclined planes are con- tinuous with the anterior region ; the posterior, with the front face of the sacrum; and the spine of the ischium is found at the point of union of these two. The direction of the inclined planes is always the same, wdiatever be the manner in which they are formed. That is, the anterior are directed from without inwards, from above downwards, and from behind forwards; the posterior, from without inwards, from above downwards, and from before backwards — in a word, in such a way as to resemble somewhat the four sides of a lozenge which is slightly curved in its length. By most authors, these inclined planes are supposed to play an important part in the mechanism of labor: for they imagine that their direction has an immediate influence upon the movements which the head of the foetus performs in the excavation. In anticipating that the description of the mechanism of labor hereafter OF THE PELVIS. 47 given will invalidate this assertion, we shall simply observe that the move- ments of rotation executed by the head, take place more frequently whilst the latter is strongly bulging out the perineum, and is so far below the inclined planes as scarcely to feel the influence of their direction, and further, that these motions often occur in an opposite direction. The great and the lesser pelvis are separated from each other by a kind of horizontal circle, which has been designated by accoucheurs as the abdom- inal, or superior strait, the isthmus, or margin of the pelvis. Finally, the apex of the pelvis presents an opening that is limited by a circle, partly osseous, partly ligamentous, to which the name of the inferior strait has been applied. Consequently, these two straits are the extreme limits of the pelvic excavation. § 3. Of the Superior Strait. The superior strait is formed, behind, by the sacro-vertebral angle, and the anterior border of the wings of the sacrum : outwardly, by the rounded margin that bounds the internal iliac fossa below; and in front, by the ilio- pectineal eminence and the horizontal ramus of the pubis, terminating at the symphysis of this bone. The abdominal strait has been variously com- pared to an ellipse, an oval, and to the heart of a playing-card. We may assert, however, with Chaussier, that its shape is that of a curvilinear triangle, the angles of which have been rounded off, and having its base behind and the apex in front. It constitutes the entrance to the lesser pelvis, and is therefore the first part of the narrow canal which the fcetus has to traverse. Hence, the pains taken by accoucheurs to study this osseous opening can readily be conceived. All the modern authors since the days of Deventer, have endeavored to fix precisely the degree of inclination of its plane and axis, to ascertain the direction the foetus should follow in engaging in the pelvic canal, and to determine carefully the dimensions of the latter, and their accordance with those of the body, which is to pass through it. The plane of the superior strait is inclined obliquely from above dosvn- wards, and from behind forwards; but writers are far from being unanimous in regard to the degree of its inclination ; that is, in determining the angle formed by the sacro-pubic line, at the point where it meets a horizontal one, drawn from the superior part of the symphysis pubis towards one of the points on the anterior face of the sacrum. Although originally placed at 45° by J. J. Miiller (1745), this angle has successively been fixed at 35° by Levret; at 75° by Camper, and at 55° by Saxtorph ; and still more recently, Professor Nsegele, after a great number of researches, has con- cluded to consider it as an angle of 60° (1819). It is now generally ad- mitted that the degree of inclination in the plane of the superior strait is from 55° to 60° in the erect position of the female. The direction of the plane being once understood, it is an easy matter to ascertain that of its axis; for the latter being a line which falls perpen- dicularly upon the centre of this plane, it must evidently form with the vertical the same angle that the plane itself does with the horizontal line, 48 FEMALE ORGANS OF GENERATION. and consequently must have just the same degree of inclination. Being thus uuderstood, the axis of the superior strait is a line (a b, Fig. 12) which, commencing near the umbilicus of the female, would pass directly through the centre of this strait, and fall upon the point of union of the upper two- thirds of the coccyx, with its inferior third. Hence, it will be directed from above downwards, and from before backwards. Further, the inclina- tion of this plane varies according to Fl °- ll - the woman's position. Thus, it is al- most nothing when recumbent, and sometimes in this position the plane of the superior strait instead of being directed forwards and upwards, even looks upwards and backwards (Du- bois) ; when the trunk is bent strongly forwards, the inclination of the plane is diminished and becomes more nearly horizontal ; towards the end of gesta- tion, on the contrary, the inclination increases, especially when, in order to restore equilibrium, the upper part of the body is carried much backwards. As the figure which represents the circumference of the superior strait is not a perfect circle, its dimensions, taken at different points, are, of course, unequal, and, accordingly, writers have admitted several diameters for it, thus : There are three principal ones (Fig. 2), namely, an antero-posterior or sacro-pubic diameter a a, which extends from the sacro-vertebral angle to the upper part of the symphysis pubis; it is from four and a quarter to four and a half inches in length. 2. A transverse one, b b, passing from the middle of the rounded border Fl °- 12- that terminates the iliac fossa of one side, to the same point on the opposite side; this is five and a quarter inches long. 3. An oblique diameter, c c, ex- tending from the anterior part of the sacro-iliac symphysis to the ilio-pectineal eminence of the opposite side; this is found on both sides, and is four and three-quarters inches long. Lastly, M. Velpeau admits a fourth diameter, called by him the sacro-cotyloidean ; before rt a. The antero-posterior, or mcro-publc diameter. 6 6. described, however, by Bums, The transverse diameter, c c. The two oblique diameters. * „ « <•.. The sacro-cotyioid intorvai. under the more exact name of c /(. The plane of the superior strait prolonged beyond the pubis, c e. The plane of the inferior ■trait prolonged beyond the pubis, c d. Shows the departure of this plane from the horizontal line. a b. The axis of the superior strait, g f. The axis of the inferior strait. OF THE PELVIS. 49 the sacro-cotyloid interval a c, existing between the promontory and the posterior part of the cotyloid cavity. This interval, according to the examinations of the French surgeon, is from four to four and one-eighth inches in extent; but from the results of Nregele and Stoltz's researches it is much less, being scarcely three and a half inches (the mean obtained from ninety pelves). The circumference of this strait varies from thirteen to seventeen inches ; Levret taught, that it equalled one-fourth of the female's height; but to establish such an approximation, the development of the pelvis should always be in direct proportion to the stature of the individual, which is certainly not the fact. § 4. Of the Inferior Strait. The inferior strait — the perineal strait — or apex of the pelvis (as it is variously called), is more irregular in shape than the superior one. Its outline presents, in fact, three tuberosities or osseous projections, separated by as many deep notches. If, however, the advice of Chaussier be followed, and a sheet of paper be placed over this opening, so as to trace its outline with a crayon, it will be found to have an oval figure, the smaller extremity of which is in front.. and the larger one, looking backwards, is broken in upon by the prominence of the coccyx. This point, disappearing at the moment of the head's pas- sage, offers no obstacle to the delivery; and, therefore, the strait may be considered as nearly an oval. The periphery of the pelvis at its apex is formed by the inferior part of the symphysis pubis, the descending branch of this bone, the ascending branch and tuberosity of the ischium, the inferior margin of the great sacro- sciatic ligament, and by the border and point of the coccyx. Hence, three triangular projections are found in it : the two ischia upon the sides, and the coccyx behind. The first two are immovable, but the last, on the con- trary, is effaced at the period of delivery, as just mentioned ; for the mobility of the sacro-coccygeal articulation allows the coccyx to be pushed downwards and backwards by the fcetal head, as it traverses the inferior strait. The two lateral prominences, made by the tuberosities of the ischia, are placed on a plane somewhat lower than the point of the coccyx ; and consequently, in the sitting posture, the weight of the body rests solely on those tuberosities, and not at all upon the coccygeal extremity. This cir- cumstance furnishes us a reason why transverse contractions of the pelvis are far more frequent at the inferior strait than the antero-posterior ones. The three notches also require a passing notice; thus, the two postero- lateral ones are very deep, but when the sciatic ligaments have been pre- Bcrved, they are comparatively superficial ; the third is found anteriorly; its apex corresponds to the inferior part of the symphysis pubis, its base to a line drawn between the anterior parts of the tuberosities of the ischia, and its sides are formed by the ischio-pubal rami. The term arch of the pubis has been applied to this notch. The columns of the arch arc distorted outwardly, as if a rounded body had been forcibly expelled from the pelvis, whilst the bones were soft, and had pushed them before ii ; and this arrange 1 4 50 FEMALE ORGANS OF GENERATION. ment, which is more marked in the female than the male, favors the descent of the head. The arch is three and a half to three and three-quarter inches hroad at the base ; but only one and a quarter to one and a half inches at its apex ; in height, it is about two, to two and a half inches. Hence the area of the inferior strait will not present a uniform plane (should it be desirable to ascertain the irregularities it exhibits), because all parts of its margin are not upon the same level. However, to obviate the difficulty met with, in determining the direction of this plane, Duges has divided the 3trait into two nearly equal portions, the one anterior, and the other pos- terior, meeting at the tuberosities of the ischium, and each presenting a distinct plane and axis; but as this method of proceeding uselessly com- plicates the question, we prefer considering the terminal plane of the pelvis, as represented by the coccy-pubal line, thus leaving out the lateral projec- tions altogether. The question is then reduced to these terms: What is the direction of the line that extends from the point of the coccyx to the inferior part of the symphysis pubis? Writers, likewise, variously describe this; for instance, according to the majority of the French accoucheurs, the plane of the inferior strait is slightly oblique, from below upwards, and from behind forwards, so that it would unite with that of the superior strait (if prolonged) in front of the symphysis pubis. On the other hand, M. Nregele concludes, from his numerous res< arches, that the inclination of the antero-posterior diameter of this strait is from 10° to 11° from the horizon, and that the point of the coccyx is found, as a mean, from a half to three-quarters of an inch higher than the Bummit of the pubic arch ; and, therefore, the coccy-pubal line is a little oblique from above downwards, and from behind forwards. The lower extremity of the axis of this plane of the inferior strait would cut the coccy- pubic diameter at right angles, and terminate above at the sacro-vertebral angle. As a further result of his labors, he has found that, in five hundred well-formed persons, of different stat- FlG - ia ures, four hundred and fifty-four have the point of the coccyx more elevated than the inferior portion of the sym- physis; in twenty-six it was lower, and in twenty individuals both points were on the same level. M. Velpeau remarks, as we think with some reason, that, at the moment of delivery, — the only time, after all, when it is requisite to form an idea of the direction of this plane, — the point of the coccyx, being pushed downwards and back- I (/ £ wards by the passage of the head, is at least on a level with, if not lower than c d. The horizontal line, c e. The piano of the in- t j ie i n f er ior part of the svmphysis. ferior strait (during lal>r). a b. The axis of the in- . _ _.r \ J terior strait I he assertion of M. JNajgele, there- OF THE PELVIS. 51 Fio. 14. fore, although true as applied to the female not in labor, fails during parturition ; and it must be admitted that th«j plane of the inferior strait is then oblique from below upwards, and from behind forwards. The axis of this strait is represented by a line (a b, Fig. 13) directed from above downwards, and from behind forwards, which, starting from the first piece of the sacrum, falls at a right angle upon the middle of the bis- ischiatic space. The remarks made upon the variations in the direction of the plane, apply with equal force to its axis. The latter crosses the axis of the superior strait in the excavation, forming with it an obtuse angle, the sine of which is in front. It is also very important to know the dimensions of the perineal strait, and hence obstetricians describe three principal diameters at that point, namely — 1. The antero-posterior or coccy-pubal diameter (a a, Fig. 14), running from the point of the coccyx to the summit of the pubic arch ; it is usually four and a quarter inches long, but may increase to four and three-quarter inches during labor, by the retrocession of the coccyx. 2. The bis-ischiatic, or transverse diameter, b b, is four and a quarter inches in ength, and goes from one tuberosity J the ischium to the other. 3. The oblique diameter, c c, commences at the middle of the great sacro-sciatic ligament, and crosses to the point of union of the ascending branch of the ischium, with the descending ramus of the pubis, and is four and a quarter inches long, but may become one- quarter of an inch more during labor, from the elasticity of these ligaments. All the diameters of the inferior strait are, therefore, in the dried pelvis, about four and a quarter inches in length, though their dimensions are susceptible of great variation during labor. § 5. Of the Excavation. The excavation is that space comprised between the superior and the inferior straits, and it is in this cavity that the fcetal head executes its prin- cipal movements; and it is somewhat surprising, that, until quite recently, this canal was scarcely mentioned in the majority of the classic works, not- withstanding the importance of a knowledge of its dimensions, as also of the direction of its plane and axis. Its dimensions comprise both the height and width at the different points: thus the height in front, is one and a half inches ; upon the sides, three and three-quarter inches ; whilst it is four and a quarter inches behind, if a Btraight line be drawn from the sacro-vertebral angle to the point of the coccyx, and five inches and a quarter, following the curve of the sacrum. a a. The anteroposterior or coccy-pubal diameter. b b. The transverse or bis-ischiatic diameter, c c. Th« two oblique diameters. 52 FEMALE ORGANS OF GENERATION". Three diameters are also described for this cavity (like the straits), so aa to appreciate its extent in the different directions. All of them are taken at the centre of the excavation, and they consist of an antero-posterior one, of four and three-quarters to five and one-eighth inches in length, a trans- verse diameter four and three-quarter inches long, and an oblique one, of the same length ; consequently, all the diameters of this cavity are very nearly four and three-quarter inches each. If the canal forming the excavation were a cylinder, it would only be necessary to divide it by a plane, perpendicular to its walls, in order to represent the opening of this cavity ; but a simple division, thus made, would not give a just conception of the excavation, for two reasons. First, the canal is not cylindrical, because its sides are not parallel, and the anterior face of the sacrum presents a FlQ - 15 - well-marked curvature ; the pubic wall being nearly straight, and the lateral parietes very oblique from without inwards, and from above downwards. Consequently, to furnish an exact idea of the general arrangement of the pelvic excavation, it seems necessary to divide the canal (see Fig. 15) by a series of planes, all passing from the point c (the point of intersection of the planes of the superior and inferior straits) to any point whatever, p q r s t, on the anterior face of the sacrum. Each of these planes will show the opening of the pelvic cavity at the level where it is found. Now, to determine, with cer- tainty, the direction of the gen- eral axis of this excavation, it is requisite to raise a perpendicular line from the geometrical centre of each of these sections, and to draw a line g k through the base of each. This line g k (which, as the student will observe, is not straight) is called the general axis of the pelvis. It is now readily understood that this line is nearly parallel to the anterior face of the sacrum, and its extremities correspond with the axes of the superior and the inferior straits ; hence, this curve exactly represents the whole axis of the pelvis, or, in other words, the line which the foetus must follow in traversing the pelvic excavation. It would be wrong to consider the line, representing the entire axis of the excavation, as a simple curve ; for M. Nsegele has well observed, that it cannot be composed of two straight lines, as often taught, nor is it a simple arc of a circle. In fact, the anterior face of the bodies of the first two bones a b. The plane of the superior strait, i d. The plane of the inferior strait, c. The point where these two planes would meet, if prolonged, m n. The horizontal line. if. The axis of the superior strait, g k. The axis of the excavation, p q r s t. Various points taken on the sacrum to show the plane of the excavation at each point. OP THE PELVIS. 53 of the sacrum forms a straight line ; the sacral curve embracing only the last three bones. Consequently, the central line, which is evidently parallel to this, will consist of a straight and a curved portion — straight, for that part of the excavation corresponding to the two superior vertebrae, and curved in the space, which is bounded behind by the last three sacral vertebra?, and in front by the anterior pelvic walls. § 6. Base of the Pelvis. The base of the cone, represented by the pelvis, has its circumference directed upwards and in front ; it exhibits, behind, a notch, into the bottom of which the base of the sacrum projects, and which is further filled up by the last lumbar vertebrae (generally left in situ to complete the posterior wall of the greater pelvis), by the ilio-lumbar ligaments, and by the qua- dratus lumborum muscles ; 2, outwardly, the anterior two-thirds of the iliac crest furnishing attachments to the external and the internal oblique and transversalis abdominis muscles ; and 3, in front, the anterior superior and inferior spinous processes of the ilium, the groove for the passage of the con- joint muscles — the psoas magnus and iliacus internus, the ilio-pectineal eminence, the superior border of the horizontal branch of the pubis, the spine, and lastly, the upper margin of the symphysis of this bone. § 7. Differences of the Pelvis. 1. According to the sex. Considered as a whole, the pelvis in the male is smaller but deeper, the bones are thicker, and the muscular impressions more marked, than in the female. The superior strait being more retracted, resembles the figure of a heart on a playing-card. The excavation is not so wide, though it is deeper, especially in front, owing to the greater length of the symphysis pubis; the arch of the pubis is straight, nearly triangular in shape, and is not widened in front. The coccyx is early joined to the sacrum, and the articulations of the pelvis are much sooner anchylosed than in the female. In the latter, we may add, that the iliac fossae are larger and more warped outwardly (whence the prominence of the haunch bones), and the iliac crest less twisted in the form of an italic/; the interval separating the angle of the pubis from the cotyloid cavity is more consider- able, causing, in part, the projection of the great trochanters, and a wider separation of the femurs ; the superior strait is larger and more elliptical ; the curve of the sacrum deeper and more regular; the tuberosities of the ischium are farther apart; the pubic symphysis shorter; the foramen thyroi- deum more triangular; the arch of the pubis broader, more rounded, and more curved, and the lateral borders, formed by the ischio-pubic ramus, more contorted outwardly. 2. According to the age. At birth, the pelvis is extremely narrow and elongated, and of such inconsiderable dimensions, that its cavity will not contain several of the organs afterwards found in it; from which circum- stance, the protuberance of the belly, observed in the foetus and in children at term, in great measure results; the excavation has the form of a cone, the abdominal strait being strongly inclined downwards; the sacrum is 54 FEMALE ORGANS OF GENERATION. nearly flat, anil so much elevated that a horizontal line diawn front the superior part of the pubis would pass beneath the coccyx ; the coxal bonea are narrow, elongated, and nearly straight at their superior part, ana the cartilaginous iliac crests are not twisted. From this disposition it necessarily happens that the greatest diameter of the pelvis extends from the sacrum to the pubis. Burns declares that this form changes by degrees as the little girl advances in age: thus, the — 1 Antero-posterior diameter measures . Transverse diameter measures, . . . At 9 years. At 10 yearn. At 13 years. At 14 years. At 18 years./ 2J4 inches. 2% inches. 314 inches. 3 in. lines. &hi inches. 3% inches. 3% inches. 4 inches. 3% inches. i]/2 inches. [3. According to Races. This subject, studied by Vrolick and Dubois, has been recently taken up by Joulin, who published an important memoir on it, in which he proves that there is nothing characteristic in the differences to be observed in the pelves of the three races, Aryan, Negro, and Mongol ; in the two latter espe- cially, the resemblance is so strong that it is impossible to distinguish them. The same author states that, contrary to what has been said, in all human races the transverse diameter of the superior strait is greater than the antero-posterior ; but that the oblique diameter of the superior strait of the pelvis of the Negress and Mongol female differs from the transverse by a few millimeters only, whilst in the Aryan female the difference amounts to a centimetre and a half. The pelves of the Negro and Mongol are, besides, less capacious than those of the white race; they have less depth, and the pubic arch is wider by several degrees.] § 8. Uses of the Pelvis. The pelvis constitutes the base of the trunk, and, according to Desor- meaux, it forms a complete ring, that may be reduced to two arches; the posterior and superior of which receives the whole weight of the trunk, whilst the anterior and inferior one serves as a buttress to it. The two lower extremities are attached to the lateral parts of this circle, and support, in the erect posture, all the weight of the superior part of the body. This use of the pelvis satisfactorily explains to the accoucheur the vicious forms the cavity often assumes when ossification is retarded, or when- ever any disease alters and softens the bones. Another function of the pelvis is to inclose and protect the bladder, rectum, and seminal vesicles of the male; the uterus, Fallopian tubes, and ovaries in the female. During gestation, it sustains and gives a proper direction to the womb ; and in labor, it affords a passage to the child. ARTICLE IV. OF THE PELVIS, COVERED BY THE SOFT PARTS. It will not suffice to study the pelvis as found in the skeleton alone, for the changes produced in its form and dimensi:ns in the living female, by the arrangement of the soft parts, also require our special attention. OF THE PELVIS. Fio. 16. Being continuous above with the abdomen, the great pelvis incloses and supports the mass of the intestines, and affords points of attachment bv its walls to two orders of muscles. The one destined to form the inclosure of the belly fills the large opening exhibited in front, and thus constitutes the anterior abdominal wall ; the extensibility of which, in comparison with the resistance of the posterior plane, accounts readily for the tendency of the uterus to incline forward in the advanced stage of gestation. The others, two in number, are placed in the iliac fossae ; they are the iliacus iuternus, and the psoas magnus muscles, which, from being situated on the late- ral parts of the abdominal strait, change both its form and di- mensions. The first of these has radiated fibres, and occu- pies the iliac fossae ; the second descends from the sides of the lumbar vertebrae, and after hav- ing been joined to the preced- ing, is inserted into the lesser trochanter of the thigh bone. These two muscles, surrounded and confined by an aponeurosis (fascia iliaca), may be regarded as a sort of cushion, forming a convenient support to the de- veloped uterus, and destined to protect it by the elasticity of the soft parts against the shocks and concussions continually produced by locomotion. Notwithstanding the presence of these muscles, the strait still resembles a curvilinear triangle in shape, the base, however, of the triangle being in front instead of behind, as it was in the dried pelvis ; the transverse diam- eter is diminished half an inch by their presence ; the antero-posterior one is, perhaps, a little abridged by the thickness of the vesical walls, uterus and soft parts that line the posterior face of the symphysis and anterior sur- face of the sacrum, the oblique diameters alone remaining unchanged ; the location of the rectum, however, on the left, shortens slightly the corre- sponding diameter. The modification of the transverse diameter, produced by the psoas mus- cles, is always much less when these are in a state of relaxation from the flexure of the thighs. Finally, as Baudelocque has remarked, the bis-iliac diameter is diminished in length, in proportion to the thickness of these muscles, and the antero-posterior one being more contracted, the strait be- comes more elliptic or rounded. Two muscles are also found on each side of the excavation, covering the obturator and ischiatic foramina; namely, the obturator internus, and the pyramidales. Flamand attributes the move- Pelvis, with the soft parts seen from above. A. A section of the aorta. B. The vena cava inferioi C. The internal iliac artery, arising together witli D, the ex- ternal iliac, from the primitive iliac trunk. E. External iliac vein. f. The iliacus internus. and o, the psoas magnus mus- cles. H. The rectum. I. The uterus with its appendages. K. The bladder, the fundus of which is depressed so as to bring the womb into view. 56 FEMALE ORGANS OF GENERATION". raents of rotation, executed by the head in the pelvis, to the action of these muscles ; but the same reasons that caused us to reject the influence of the inclined planes on this process, equally deter us from entertaining the opinion of the Strasburg Professor. The pelvic cavity is still further diminished by the rectum, bladder, and cellular tissue; more especially when the latter is loaded with fat. Consequently, the fetal head descends with more difficulty in very corpulent women than in others. The perineal strait, although open in the dried skeleton, is here occupied by a sort of contractile concave partition, which sustains the viscera of the pelvic and abdominal cavities. This floor, so to speak, is composed of two muscular planes ; the interior of which, formed by the levator ani and coccy- geal muscles, is concave above ; and the other, having its concavity below, is constituted by the sphincter ani, the transversus perinei, the ischio-cavern- ous, and the constrictor vaginae muscles. The internal pudic vessels and nerves, a large amount of cellular tissue, the skin, the pelvic aponeurosis, and an inter-muscular aponeurosis complete this floor, which, in the hour of labor, ought to become thin and distended, but which occasionally offers such an obstacle to the spontaneous delivery of the fetus as to require the intervention of art. The extent of the perineum, in its ordinary condition, is three inches, namely : from the point of the coccyx to the anus, there are one and three- quarter inches, and from the anus to the vulva, one and one-quarter inches; but at the instant of the passage of the head through the genital fissure it becomes so distended, that the interval separating the anterior commissure from the coccyx, is increased from four to four and three-quarter inches. It must now be evident that the terminal outlet of the pelvic canal, in the pelvis, covered with its soft parts, is not at the point of the coccyx, but rather at the anterior commissure of the perineum ; in fact, the latter is so greatly distended in the last moments of labor, that its anterior border goes beyond the inferior part of the symphysis pubis, thereby prolonging very considerably the posterior wall of the pelvic excavation, and, as a conse- quence, the canal to be traversed by the fetus. Wherefore, the direction in which the head is ultimately disengaged is not represented by the axis of the inferior strait, but by that of a plane vhich may be drawn from the lower part of the symphysis to the anterior commissure of the distended perineum. Hence, in order to form an exact idea of the line traversed by the fetus, from its entrance into the superior strait until its final exit from the vulva, it will be necessary to continue the operation already pursued upon the anterior face of the sacrum (see page 52) over the curve represented by the anterior face of the distended perineum : that is, to make a series of planes from the point c (Fig. 15) to the divers parts of the perineal curve ; and, from the centre of each, raise a perpendicular, so as to form by their unioD a complete axis, the upper extremity of which is the axis of the superior strait ; the middle part, a curved line, having its concavity anterior and its convexity parallel to the front face of the sacrum and perineum, and the inferior extremity directed from before backwards, and slightly from above downwards. EXTERNAL ORGANS OF GENERATION. 57 It must not, however, be forgotten, that the direction just described be- longs to the vertical posture, and that it becomes remarkably altered in the various attitudes assumed by the female. Thus, whilst lying upon the back, as is usual in France during labor, the plane of the superior strait instead of looking upward and forward will be turned upward and back- ward, and its axis directed from above downward and from behind forward. At the same time, the plane of the inferior strait, which before looked back- ward and downward, will be turned almost directly forward, its axis also passing directly from before backward. Finally, the terminal orifice formed by the contour of the vulva presents another plane, which at the moment of delivery (the horizontal position being still maintained) is directed up- ward and forward. In short, the central line followed by the foetus during \ --X2 7 58 FEMALE ORGANS Oif GENERATION. ARTICLE I. MONS VENERIS. The mom veneris is a rounded eminence, a species of relief, more or lesa prominent according to the embonpoint of the individual, situated in front of the pubis, and surmounting the vulva ; this eminence is partly produced by the bones, and partly by the subcutaneous adipose tissue; the skin covering it is very thick and elastic, but being little extensible, it cannot aid in the enlargement of the vulva, as asserted by M. Moreau, at the period of delivery. In the adult female, it is covered with hair, and con lains a great number of sebaceous follicles. ARTICLE II. VULVA. The vulva is a longitudinal opening or fissure, situated on the median - at * e base of the trunk : be?n<- ' I i r *V on t by the mons veneris, ,; ng thereto, EXTERNAL ORGANS OF GENERATION. 59 They consist of a cutaneous and a mucous layer, between which is a Bbrous partition, a continuation of the superficial fascia of the perineum. Between this aponeurosis and the internal surface of the integument, is found a very thick layer of cellulo-adipose tissue, filling up a peculiar pouch hitherto unknown to anatomists until discovered by M. Broca. [This pouch is constituted by a membranous sac situated between the skin and the superficial aponeurosis : its bottom is directed towards the fourchette, where it becomes blended with the fascia superficialis of the parts on each side of the anus. It has a long and narrow neck, which is directed toward the external inguinal ring, and receives into its opening a portion of the fibres of the round ligament. Its cavity is filled with cellulo-adipose tissue, varying in quantity with the embonpoint of the individual. The pouch forms of itself the greater part of the thickness of the labia majora. The fibres of which the pouch is composed are derived chiefly from the fascia superficialis of the thigh and abdomen, but some proceed directly from the spine of the pubis; the most external are attached to the rami of the pubes and ischia, whilst the most internal unite and become blended with the suspensory ligament of the clitoris. According to M. Broca, this sac is the analogue of the dartos of the male ; M. Sappey, however, believes that it is comparable only to the suspensory ligament of the scrotum and penis. The microscope proves it to be composed of interlaced fibres of elastic tissue. The arteries of the labia majora are derived from the perineal artery, itself a branch of the internal pudic or of the external pudic or epigastric. The veins for the most part accompany the arteries, some, however, pass back- ward and form a plexus, which communicates with the bulb and vaginal veins. These veins, which are very numerous, often become dilated during pregnancy. The nerves proceed from the genito-crural branch of the lumbar plexus, and from the perineal branch of the internal pudic nerve. The lymphatics all pass into the inguinal glands.] 2. The nymphoz, or labia interna, are brought into view, by separating the external lips, under the form of two mucous folds, resembling the comb of a young cock. Contracted behind, where they are continuous with the internal face of the labia externa, they spread out in front as they con- verge towards each other. These lips scarcely descend to the middle of the external ones, but they mount up in front as high as the clitoris, where they bifurcate; the inferior branch of this bifurcation is lost in the clitoris; but the other surmounts it, joins its fellow of the opposite side, and forms above this body a little fold in the shape of a hood, called the prepuce of the clitoris. At birth, the nymphse project beyond the external lips, but at puberty they are concealed by the latter. Again, they become visible in child-bearing women ; rather, however, by the separation of the labia majora than by their own prominence. Further, their dimensions are very variable in different individuals, and in various climates ; thus, in certain countries of Africa, they are very long, and constitute the famous apron of the Hottentots. Besides, as Velpeau has remarked, these parts are so extensible that, under the influence of continual tractions, they may become very much elongated. I have met wi'.h a young female in my own practice, who was afflicted with an ex- 60 FEMALE ORGANS OF GENERATION. cessive itching at the vulva at the commencement of her pregnancy. To relieve this, she was in the habit of scratching continually, and in her im- patience dragged on the right nympha, so that, in less than a fortnight, it had become twice as long as its fellow. [The internal labia are covered with tesselated epithelium, below which are papillae whose sensibility is especially exercised during copulation. The papillae of the internal surface have a greater development than those of the external surface, and their size is found to increase as they approach the orifice of the vagina. The blood-vessels of the internal labia are supplied by those of the labia inajora A portion of the veins anastomose largely with those of the bulb and of the vagina. The nerves come from the perineal branch. The lymphatics proceed to the inguinal glands.] 3. The Clitoris. — Under this name, a little erectile tubercle, resembling the corpus cavernosum of the male (except iu volume), is described. Its free extremity appears at the front part of the vulva, about half an inch behind the anterior commissure of the labia externa, and its body is attached by two crura to ischio-pubic rami ; these roots ascend, converging and increas- ing in size, to the level of the symphysis, where they unite to form a single cavernous body, flattened on its sides, which after a course of two or three lines in front of the symphysis, becomes detached and curved forward so as to present a convexity above and in front, at the same time growing more and more slender towards the free extremity, which is called the glana clitoridis. During the first months of the intra-uterine life it is difficult to make out the distinction of the sexes, because the clitoris is as long as the penis ; even in the earlier years of existence its dimensions are quite considerable, but after this period it ceases to grow, and, in some females, apparently diminishes. Again, in certain rare cases, it acquires a great length ; for instance, M. Cruveilhier has seen one whose free extremity measured two inches, and a case is on record where it reached from four and a quarter to five inches. Most of the pretended hermaphrodites may be referred to anomalies of this kind. Henle gives a representation of a case so singular and rare as to deserve mention. It is a congenital division of the clitoris occurring in a girl of seventeen years of age, in which the body of that organ was completely divided through the middle so as to form two nipples, each invested with a prepuce. The halves of the prepuce thus divided, are prolonged respec- tively toward the corresponding nympha, from which it is separated by a notch, and is lost, above, in the frenum clitoridis. The clitoris, like the penis, has a suspensory ligament, and an erector muscle; the canal of the urethra in the female passes between the two branches of the cavernous body, as it does iri the male. [The structure of the clitoris is, in all respects, precisely that of the corpus cav- ernosum of 1 1 1 • > male, except in point of size. It presents the fibrous envelope, the muscular trabecule, ami the heliciue. arteries, all characteristic of the erectile EXTERNAL ORGAN'S OF GENERATION. 61 cissue. During coiuon, blood accumulates in it, dilates it, and thereby causes it? erection. The arteries of the clitoris come from the perineal artery, and are distributed aa in the male, presenting therefore the cavernous artery, which on each side enters the corresponding corpus cavernosum, and the dorsal artery, which is distributed to the mucous membrane known as the prepuce of the clitoris. The veins form a plexus arranged in two planes, the most superficial of which furnishes the dorsal vein, whilst the deeper communicates with the veins of the bulb, of the vagina, and of the bladder. The nerves proceed from the perineal branch of the internal pudic; the. y send branches to the corpus cavernosum, and terminate in the prepuce, which is the principal seat of voluptuousness in the female.] 4. The vestibule is a small triangular space placed at the upper pirt of the vulva. It is bounded above by the clitoris, below by the urethra, and laterally by the nymphse. 5. The Urethra. — The meatus urinarius is situated just below the ves- tibule, about an inch from the clitoris, and immediately above the promi- nent enlargement of the anterior part of the vagina. The orifice is usually more contracted than the canal, but the tubercle or enlargement just alluded to, enables us to sound females without uncovering them, for it is only necessary to recognize it by the finger in order to direct the instru- ment properly. In my estimation, the following is the most simple method of introducing the catheter without uncovering the patient ; 1 first intro- duce my finger into the orifice of the vagina, and rest its palmar face against the anterior vaginal wall ; I then slide the instrument along this palmar face until it is arrested by the fold already alluded to; then I depress the extremity so as to elevate the point of the instrument one or two lines, and in the majority of cases, the canal is easily entered in this manner. [If the first attempt should fail, it may be tried again in another way. The point of the forefinger finds the clitoris, and passes from above downwards to the middle of the vestibule; the first inequality met with is the orifice of the urethra, into which the instrument can then be inserted. I have often succeeded in this way, after having failed by the ordinary method. In some women, those especially who have borne children, the parts adjoining the meatus are so deformed, that it becomes absolutely necessary to expose the parts in order to introduce the catheter; even then it is by no means easily done, and I have seen the most skilful foiled in attempting it. It may be accomplished with certainty by separating carefully the greater and lesser labia, and then sliding the extremity of the catheter from above downward along the median line of the vestibule below the clitoris, which is the chief rallying point. During this movement the instrument falls, so to speak, of its own accord into the orifice of the urethra ; but if slid either to the right or left, it will be sure to go astray. We shall learn hereafter (article Pregnancy) the cause of the difficulties met with in catheterizing pregnant women.] The urethra, a continuation of the meatus urinarius, just described, varies in the female from one to one and a half inches in length. It is large, conical, and slightly curved. Its inferior portion is confounded 62 FEMALE ORGANS OF GENERATION". with, or at least intimately united to, the anterior vaginal wall, and its anterior parietes, separated in front from the pubis by some cellular tissue only, is located on a level with the symphysis, under the junction of the two crura of the clitoris. The canal of the urethra is muscular and erectile, having a thick lamina of muscular fibres, which seem to be a continuation of those of the blad- der ; another thick layer formed by a venous plexus, lies subjacent to the mucous membrane. Occasionally, this canal is enormously dilated. Flamand met with a case that permitted the introduction of the finger, and Meyer, with another, which eventually admitted of coition ! 6. TJie Hymen. — The irregular opening of the vagina is found beneath the meatus urinarius ; it is of variable dimensions after coition, and in females who have had children ; but in virgins, it is provided with a mem- brane by which the orifice is diminished. This membrane is the hymen, a species of diaphragm, interposed between the internal organs and the external genital apparatus and the urinary passages. It resembles a crescent in shape (Fig. 19), the concavity being anterior ; sometimes the horns of the crescent are prolonged enough to join each other, thus forming a com- plete circle, perforated in the centre (Fig. 20) ; its free margin is thin and concave ; the convex one is continuous with the membrane of the vagina or vulva, and as this blocks up the posterior and lateral parts of the v< gina, a notable difference will exist in the extent of the orifice, dependent upon the greater or less size of the hymen. Sometimes the hymen forms a complete imperforate membrane. Tt e by approximating its edges. (See Plate xii.) The hymen is composed of a fold of mucous membrane, containing between its laminae a few vessels and some areolar tissue. 7. The carunculce myrtiformes are some little tubercles, two to five in number, which appear to be the debris of the ruptured hymen ; the two most anterior ones, according to certain physiologists, appertain to the median columns of the vagina. In consequence of oft-repeated friction, these caruncles may inflame, degenerate, and even become the source of an abundant purulent discharge ; they have been mistaken under such circumstances for syphilitic vegetations, and the patient subjected to anti-venereal treatment, which, at least, was useless. Personal cleanliness, and some of the vegeto-mincral lotions are usually sufficient to cause their disappearance. M. Velpeau has resorted, however, in some cases, to excision. 8. Fossa Navicularis. — This is a little depression, of half an inch only in extent, bounded behind by the fourchette, and in front by the convex border of the hymen. It, like the fourchette, formed, as before stated, by the junction of the inferior extremities of the labia majora, mostly disappea? u after delivery. 64 FEMALE ORGANS OF GENERATION". ARTICLE III. OF THE SECRETORY APPARATUS OF THE EXTERNAL ORGANS OF GENERATION. [The secretory apparatus of the female genital organs has been the subject of numerous investigations, but of late a fresh interest in the subject has given rise to works bj Robert, lluguier, Sappey, Martin, and Leger, all of which are placed under contribution in the preparation nf tins article. Aside from the piliferous bulbs, the glands of the vulva may be arranged in three classes: 1. Sudoriparous glands; 2. Sebaceous glands; 3. Muciparous glands and follicles. First class. — The sudoriparous glands are found on the penil and the external surface of the labia major a ; they are mingled with the sebaceous glands and surround the bases of the hair bulbs. Presenting the same arrangement as in other parts of the body, they are noticeable here on account of their great number. Second class. — The sebaceous glands of the vulva are extremely numerous. Those of the mons veneris and of the outer surface of the labia majora are remark- able for their size, having an average diameter of T g ff of an inch. They are generally composed of from four to six lobules, each containing eight or ten culs~ desac. They always open upon a piliferous bulb. The internal surfaces of the labia majora are also provided with sebaceous glands to the extent of about forty to every 'i of an inch square. They are still more numerous upon both sides of the lesser labia, the inner surfaces of which present about one hundred and fifty to every § of an inch square. Martin and Leger note the fact, that these glands, which are very apparent in the adult female, become atrophied after the cessation of the menstrual function, and cannot be found at all in the foetus. The sebaceous glands are also found on the fourcbette and the prepuce of the clitoris. No trace of them, however, is to be discovered either in the vestibule or around the orifice of the urethra. These glands secrete an oily matter, which maintains the suppleness of the parts to which it is applied, prevents them from contracting abnormal adhesions, and preserves them from irritation by the urine. Third class. — The muciparous follicles as described by M. lluguier, present two varieties: in the first, they are i.solated or simply agminated, isolated or agminated follicles; in the second they are enclosed in one envelope, and discharge into the same excretory canal, vulvo-vaginal glands. A. Isolated or agminated muciparous follicles. These follicles exist, according [*\ lluguier, upon several points of the circumference of the vaginal orifice ; they are sometimes absent and always difficult to discover; their existence even has been denied by some anatomists (Sappey, Martin, Leger). lluguier describes three groups of them. 1. — Eight or ten of them are found in the vestibule below the clitoris, where they open by separate orifices, which are very small and partly covered by a root of valve easily raised by a probe; (Vestibular follicles of lluguier) (fig. 21, A). These follicles arc mere depressions in the mucous membrane without a diverticu- lum. So simple is their structure, that Martin and L6ger refused to call them muciparous follicles. } 2. Other?, termed urethral follicles on account of their situation, are stated by M. Huguier to be less readily discoverable than the preceding, on which account they were supposed by. M. Robert to be less numerous. They are EXTERNAL ORGANS OF GENERATION. 65 of considerable size, and are situated at a depth of from three-eighths to four-eighths of an inch in the cellulo-vascular tissue of the urethra (Fig. 21, c). They are placed beneath the mucous membrane in a direction parallel to the canal, and discharge in close proximity to the orifice of the urethra upon the surface of the projection which Fw.21. forms the inferior boundary of that opening in such a way as to form a semicircle, or some- times even an entire circle, around it. They are closer together than those which have been just described, and sometimes several of them open into the same excretory cavity, so as to produce the ramified arrangement which Graaf has figured and described. 3. Laterally, and at some distance from the urethral orifice, are several small and shallow ones, with a common opening at the bottom of a remarkable conical depression. M. Huguier states that these are often absent, and he pro- poses calling them the lateral urethral follicles (Fig. 21, b). 4. Besides these, some two, three, or four large follicles are found in some females upon the lateral parts of the vaginal orifice, immediately below the hymen or the upper carunculse myrtiformes (Fig. 21, d) ; they are the lateral follicles of the orifice of the vagina. Their openings ordinarily correspond neither in number, situation, nor arrangement, with those of the opposite side ; some are slightly projecting whilst others are not so, and some are readily visible whilst others are hidden beneath the myrtiform caruncles. b. Vulvo-vaginal gland. — This gland had been completely lost sight of by modern anatomists, although described by Gaspar Bartholin ; and attention has only recently been called to it by M. Huguier. It belongs to the class of conglomerate glands. There are two vulvo-vaginal glands, one on each side, where they form peculiar bodies whose position it is important to define with exactness. They are situated at the limits of the vulva and vagina, upon the lateral and posterior parts of the latter, about three-eighths of an inch above the upper surface of the hymen or of the myrtiform caruncles, io the triangular space formed on each side by the juxtaposition of the lectum and vagina, upon the latter of which they repose. They lie at a distance of from three-eighths to five-eighths of an inch from the internal turface of the ascending rami of the ischia, and from three-quarters of an i ich to one and a quarter inches from the external labia. The vulvo-vaginal gland has somewhat the shape of an apricot-kernel, resembling in this respect the lachrymal gland ; like the latter, its two surfaces are flattened, and it is besides slightly lobular and mamelonated. According to M. Huguier, it is much flatter in women who have borne children, which he attributes to the species of separation which its granular dements must undergo from the enormous distention of the vulva during 6 66 FEMALE ORGANS OF GENERATION. Fio. 22. labor. The gland of the right side does not always resemble that of the left , it is indeed not uncommon to find one much more developed than the other. Its size varies much according to age, habits, and, adds M. Huguier, according to the development of tho ovaries, which appear to exercise a de- cided influence over it ; for he has always found the largest gland upon the same side with the most voluminous ovary. It also appears larger in females who indulge immoderately in sexual plea- sures. Its size is greatest, in general, between the ages of sixteen and thirty- five years. Its diameter at this period of life is, on an average, from four-eighths to five-eighths of an inch. It is very small at puberty, and becomes atrophied in old age. Excretory Duct. — Each of the gran- ules of which the gland is composed, is furnished with a minute duct, which, by uniting with those of the neighboring granules, gives rise to three separate ducts. The latter soon join to form a single canal, which proceeds from the internal surface and vulvar extremity of the gland (Fig. 22, D), and opens in virgins, or in females in whom the hymen has been only dilated, in the internal angle which the great circumference of this membrane forms by its union with the contour of the vulvar opening, and, when the hymen has been ruptured, at the base of the lateral and posterior myrtiform caruncles (Fig. 22, E). The orifice, which is smaller than the duct which it terminates, is in most women surrounded by a vascular area, which serves, by its lively red color, to distinguish it from the neighboring parts. If required, it will only be necessary to turn the caruncle inward in order to render it conspicuous . it should however be distinguished from three or four minute openings found in the same furrow, and which belong to the lateral follicles of the orifice of the vagina. The direction of the opening of the duct is perpendicular, but its oblicpie orifice is directed upwards and inwards. Its external semi-circumference is provided with a small falciform, valvular fold of mucous membrane, which increases the difficulty of its detection. In the normal condition the diameter of the orifice hardly exceeds the one-one-hundreth of an inch. The diameter of the duct varies from the one-twenty-fourth to the one- eighth of an inch, and its length, which lessens as the gland is more volu- minous and approaches near the in\ rlit'orm caruncles, is, on an average, about five-eighths of an inch. Vulvovaginal Gland. A A. Section of the labia majora and of the nymphs, showing the excretory duct and its orifice. B. The gland. C. Excretory duct, C. Stylet engaged in the orifice of the excretory duct. D. Its glandular extremity. E. Its vulvar extremity and orifice. F. Bulb of the vagina. 0. Ascending ramus of the ischium. EXTERNAL ORGANS OF GENERATION. 67 Uses and Functions. — The vulvovaginal gland, like the entire generative apparatus of which it forms a part, acquires its full development only at puberty. This concordance alone, independently of observation, would lead to the supposition that the fluid which it secretes is destined to bear a part in the generative act. The amount of its secretion is, in fact, variable. It is especially increased during sexual intercourse, illicit contacts, and under the influence of lasciv- ious thoughts, desires, and dreams. When, during coition, the muscles of the perineum and vulva are excited to involuntary and convulsive contrac- tions, it is expelled in an intermittent manner or by jets, as is the sperm in the ejaculation of the male. According to M. Huguier, the use of this abundant secretion is to lubricate the external parts, and thus render the first approaches less painful, to maintain the humidity of the organs during the act, and thereby preserve their extreme sensibility. ARTICLE IV. ,\ H % PERINEUM - J - PERINEAL FLOOR — PERINEAL BODY. The pelvic floor is formed by sue- iv.. 220. cessive layers of fasciae and muscles, 1 ^ which are pierced by the anus, vulva, and urethra. Beginning externally, Y j* it consists of the external cutaneous , ' ., J_ l j/f i tissue, the sub-cutaneous cellular tis- ■ ', . sue, the sub-peritoneal tissue, and the 4 f- M mw ' f I '"' peritoneum. The space between the vagina and rectum is occupied by a structure peculiar to the female, which is known as the 'perineal body. It is a point of attachment for a num- ber of fasciae, which, midway between the posterior vulvar commissure and the anus, are fused together with con- nective tissue and elastic fibres, form- ing an elastic and extensible structure, upon which the integrity of the parts depends in the last stage of labor. The perineal body is triangular in shape. The apex extends a little above the noddle of the vagina. The base of the triangle forms the interior coccygeus. 12. Obturator externus. plane covered by the skin, separating the vulva from the anus, and is known as the perineum. It is from an inch to an inch and a half long. During labor, the fetal head, forced down by t lie uterine contractions upon the perineal body, dilates the vagina, compresses the rectum behind ami the bladder in front, bulges the perineum, and stretches it from three to live inches. "- ■-£. Muscles of the Female Perineum (Pnvage). i. Anus. b. Bulb of vagina, c. Coccyx. L. Larger sacro-sciatic ligament, p. Perineal body. u. Urethra. a. Vagina, g. Vulvo-vaginal gland. 1. Clitoris. 2, Its suspensory ligament. 8. Crura clitoridis. 4. Erec- tor clitoridis muscle. •"'. Bulbo-cavernosus muscle. 7. Superficial transverse muscle. 8. Sphincter. '.'. Pubo- ns muscle. 10. Obturato-coccygeus. 11. Ischio- Q8 FEMALE ORGANS OF GENERATION. CHAPTER III. OF THE INTERNAL ORGANS OF GENERATION. TnE internal organs of generation are the vagina and the uterus, together ■vith its appendages, the Fallopian tubes and ovaries. ARTICLE I. OF THE VAGINA. The vagina, or vulvo-uterine canal, is a cylindrical membranous tube, extending from the vulva to the uterus ; it is situated in the pelvic excava- tion between the bladder and rectum ; extending from the vulva to the Huperior strait, it has of course the same direction as the general axis of the pelvis: that is, it forms a curve, the concavity of which is anterior; the walls are soft and yielding, flattened from before backwards, with their sur- faces in contact. Its length varies from four and a quarter to five and a quarter inches, though, according to Professor Velpeau (Lemons Orales), it is much less than has been generally imagined, or than he himself has pointed out in his works, being hardly two and a quarter to two and three- quarter inches long. Although this remark may be true, if the length be measured in the dead subject, where the soft flabby walls of the vagina of the ™ Ui P ar0US - one of whom had seventeen, theother nineteen children, have been under my care; the neck in each was completely destroyed in its intra- vaginal portion. This diminished length of the intra-vaginal portion of the neck in women who have borne many children, is due to the strong traction upon the upper extremity of the vagina in the preceding pregnancies, produced by the ele- vation of the uterus ; in consequence of this traction, and the laxity of its adhesions with the middle part of the neck, the vagina becomes detached from it at that point, and adheres to it only at its inferior extremity. When this has occurred, it is plain that the portion which projects into the vagina must be much less considerable than before. Although it still preserves a certain length, the regular form that it previously had is wanting, for it is no longer a fusiform body, with an exterior surface polished and smooth everywhere, but a kind of irregular teat, covered on its external face by more or less numerous elevations. Sometimes it is more swollen at the inferior portion, whilst the upper part appears to be hollowed out in its wdiole circumference by a deep exca- vation. The orifice of the os tincie is sufficiently patulous to admit the extremity of the finger, or even one-half of its ungual portion may occasionally be introduced. The lips are unequal, presenting a variable number of notches Being rarely found on the middle part of the lips, these depressions are con- tinually met with about the level of the commissures, and more frequently 76 FEMALE ORGANS OF GENERATION. on the left side than the right. They result from the lacerations that have occurred in former labors, at the moment when the head cleared the oa uteri ; and the lochial discharges have prevented the lips of these little wounds from uniting, and they have cicatrized separately. The depression? are sometimes so numerous as to subdivide the lips into six or eight small tubercles, separated by as many fissures of variable depth. In case the woman has not had children for several years, and more espe- cially if she has had but one or two of them, these characters are much less determined, the orifice is nearly obliterated, and the neck has gradually resumed its primitive form ; nevertheless, the fissure of the orifice is always sufficiently marked, as well as the inequalities on the lips, to indicate ante- cedent labors. These marks may become more and more faint, but they never disappear altogether. The frequency of these depressions on the left side may be, I think, readily explained. When the head passes through the neck, it is evident that, if a laceration be produced, it will be at the point which sustains the greatest strain. Now, the left occipito-iliac positions being much the more frequent, the occiput, which constitutes the largest extremity of the head, will consequently correspond to the left commissure of the neck. Further, the uterus is habitually inclined to the right, so that the line of its con- tractions is directed from right to left, and, therefore, acts more energetically on the left side of the cervix. Hence the greatest strains occur at this point. § 2. Internal Surface. [The uterus has an internal surface which defines its cavity. This cavity lias, in the virgin condition, a longitudinal extent of about two and a quarter inches, and of two and a half inches after several labors. We may distinguish the cavity of the body and the cavity of the neck. The length of the former is, in virgins, rather less than that of the neck, whilst in multiparas the two dimensions are nearly equal; — that of the body being, perhaps, rather greater than that of the neck. a The cavity of the body is triangular in shape, having two faces, three edges, itnd Miree angles. The two faces are plane, and separated only by a thin layer jf mucus, so that they may be said to be in contact. Cavity of the Uterus and the Fallopian Tubes. a. Superior border or fundus of the womb. b. Cavity of the womb. o. Cavity of the neck of the uterus. D. The canal of the Fallopian tube cut open. e. The fimbriated extremity or pavilion, likewise laid open. pp. The ovaries, one-half of which has I n removed son- to bring into view several ol the Graafian -. q. The cavity of the vagina, h ii. The ligaments of the ovaries, g g. The round ligament. INTERNAL OBGANS OF GENERATION. 77 Of the three edges, the upper extends from the orifice of one Fallopian tube to the other, and the two lateral ones, from the orifice of each tube to the upper or internal orifice of the neck. In virgins, the three edges are curvilinear, with con- vexity directed inward; in multipara, they are either rectilinear, or present a slight curvature with concavity directed internally. The three angles are described as the superior or lateral, and the inferior. The two superior angles are at the extremities of the upper edge where it joins the lateral edges, and where are situated the very minute orifices of the Fallopian tubes. The inferior angle, formed by the convergence of the two lateral edges, also presents an opening in the internal orifice of the neck, by which the cavity of the body communicates with that of the neck.] In the state of vacuity, no cavity, to speak correctly, exists in the womb, for the uterine walls are in contact throughout their extent ; the cavity Fig. 25. Virgin uterus, a. Anterior view; b. Median section; c. Lateral section. (Sappey.) like that of the pleura for example, has a real existence only when the walls hecome separated by a liquid effusion. The congenital deficiency of a cavity in the body is very rare, but yet no trace of it existed in a uterus presented to M. Cruveilhier by M. Etostan, although that of the neck remained. In aged women, however, it is not very rare to find the cavity partly effaced by more or less extensive adhesions. B. The cavity of the neck is fusiform, flattened from before backwards, and presents an assemblage of rugte on its anterior and posterior Avails, winch constitute a median vertical column upon each wall, occupying the whole length of the neck, and from which a number of smaller columns pass off at various angles, representing a fern in relief. The term arbor vita has been applied to these rugosities. After delivery they frequently disappear, but sometimes they still persist. The uterine cavity likewise exhibits a variable number of transparent vesicles, mistaken by Naboth for eggs, hence they have been called the 78 FEMALE ORGANS OF GENERATION, ovuia Nabothi. These vesicles are nothing more than simple muciparous follicles, and they are particularly abundant in the neighborhood of the neck. They secrete a gelatinous mucus, which may accumulate in the cavity of the neck, and so obstruct it as to render fecundation impossible. The internal surface of the uterus is much more vascular in the body than in the neck. This difference is particularly well marked in women who have died during the menstrual period. The cavity of the body is of a rose color, and that of the neck of a pearly gray hue, which is probably due to the slight vascularity of this part in comparison with that of the lining membrane of the body. § 3. Structure of the Uterus. In the ordinary condition of the womb, this structure is difficult to make out, but it becomes much more evident during the period of gestation. The constituent parts of the organ are : a middle or tissue proper, an external peritoneal membrane, and an internal mucous one, together with numerous vessels and nerves. a. Tissue Proper. — This tissue is of a grayish color, and is very dense in structure, creaking like cartilage under the scalpel. In general, the neck appears less firm in consistence than the body, resulting, as M. Cru- veilhier supposes, from the former being the more frequent seat of san- guineous fluxions. It sometimes happens, as after a suppression of the menses, or just before or after menstruation, that the uterus has a more decided red color and its tissue is more supple. (See Menstruation.*) The proper tissue of the womb is composed of fibres disposed lengthwise. The nature of these fibres has led to numerous discussions, but at the present day they are proven by the microscope to be muscular, and since this muscular nature becomes clearly evident towards the end of gestation (see Pregnancy), we must acknowledge that, notwithstanding the fibrous appearance of its tissue in the unimpregnated condition, the fibres composing it are not the less muscular in their structure. This organization is con- cealed by the state of condensation ; of atrophy, maintained either by inertia or want of action ; but which becomes distinct, in consequence of the very considerable determination to the uterus, of its distention, and of the development of its fibres during pregnancy. According to most anatomists, the direction of these fibres in the state of vacuity is very irregular, and their inter-crossing is nearly inextricable, as every one must confess, in this particular condition, says M. Cruveilhier. But as the structure of the uterus, except in gestation, is not of any conse- quence (practically speaking) to the accoucheur, we refer to the article Pregnancy for the more particular study thereof. B. The External or Peritoneal Membrane. — The peritoneum having covered the posterior face of the bladder, is reflected upon the anterior one of the uterus, covering only its superior three-fourths ; and having reached the fundus uttri, and gained the posterior wall, it ".overs this entirely, ia prolonged on the vagina for a short distance, and is then reflected upon the INTERNAL ORGANS OF GENERATION. 79 rectum. The broad ligaments are produced by the transverse elongations of this membrane; and its falciform folds, seen in the interval that separates the bladder from the uterus, are called the vesico-uterine, or the anterior ligaments; and those formed by it, between the rectum and uterus, are called the posterior, or the recto-uterine ligaments. The adherence of the peritoneum is quite loose on the borders of the uterus, but it becomes more intimate towards the median line. c. The Internal or Mucous Membrane. — The existence of this membrane was for a long time contested, and there can be no doubt, that if a mem- brane resembling the majority of those which line all the mucous cavities be sought for in the uterus, it will be sought in vain. Still its existence is rendered very probable by the functions of the organ, for, as Cruveilhier has remarked : 1st. Every organic cavity communicating with the exterior is lined by a mucous membrane. 2d. Anatomy demonstrates that the vaginal mucous membrane is continued into the cavity of the neck, and then into that of the uterus. 3d. When examined by a lens, the internal surface of the uterus exhibits a papillary disposition, but the papilla? are imperfectly developed. 4th. This internal surface has follicles or crypts scattered over it, from which mucus can be squeezed out, and which, if their orifices be obstructed or obliterated, become distended by the liquid, and form little vesicles. 5th. It is continually lubricated by mucus. 6th, and lastly ; the internal surface of the uterus, like all other mucous membranes, is subject to spontaneous hemorrhages, to catarrhal secretions, and to the mucous, fibrous, and vesicular vegetations called polypi; and it is generally admitted that, wherever there is an identity of action, there is also an iden- tity of nature. These physiological probabilities are at present fully confirmed by ana- tomical research, the numerous preparations in the possession of M. Coste leaving no doubt whatever as to the existence of the mucous membrane. I shall therefore borrow from this able physiologist the principal facts which pertain to its description. The thickness of the uterine mucous membrane varies in different parts of its extent. Towards the middle of the body, it forms one-fourth of the thickness of the walls of the uterus ; that is to say, its usual depth at this point is from one-eighth to three-sixteenths of an inch, amounting to about the one-fourth of the thickness of the uterine parietes. It thins oft" rapidly towards the point of union of the body with the neck, as also towards the apertures of the Fallopian tubes. Its greatest thickness in the neck does not exceed the one twenty-fourth part of an inch. The thickness of the mucous membrane is clearly exhibited by the assist- ance of a perpendicular section of the uterus. It is then found to be in- jected, and varying in color from a deep or bright red to a semi-transparent reddish or pearly gray : the muscular tissue, on the contrary, is almost always of a reddish-gra 'olor, and is besides easily distinguished by the numerous vascular openings upon the surface of the section, and from which blood may be caused to exude by pressure. In addition, there is always a 80 FEMALE ORGANS OF GENERATION. whitish line of demarcation between the two tissues, which becomes most distinct when the injection of the mucous membrane is greatest. Its consistence is less than that of the tissue proper of the uterus, being very friable, and easily crushed. It adheres very strongly to the Fl0 - 26 substance of the uterus, and is separated from it with great diffi- culty : it is also incapable of any gliding motion upon the parts which it covers, on account of the entire absence of a sub-mucous cel- lular tissue. Its internal surface presents a multitude of small orifices, rather regularly arranged, -which, though barely perceptible to the naked eye, become very evident with the as- sistance of a lens. About forty- five of them are contained in a space equivalent to the square of one- eighth of an inch. They are the orifices of glands. M. Kobin has given an excellent description of the elements which enter into the composition of the mucous membrane ; they are : 1. Embryo-plastic nuclei; 2. Ele- ments of laminated tissue ; 3. Spe- cial cells, in very small amount except during pregnancy ; 4. Amor- phous connective matter ; 5. Glands ; 6. Capillary vessels ; 7. Epithelium, at first prismatic but becoming pavimentous during pregnancy. A few words in regard to the uterine glands. Two species of glands exist in this mucous membrane, one being found only within the body of the uterus, whilst the other is confined to the neck. 1. According to M. Coste, who was the first to describe them, the glands of the body are especially visible when death has occurred during menstrua- tion ; they then appear as minute canals of about the one two-hundred-and- fiftieth part of an inch in diameter, placed vertically beside each other. Thev are, however, disposed so compactly, that the mucous membrane as seen by a lens appears to be formed of them almost exclusively. Their adherent extremities terminate in culs-de-sac and repose upon the muscular tissue. The bodies of the glands are rendered somewhat flexuous by the mucous membrane being too thin, as it were, in the state of vacuity, for the length of the tubes. They contain a whitish, viscid fluid, which may be squeezed from them, especially at the menstrual period. This figure represents the arrangement of the mucous ir.ambrane and of the tissue proper of the uterus, as also their relative dimensions. a. Cavity of the neck and arbor vitae. b. Cavity of the body. c. Mucous membrane. D. Intervening mem- brane, e. Represents the marked thinning off of the mucous membrane towards the neck. INTERNAL ORGANS OF GENERATION. 81 2. The glands of the neck (glands, or ovula of Naboth) are found in all the interval between the line separating the cavity of the neck from that of the body, and the neighborhood of the borders of the os tincse. Their orifices are readily seen upon, and especially between, the folds of the arbor vita?. These glands have the form of a minute cylinder, terminating in a rounded cul-de-sac, which is inflated into the form of a lentil or vial, and inclosed in the tissue of the mucous membrane, even descending a little between the fibres of the muscular structure. The excretory orifice is always smaller than the glandular tube. Pres- sure causes the escape from it of a transparent, viscid, tenacious, and com- pletely homogeneous fluid. We shall treat hereafter of the modifications which these glands undergo during gestation. [The epithelium of the uterine mucous membrane is cylindric, with vibratile cilia moving from without inward. It is therefore impossible that the ciliary motion should carry the spermatic fluid toward the openings of the tubes, as has been erroneously supposed. The entire cavity of the body and of the neck, to a point near the external ori- fice of the latter, is covered with vibratile epithelium. Below this point the mucous membrane of the neck is ^urnished with the pavimentous variety. D. Vessels. — The arteries of the uterus proceed from the hypogastric and ovarian arteries. Both present many flexuosities in their course through the tissue of the organ, and are remarkable for their corkscrew form, recalling the arrangement of the helicine arteries. The neck is less vascular than the body. The veins are highly developed, anastomosing freely, and forming cavities, as it were, in the muscular tissue. They are called uterine sinuses, and communicate largely with the venous plexuses within the folds of the broad ligaments. From the latter proceed the uterine and ovarian veins which empty into the correspond- ing trunks. From the arrangement of the uterine arteries and veins, surrounded as they are everywhere by muscular partitions, it results, that the uterus is a true erectile organ, as has been placed beyond doubt by an excellent memoir published by Professor Rouget. This skilful anatomist has, in fact, shown that by injecting the veins of the uterus the organ is put in a state of true erection, whereby it rises, swells, and moves up toward the abdomen. Under these circumstances its volume is greater by one-half than in the empty condition, and the Avails of the cavity separate from each other. These phenomena doubtless take place during coition, and probably facilitate the ascent of the spermatic fluid. The lymphatic vessels are very abundant, and pass into the pelvic and lumbar ganglia. e. Nerves. — The nerves are derived from the great sympathetic, some of them, pro- ceeding from the renal and others from the hypogastric plexuses ; to the latter are united some fibres from the sacral plexus.] It is an important practical remark of M. Jobcrt, that the entire intra- vaginal portion of the neck is destitute of a supply of nervous fibres, whilst the portion above the insertion of the vagina receives a great number of them, which form species of plexuses, furnishing ascending or uterine 82 FEMALE ORGANS OF GENERATION. branches and descending or vaginal ones. The latter are extremely numer- ous, and ramify to infinity in the substance of the vagina. This distribution, which would explain a number of physiological and pathological facts, needs confirmation from new researches, for recent prepa- rations deposited by M. Boulard in the museum of the School of Medicine, give it a formal denial. Development. — According to some authors, the uterus is bifid in the em- bryo as late as the end of the third month, but M. Cruveilhier says he has never observed this bifurcation. During the intra-uterine life, the volume of the neck surpasses that of the body, and at this period its largest por- tion corresponds to the vaginal extremity. After birth it remains nearly stationary until puberty, and then it acquires in a very short time the dimensions observed in the adult woman. The organ often becomes atro- phied in old age. § 4. Ligaments of the Uterus. We have already spoken of the anterior and posterior ligaments. The broad and round ones still remain to be described. The Broad Ligaments. — As elsewhere stated, the double lamina of the peritoneum, which covers the anterior and posterior faces of the uterus, is prolonged transversely, the two folds resting against each other, and form- ing by their union a transverse partition, extending from each side of the uterus, which divides the pelvis into two cavities ; the anterior of which lodges the bladder, and the posterior the rectum. Outwardly, and below, these ligaments are continuous with the peritoneum that lines the excava- tion ; their superior border is free, and is extended from the angles of the uterus to the iliac fossae — presenting three folds, called the wings. The anterior wing is not admitted by some anatomists ; it is but slightly devel- oped, and is occupied by the round ligament. The middle one incloses the Fallopian tube, and the posterior contains the ovary and its ligament. [Between the two layers of serous membrane, whose apposition forms the broad ligament, are found two muscular layers, discovered and described by M. Rouget, who represents them as formed of muscular fibres making by their interlacement a network in a transverse direction. The anterior of these two layers is continuous with the superficial muscular fibres of the anterior surface of the uterus, and is directed outward so as to form a part of the round ligament. The posterior mus- cular layer is continuous with the superficial fibres of the posterior surface of the uterus, and is so directed outwardly as to become attached for the most part to the sacro-iliac symphysis.] The two serous folds that constitute the broad ligament, are separated by a loose and very extensible lamellated cellular tissue, continuous with the fascia propria of the pelvis. The broad ligaments disappear during gesta- tion, their two laminae assisting to cover the anterior and posterior faces of the developed womb. Bodirs <,f Roxenmuller, Parovarium. — By the inspection of pieces prepared by M. Follin, we have become assured of the existence of an organ be- tween the two laminse of the broad ligament, which hasnot been even noticed INTERNAL ORGANS OF GENERATION. 83 Fio. 27. Bullies of Rusenmiiller. A. Ovary. B. Fallopian tube. C. Fimbriated extremity of Fallopian tube. D. Culs-de-sac of the tubes. E. Canaliculi proceeding to the ovary. F. Point to which the tubes converge. G. Vesicle appended to the Fallopian tube. by French anatomists, but which certain German anatomists figure under the name of the organ of RosenmyMer, who was the first to discover it. Its general arrangement is not yet well understood, its development is involved in obscurity, and the details of its histology had not hitherto been described. It is at present known as the Parovarium. The organ is composed of seven or eight tubes folded upon themselves, terminating in blind extremities, and all converging towards the tube which serves as a point of en- trance for the vessels of the ovary. The tubes are gener- ally closely approximated to each other, so that their in- flexions frequently correspond. When examined by trans- mitted light, the assemblage of canals is distinctly seen in the broad ligament near the fimbriated extremity of the Fallopian tube. Sometimes these tubes are not very appar- ent, and their number is much less, yet some are always to be found. They exist at all ages, but are much more readily distinguished in the broad liga- ments of the foetus, of of children, for then the slight development of the blood-vessels does not obscure them, nor are they hidden from observation by the fat, which infiltrates the laminre of the broad ligaments in adults. The size of the tubes is variable: and they often present dilatations, and sometimes true cysts filled with a citrine fluid. M. Follin has not been able to discover an excretory orifice to these tubes, either in young girls or adult women. Their structure resembles that of the glandular tubes of many simple glands. They are provided with a central cavity, which presents the dila- tations so often observed in tubes of this class. Externally, the tube is formed of cellular-tissue-membrane with longitudinal fibres. The internal surface of the tube is covered with pavement epithelium. Some observations are calculated to produce the impression, without how- ever confirming it, that this assemblage of tubes has, in its origin, some relation with the corpora Wolffiana. Attached to the free edge of the broad ligaments, it is not uncommon to find five, six, or even more small cysts. They are generally connected with the ligament by a very slender pedicle, of variable length, but which is sometimes so short, that the cyst appears to be sessile, and directly adherent to the ligament. (See Fig. 28.) It is difficult to understand the mode of the development of these cysts. They may, perhaps, have some relation with the tubes of which the bodies 84 FEMALE ORGAN'S OF GENERATION". of Rosenmuller are composed. It has however seemed to us worth while to call attention to them particularly, as they are stated by M. Broca to be present in the great majority of cases. The round ligaments, or supra-pubic cords, are evidently continuous with the tissue of the uterus, to which their proper substance is precisely similar; arising from the lateral border of this organ, below and a little in advance of the Fallopian tube, it runs upwards and outwards. According to M. Deville, this fringe, or ligament, is bent downward in the anterior fold of the broad ligament, and reaches the internal orifice of the inguinal canal, i-ato Fio. 28. The figure exhibits the small cysts appended t i the free edge of the broaii ligaments. One of the Fallopian tubes is repr - nted with a double fimbriated extremity, as in the case described by Q, Richard. 4. L't'-nis. b. Fallopian tubes, o. The additional fimbriated extremity, n, e. 'J he normal fimbriated r-xtreniities. f, o, n. The cysts described above. which it enters, accompanied by a prolongation of the peritoneum, bearing the name of the Canal of Nuck. It then divides into a number of fibrous fasciculi, which are lost in the cellular tissue of the mons veneris and that which fills the dartoid sac, described as existing in the labia externa. Ac- cording to Madame Boivin, the round ligament on the right side is the shorter and larger of tlie two. They contain a great number of veins, which are liable to become varicose. These ligaments serve to retain the uterus in position, and to prevent its displacements ; and it is probably to them that the pains in the groins, experienced by some women during chronic affections or displacements of the womb, may be referred. They are, in a great measure, composed of cellular tissue and vessels, but containing also some muscular fasciculi, the superior of which are prolonged from the uterus, and the inferior come from the transversalis muscle. The superior muscular fibres are much more evident during pregnancy. Finally, the vesico-vAerine and utero-sacral ligaments, formed, as we have stated, of folds of the peritoneum, which, after having covered the uterus, are reflected upon the posterior surface of the bladder and the anterior sur- face of the rectum ; these ligaments are, so to speak, reinforced by collec- tions of fibres which appear to be prolongations from the tissue proper of the womb, and which are attached anteriorly to the posterior surface of the bladder, and posteriorly to the anterior surface of the rectum. INTERNAL ORGANS OF GENERATION. 85 ARTICLE III. OF THE FALLOPIAN TUBES. The uterine or Fallopian tubes are two canals, varying from four and n quarter to five inches in length, and placed in the thickness of the superior border of the broad ligament. They extend transversely from the lateral angles of the womb nearly to the -iliac fossa on the corresponding side. Their volume is made more evident by inflating them. (G. Richard.) It may then be ascertained that beyond the uterine parietes, the tube has a diameter of about three-sixteenths of an inch ; towards the middle of its course it increases to about one-quarter of an inch, and just before the ostium abdominale, to five-sixteenths of an inch. Their calibre is very variable at different points. The elasticity of the walls is however so great as to allow of their increase to an enormous extent, as is proved by the cysts which are frequently found in them. The internal orifice of the tube (ostium uterinum) is stated by M. Richard to be the one-sixteenth of an inch in diameter ; from thence, the calibre of the canal increases gradually to its external orifice. Near the free extremity it spreads out and becomes fringed. This termination constitutes the pavil- ion, or fimbriated extremity (the morsus diaboli). It is generally taught that one of these fringes, which is longer than the others, attaches itself to the extremity of the ovary. On the contrary, M. Cruveilhier believes that this adherence takes place through the interven- tion of a groove, the concavity of which looks downwards and backwards, and facilitates the communication between the ovary and the cavity of the tube. All the fringed folds are attached to a small circle which, is more contracted than the part of the tube which it terminates. This small circle is called the external orifice of the tube. The internal or uterine orifice is the name given to the one by which it opens in the uterine cavity. [The Fallopian tubes are composed of three layers : an external or serous, a middle or muscular, and an internal or mucous layer. The external layer is a part of the peritoneum which lines the entire length of the oviduct, and is extended to the free edge of the fimbriated extremity, where it ends abruptly. The middle layer is composed of two planes of muscular fibres — the external being longitudinal, and the internal circular. The tubes have often been described as prolongations of the uterus, whereas M. Robin regards them as entirely dis- tinct. A thin, cellular septum is, in fact, interposed between the tissues of the two organs, allowing of their separation by the scalpel. The mucous layer is continuous internally with the uterine mucous membrane, and terminates externally upon the free edge of the fimbriated extremity where it is connected with the peritoneal layer. Thus affording the only example of a mucous membrane in continuity with a serous one. The mucous membrane of the oviduct is devoid of papilli and glands, but presents longitudinal folds so adjusted to each other as to transform the canal into numerous capillary tubes, well adapted to convey readily the spermatic fluid to the ovary. The mucous membrane is also covered with a vibratilo epithelium, tin' motion of whose cilia being directed toward the uterus are, doubtless, intended to impel the jvuIj toward the uterine orifice of the tube.] 86 FEMALE ORGANS OF GENERATION". A special artery, derived from the numerous branches with which the uterus is supplied, and two veins, which join the ovarian veins, constitute the vascular apparatus of the tube. It is provided with nerves from the spermatic and hypogastric plexuses. The Fallopian tube serves the double purpose of a canal for transmitting the fecundating principle of the male, and for carrying the germ furnished by the female from the ovary to the uterus. Injections into the uterus may pass through the Fallopian tubes into the peritonea] cavity and be a cause of peritonitis. At each menstrual period the ovule passes with the serum current along the ovarian fimbriae into the Fallopian tube. At this time, the vessels of the Fallopian tubes arc engorged — the mucous membrane assumes a well-marked nd color — the walls are thickened, and the canal is enlarged. The tubes arc at the same time affected with peristaltic contractions, which are prob- ably intended to propel the ovule into the uterine cavity. The anomaly presented by the existence of supernumerary pavilions, or fimbriated extremities, upon the same tube, as described by M. Gustave Richard, is here deserving of notice. In the bodies of twenty women, selected at random, he observed it five times. One or several of them were found attached to the tube either immediately behind the normal fimbriated extremity, or at distances varying from three-quarters of an inch to an inch and a quarter beyond it ; all of them were formed like the one which terminated the oviduct by the fringe-like division of the mucous membrane. By floating the fringes under water, an opening was discovered conducting into the tube, through which a stylet might be introduced and brought out through either the internal or external orifice of the tube. According to Dr. Hamilton, of Edinburgh, the Fallopian tube undergoes some modification during gestation, to which he attaches great importance. as a characteristic sign of pregnancy. This change consists in the forma- tion of a little pocket, or sac, about an inch from the fringed extremity. This partial dilatation of the tube, previously described by Roederer under the name of antrum tubce, is certainly an exceptional fact. I have never observed it ; and M. Montgomery has encountered it but once in fourteen uteri, examined in the state of gestation ; so that it cannot have all the im- portance that certain authors wish to ascribe to it. ARTICLE IV. OF THE OVARIES. The ovaries (testes muliebres) are the analogues, in the female, to the testi- cles of the male: that is, both of them secrete a product indispensable to reproduction. Two in number, they are situated on the sides of the uterus, in that portion of the broad ligament called the posterior wing, just behind the Fallopian tube. They are maintained in position by those ligaments, as also by a special one, denominated the ligament of the ovary. The ovaries vary in situation, according to the age of the individual, and the state of the uterus. In the foetus, they are placed, like the fundus uteri, in the lumbar region ; but, during gestation, they rise into the abdomeD alons with the body of the uterus, upon the sides of which they lie. INTERNAL ORGANS OF GENERATION. 87 Immediately after delivery the ovaries occupy the iliac fossse, where they fcometimes continue throughout life; again, it is not at all uncommcn to iind them turned backwards, and adherent to the posterior face of the womb The ovaries vary in size, both from age, from the plenitude or vacuity of the uterus, and from health or disease. Being proportionably larger in tl e foetus than in adult age, they diminish after birth, augment in volume at puberty, especially at the monthly periods, and dwindle away in old age. During pregnancy and after delivery, they acquire in some cases quite a considerable volume. Fio. 29. Ovary of the Young Female after Puberty. A. Body of the orary. b. Otero-ovarian ligament, c. Tubo-ovavian ligament, d. Fallopian tubi . E. Fimbriated extremity of the tube. Before the age of puberty, the external surface of the ovaries is of a Jight rose color, and is smooth and free from inequalities. In women who have menstruated for several years the surface is rough, fissured, covered with small blackish cicatrices, and sometimes with ecchymotic spots. Some of these cicatrices are linear, others are triangular or radiated ; they are of a red color when recent, but become brown in the course of a few months. Sometimes a complete union fails to take place between their edges, leaving a small opening, which communicates with the ruptured cavity. After the period of life at which the menses disappear, the external surface presents numerous wrinkles, which are not, as has been supposed, the result of old cicatrices, but are due simply to the atrophy of the ovaries, and the plica- tion of the external envelope which is the consequence. The ovaries are ovoidal in shape, a little flattened from before backwards, and of a whitish color. The external extremity of the ovary is adherent, as we have said, to one of the fringes of the fimbriated extremity of the Fallopian tube; the internal extremity is attached to the uterus by the ligament of the ovary, which it inserted at the corresponding angle of that organ. The ligament of the ovary, which we have already considered, was for a long time regarded as a canal, designed like the Fallopian tube to convoy the fecundated ovule into the cavity of the uterus; modern anatomy, how- ever, proves it to be solid. From the researches of Gartner, of Copenhagen, and of M. de Blainyille, it appears that in some quadrupeds, and especially the sow, a canal i? almost always to be found extending from its external orifice by the iide 83 FEMALE ORGANS OF GENERATION. of the meatus urinarius (corresponding with a similar orifice on the othei side of the meatus), through the substance of the muscular fibres of the vagina to the neck of the uterus ; here the canal becomes narrower, but continues on, following the body of the uterus and imbedded in its fibrous structure, and finally leaves it to pass in a direction parallel to the corre- sponding angle into the substance of the broad ligament. M. Follin found, whilst injecting the duct of Gartner in the sow, that he injected at the same time a long tortuous tube, situated in the substance of the ligament, at the point occupied in the human female, by the collection of glandular tubes which I have described. I have been able to determine the fact that in the sow this duct does not open by a large orifice at the lower part of the vagina, as has been represented, but in reality by a very narrow one. It is not terminated at its entrance into the broad ligament by a few brush-like divisions, as stated by M. de Blainville, but is continuous with a very fine tortuous tube which extends to the external extremity of that ligament. The duct of Gartner is furnished internally with a pavement epithelium, and communicates throughout its course with many glandular tubes finer than itself. (Follin.) We have sought for this duct of Gartner in the human female, but found nothing which could be reconciled with the description given by him of it; however, we cannot avoid remarking that since these researches N. C. Baudelocque has observed in a woman a canal which seemed to be pro- duced by a bifurcation of the Fallopian tube, and which, after passing through the entire uterine walls, opened into the upper part of the vagina near the neck of the womb. Madame Boivin and some others have met with a similar canal, and Mauriceau and Dulaurens considered it of quite frequent occurrence. The arteries which supply the ovary are the spermatics, and proceed directly from the aorta. The numerous small venous branches found in the ovary unite below the organ so as to form a plexus which gives origin to the ovarian veins; th^ latter emptying into the vena cava inferior, and into the renal vein. The numerous lymphatic vessels with which it is provided contribute to the formation of the spermatic plexus, which itself empties into the lumbar plexus, and thence passes to the thoracic duct. The nerves are derived from the great sympathetic. § 1. Structure of the Ovaries. [The ovary consists of a special parenchyma inclosed by two envelopes, one ot which is serous, the other fibrous. The serous envelope is formed by the peritoneum and is closely attached to the subjacent one. It covers the entire gland except at its lower edge, where the two layers of peritoneum separate to allow passage for the vessels and nerves distributed to the ovary. The fibrous envelope corresponds with the peritoneum by its external surface, whilst its internal surface is blended with the glandular parenchyma. It is much thinner than the tunica albiiginea of the testicle with which it has been compared. M. Sappey even denies its existence, and regards the peritoneum as the only envelope of the organ ; his opinion, however, is not yet adopted by most anatomists. INTERNAL ORGANS OF GENERATION. 89 Within the envelopes mentioned, is a special tissue of a grayish-white color, termed the stroma, which is formed in great part hy the interlacement of muscular fibres, some of which are peculiar to the ovary, whilst others are but a prolongation of the same kind of fibres as constitute the ligament of the organ. Other fibres take their origin from the Fallopian tube. The existence of all these fibres was shown by M. Rouget in 1858. With the muscular fibres are mingled others of connective tissue. The arteries are situated between the muscular fibres, are flexuous, and have a spiral form. The veins, contorted in like manner, form a rich network which empties into a venous plexus immediately below the ovary. The arteries and veins, surrounded as they are by muscular fibres, form a true erectile organ, and the ovary is regarded as such by M. Rouget. Within the fibrous structure of the stroma exist small cavities, called ovisacs or Graafian vesicles, of a size varying ordinarily from that of a millet-seed to that of a hemp-seed. Some of the more developed vesicles project from the surface of the ovary, where they acquire, as we shall see hereafter, a comparatively large size. About fifteen or twenty vesicles may be readily distinguished in the adult female, but with the microscope many more are observable, all of which will be developed when the first shall have disappeared. Fig. 30. 12 ^>V' is rr 7 ii Section of ovary. 1. Cortical portion containing the ovisacs and ovules. 2, 3, 4, 5. 6, 7. 8. Follicles in different stages • development. 9. Epithelium oi the follicle (meiubrana granulosa). 10, 11. Ovum with the discus proligerus, M. Sappey's microscopical examinations have shown that in one healthy ovary of a woman of from eighteen to twenty years of age, the number of ovisacs and ovules is more than 300.U0<>, making near 700,000 for the individual. He therefore calculates, that if all the ova existing in the surface oi the ovaries of a young woman were to be fecundated and undergo all their phases of development, it would require but one woman to populate four Buch cities as Lyons, Marseilles, Bordeaux, and Rouen, and but two, to furnish inhabitants for a capital like Paris, containing 1,600,00(1 souls. There are as many ovisacs in the foetus as there will be at pubfrty, but as the ao FEMALE ORGANS OF GENERATION. gland is tlien small, the vesicles conglomerated, but separate as the ovary dovtlopa After puberty, the number of ovisacs lessens ; in old women tbey disappear. § 2. Of the Ovarian Vesicles. From birth to puberty the Graafian vesicles undergo no change. They have a rounded form and a diameter of y^-j of an inch. At puberty some of them hav* become developed, and. as stated, have attained the size of a millet-seed, of a hemp seed, or even of a pea. Each vesicle adheres firmly to the substance of the stroma in which it is lodged, and which forms for it a sort of retractile tegument. The special structure of each ovisac consists: 1, in a capsule or envelope; 2, of a contained body or nucleus. 1. The capsule or envelope is formed of a special, transparent, extremely thin, but resisting, non-contractile membrane. It is vascular and forms the vesicle con taining the nucleus.] 2. The Nucleus. — The parts entering into the composition of the nucleus are: 1st, a granular membrane which incloses the humor of the Graafian vesicle; and 2d, a liquid produced by the aggregation of three humors of a different aspect, viz., a limpid mucosity, clear, though a little oily, a number of small rounded granulations, transparent in their central cavity, and slightly opaque at their periphery, and some oil globules. 3d, and lastly, an ovule floating in the midst of this liquid. The Granular Membrane (see Fig. 31, g'). — A delicate membrane is Via. 3i. found applied on the internal face of the Graafian vesicle, formed of granules, or rather of cellules, and bearing the name of the granular membrane. It tears with great facility, from its extreme tenuity ; and hence many authors have denied its existence. Upon one part of the mem- brane (that corresponding to the free side of the vesicle) the granulations, or cells producing it, are more numerous or more compact, and in the centre of this com- pact mass, which has been called the pro- ligerous disk, the ovule is found. The granulations, constituting the pro- ligerous disk (see G, Fig. 31), are so closely united both with each other and with the latter, that upon opening the Graafian vesicle, even where the granular membrane is destroyed, this portion remains adherent to the ovule, forming round it, as it were, a granular bed. This membrane is entirely destitute of vessels. § 3. The Ovule. Since the labors of Graaf, the majority of authors agree with him, that the ovule is constituted by the vesicle just described; but the honor of baying first discovered the ovule, as a distinct organ in this vesicle, belongs to Charles Ernest Baer. The ovule is completely formed in the ovary during the earlier years of life. It is imbedded from the period of its maturity, as stated above, in the midst of a mass of granulations, which are moie compac' than those which fill the remainder of tbp. vosielp Ovule in the Graafian vesicle. A. Ovule. B. Cumulus granulosus. C. Gran- ular membrane. r>. Cavity of the Graafian vesicle. E. Membrane proper of the ovisac. F. Stroma of the ovary, o Fibrous envelope of the ovary, a. Peritoneal layer of the ovary. INTERNAL ORGANS OF GENERATION. 91 It therefore occupies a fixed position in the vesicle, and is almost con Btantly met with at a point opposite to that whence the large vascular trunks spread out upon the ovarian capsule, that is to say, at the point which projects from the surface of the ovary. When examined with a lens, it appears as an opaque rounded body, at least more opaque than the liquid inclosed in the same vesicle ; it is extremely minute, although the diameter of the little sphere it represents is subject to variations. "The largest human ovules I have seen and manipulated," says Bisch^rT. "did not exceed the tenth of a line, being barely perceptible to the naked eye." When placed under a microscope, it is seen to consist of an exterior envelope, called the vitelline membrane (Coste), transparent zone, cortical membrane, or chorion (Baer), of a substance aptly compared to the yolk of an egg, and designated as the vitellus, and of another vesicle (placed within the latter) Fig. 32. called the germinal vesicle. ^ ^^-^ A. Vitelline Membrane. — If the ovule be examined by a magnifying glass of sufficient power, an obscure sphere will be brought into view, surrounded by a large clear ring, the nature of which it is difficult to make out. M. Coste has given the name of the vitelline mem- brane to this ring. It is evidently a thick membrane, the external and internal outlines of which assume the appearance of two circular lines inclosing a transparent ring. Many per- sons have merely considered it as a layer of albumen surrounding the yolk, but any one parent zone. b. The viteiius, or yolk. -! . , . 1% ,1 , -, • ,1 , c. Tlie vesicle of I'urkinje, or tlie ger- may easily convince himself that it is at least ni3nul vesicle, d. The germinal spot, a resisting membrane, by cutting the ovule, or by compressing it by means of an instrument called the compressor ; " for after proceeding in this manner," says Bischoff, "there cannot be a doubt that the transparent zone is an elastic, thick, hyaline, and transparent membrane, without a determinate texture." Though entirely destitute of cells and vessels, it is nevertheless a living envelope; because, as soon as the ovum in the mammalia arrives in the cavity of the uterus, it becomes the seat of an active vegetation, and pro- duces villosities which are more or less ramified. The latter, as they become developed, insinuate themselves into the tissue of the uterine mucous membrane, and thus attach the ovum to the place which it is to occupy for the future. B. Yolk or Vitellus. — The cavity of the vitelline membrane is occupied, in great measure, by a granular liquid, that does not adhere to the ex- terior envelope, and even escapes from it readily when the latter is broken. According to Bischoff, the yolk of a human ovum is formed of a coher- ent, indistinctly granular, transparent, and viscous mass, which does not run out when the egg is cut or crushed ; each portion of the zone leserving its particular segment or yolk, or the hitter escaping altogether. "In certain cases," says he, "the vitelline granulations are not united In A Non-fecundated Human Ovule. A. The vitelline membrane, or tram- 92 FEMALE ORGANS OF GENERATION. a single mass. I have seen the yolk divided in two, and, on one occasion, into five parts of different volume." The vitellus usually fills the interior of the zone completely, and has the same form, but sometimes the vitelline sphere is smaller than that destined to receive it. Some authors likewise believe that a very delicate membrane exists, which incloses and unites the yolk in a single mass ; but Messrs. Coste and Bischoff agree in rejecting the existence of this, and contend that the granulations of the vitellus are placed in juxtaposition with the transparent zone, whioh forms its sole and only envelope. c. Germinal Vesicle. — In the midst of the vitellus, in very young girls, or on one of the neighboring points of the peripheral envelope in the matured ovules, a small, perfectly transparent, and colorless vesicle is seen like a clear spot, surrounded by a mass of a deeper yellow. Purkinje had described it in the eggs of birds, and gave his own name to it; but M. Coste is entitled to the honor of having first demonstrated its existence in the ovum of mammifera}, and of thus having established the perfect identity between the latter and the eggs of birds. This is the vesicle of Purkinje, or the germ and vesicle. It is slightly oval, and consists of a very delicate, transparent, and colorless membrane, which incloses a liquid that is frequently as limpid and transparent as itself, though it sometimes contains a few granules. Notwith- standing its extreme tenuity, this vesicle still offers a certain consistence, since it has been seen intact, after leaving the ovule, and being completely separated from the granular liquid in which it was placed. It is always very small, and scarcely measures the sixtieth of a line in diameter. d. The Germinal Spot. — If the germinal vesicle be attentively observed, an obscure rounded spot will be seen on some part of its periphery ; this was first discovered by Wagner, who gave it the name of the germinal spot. It seems to be formed by the aggregation of fine small granules, or little globules, the obscure hue of which is brought out by the clear contents of the vesicle. Wagner has sometimes met with two, or even more, germinal spots in the mammiferce. Before fecundation, therefore, the ovule is composed : 1st, of an exterior envelope, the vitelline membrane, or transparent zone ; 2d, of a vitellus, or yolk, contained in this vesicle; 3d, of a little vesicle inclosed in the first and swimming in the vitelline fluid — the germinal vesicle; 4th, and lastly, of the germinal spot. EXPLANATION OF PLATE I. MEDIAN PERPENDICULAR SECTION OF PELVIS FROM FRONT TO BACK, SHOWING BOTH PELVIC SPACES. [Taken from Savage on the Female Pelvic Organs.'] a. Anus, marking the columns of Morgagni. it. Rectum, projections in the cavity, the valves (?) of Houston. These folds include all the coats of the rectum, and are readily etfaceable by slight distension. Note minute circular markings at the anal end, indicating transverse Bections of the inferior circular fibres of the rectum (internal sphincter), and lines near the coccyx indicating the posterior half of external sphinc- ter, the coccygeal attachment of the pubo-coccygeal muscle, and the recto-coccygeus OVULATION AND MENSTRUATION. 93 muscle, or retractor recti, Luschka. u. Left half of the uterus; its central more vas- cular, erectile portion surrounded by its internal and external muscular cortex ; its cavity a mere rima between its antero-posterior surfaces, v. Vagina, its muscular coats gradually losing themselves on the uterine neck up to its junction with the uterine body. b. Bladder, moderately distended ; its outer longitudinal coat in front passing off to its attachments to the inferior edge of the pubic symphysis, and to the ligamentous process of the pubo-coccygeal muscle, bridging over the urethro-pubic venous plexus, separating that space from the vesico-pubic space above, which is bridged over by the vesical ligaments formed by the urachus and two remnants of the hypogastric arteries, c. Section of Clitoris, l. Vulvar labium, i. Nympha. v. Perineal body, black dots indicating the site of its many small vessels; behind it, anterior sections of the lower circular fibres of the rectum (internal sphincter), s. Pubic symj)hysis and vesico-pubic space, u. Urethra, inner longitudinal muscular coat surrounded by m, m, outer circular coat, those at u constituting a true compound sphincter composed of organic and voluntary muscular fibres, p, P. Vesico-uterine and recto-uterine (Pouch of Douglas) peritoneal folds. CHAPTER IV. OVULATION AND MENSTRUATION. Another physiological phenomenon, namely, menstruation, is both ex- cited by and dependent upon the evolution of the Graafian vesicles or ovu- lation. Ovulation and menstruation are, therefore, intimately connected and should be studied consecutively. ARTICLE I. OF THE MODIFICATIONS UNDERGONE BY THE OVARIAN VESICLES. Until the age of puberty the Graafian vesicles are of small size ; but at this period, some fifteen to twenty of them, which appear more advanced than the others, increase in size, and project from the external surface of the ovary. At the time when the young girl becomes nubile, one of the latter vesicles seems to have received a great increase of vitality ; it under- goes a remarkable hypertrophy, and forms a projection upon the surface of the ovary ; this projection becomes greater and greater until after some days it forms a tumor of the size of a cherry, or even of a small nut, upon the ovarian surface. This considerable augmentation of size is due to the distention of the walls of the vesicle by an increased secretion of the fluid which it contains. In proportion as the development proceeds, the walls of the vesicle become thin ; the vessels which supply them being compressed by the dilatation, lose their volume and become obliterated and atrophied, especially upon the point of culmination, where the resistance is least. When at last it has arrived at its full development, the ovarian capsule appears to remain stationary until an over-excitement, produced either by the maturity of the ovule, 01 by sexual intercourse, occasions its rupture. (Coste.) Then, the walls of the vesicle, although more and more distended, begin to lose their trans 94 FEMALE ORGANS OF GENERATION. pareucy, on account of the hemorrhage which ensues. This is sometime.* limited to the production of small extravasations upon the as yet entire walls of the vesicle, though most frequently a true effusion takes place within the cavity. The effused blood and the superabundant secretion increase still more the distention of the walls, which is finally carried so far that rupture becomes imminent, and it is possible to distinguish at the most pro- jecting part of the tumor, the point where it is about to ensue. This point is generally indicated by a small reddish spot, of about a line in extent, produced by a strong injection, or even by a slight effusion of blood in the Fia. 34. FlO. 33. Showing the ovary, and a Graafian vesicle at its highest degree of development, and just before its •upture. ' a. The hypertrophied vesicle (drawn from n iture, and of its real size), b, c, c. R idi ited cicatrices, left by ? r eviously ruptured vesicles. Fw. 34. The ovary, with the raptured vesicle and the large clot that fills its cavity. (Drawn from nature.) texture of the walls of the vesicle. (Raciborsky.) The thinned walls finally give way and tear gradually ; the membranes of the vesicle itself being the first to yield, and after them the peritoneal layer. As a consequence of this rupture, the ovule is expelled, and carries along with it a part of the granular contents of the vesicle ; it enters the Fallopian tube, the fimbriated extremity of which is prepared to receive it, and after traversing its canal arrives at a later period in the cavity of the uterus. The walls of the follicle collapse after the rupture, and its cavity becomes filled with a small quantity of blood, which is found fluid or coagulated according to the time at which the examination is made. The walls of the torn vesicle contract gradually, and the clot, which some- times at first is the size of a small cherry, is slowly absorbed ; the originally spacious cavity diminishes, the margins of the rupture approximate, so as even to become united occasionally by cicatrization, and order is finally restored. The evolution just described, which is terminated by the rupture of a venicle and the spontaneous expulsion of an ovule, is not an isolated face ; on the contrary, it excites numerous sympathies in the remainder of the gen- 1 This figure, borrowed from M. Raciborsky, is the exact copy of a preparation which he had the kindness to show me. But since that time (1843) I have never met with so enormously developed a vesicle, and I am disposed to believe that this great size is rather pathological than normal. OVULATION" AND MENSTRUATION. 95 erative apparatus and throughout the organism of the female. We shall first study the generative organs and the modifications which they undergo before, during, and after this evolution. The ovary, which produces the hypertrophied vesicle, is notably enlarged. It is of a deep red color, and its vascular apparatus is remarkably con- gested. The Fallopian tube itself shares in the congestion, being often of a violet- red color, especially at its fimbriated extremity, which has a sort of velvety appearance. It is also endowed at this time with a special erethism, in virtue of which it applies its floating extremity upon the ovary, in such a manner as to receive the ovule and conduct it into its cavity. The uterus undergoes such important changes that, before the discovery of spontaneous ovulation, it was erroneously supposed to play the principal part in the phenomena which we are about to study. I shall continue to draw from the beautiful works of M. Coste, from which I have already bor- rowed so freely in the preparation of this chapter, the principal features of the ensuing description. Whilst the ovarian vesicle is undergoing the rapid evolution which we have just described, the vascular apparatus of the womb becomes developed and injected in an unusual manner; immediately beneath the delicate layer of epithelium which covers the surface of the mucous membrane, it forms in particular elegant reticulations, with irregular, lozenge-shaped intervals, surrounding the orifice of each of the numerous glandular tubes of which this membrane is almost entirely composed. This network is so fine as to give a violet hue of greater or less intensity to the internal surface of the womb, and is formed of very delicate venous ramuscules. The utricular glands increase perceptibly in size, and the muscular structure of the uterus, in consequence of the congestion which it undergoes, acquires greater exten- sion, is of a more lively red color, and becomes more spongy and supple. The entire volume of the organ is increased, the neck is tumefied and its orifice narrower; the lips of the os tincse are warmer and their color deeper. The mucous membrane, in consequence of this development of its vessels, and especially of the glandules of which it is composed, has its thickness so much increased in proportion to the size of the uterine cavity, as to be thrown, in a great many subjects, into soft, projecting folds or circumvolu- tions, which are so pressed together as to leave no vacant space in the cavity of the organ. M. Coste has several wombs in his possession, whose mucous membranes measure at certain points, from two to three-eighths of an inch in thickness ; still, to whatever degree the hypertrophy may be carried, it never presents the floating villi which Baer and Weber thought they had observed ; neither, except in some pathological cases, does it ever exhibit the pseudo-membranous exudation which is acknowledged by almost all physiologists. (See Deciduous Membrane.) This great vascularity of the mucous membrane, and the high vascular congestion which the entire organ undergoes, is at first accompanied with the exudation of a few drops of blood, which by admixture below with the vaginal mucus, which is itself at this period increased both in quantity and fluidity, communicates to it at first a rosy, and then a light reddish hue 96 FEMALE ORGANS OF GENERATION. After two or three days, a flow of blood, derived principally from the super- ficial network of the mucous membrane, escapes through the neck and mingles with the vaginal secretions. Henceforth, the effusion presents all the characters of a true hemorrhage. There can be no doubt that the chief source of this hemorrhage is the superficial vascular network of the mucous membrane; and in women who have died at this period the blood may be seen to transude through micro- scopic fissures. The flow preserves the same characters during the two or three, be they more or less, days of its duration ; then, as the quantity of blood diminishes, it resumes gradually the mucous and serous characters peculiar to the vagi- nal secretion. It is impossible, in the present state of our knowledge of the subject, to determine precisely at what mo- ment during the flow of blood the rupture of the Graafian vesicle takes place. The result of numer- ous autopsies admits of the sup- position that this moment is vari- able, and the curious experiments of M. Coste leave no doubt what- ever as to the influence which veneral excitement is capable of exerting upon it; this influence is so great, that it may determine the rupture of an hypertrophied vesicle, which, without sexual in- tercourse, would have remained intact for several days longer. However, it may be admitted, as a general rule, that the rupture occurs during the last days of the flow. The series of phenomena of which the ovary is the seat, is not terminated by the rupture of the vesicle, and it remains for us to state what becomes of its walls after the expulsion of the ovule. Of the Corpora Lutea. — Immediately after the rupture of the Graafian vesicle and the consequent expulsion of the ovule, an effusion of blood, according to some, and of plastic lymph, according to others, takes place into the emptied cavity; moreover, the walls, which were greatly distended, retract strongly upon the effused matter, and form with it a more or less compact mass, which after a time assumes an orange-yellow color. From this latter circumstance, the tumor has acquired the name of the yellow body, or corpus luteuin. Although for a long time considered by nearly every author as an ir- refragable proof of a previous conception, it is at present well known that IJt 5 o o c a « n o p3 a" tc C CS S3 « £ a :o ', O 1 2 « £9 M "B S a 2 & s i t< < 4 4 13 14 20 13 13 6 8 3 1 1 6 years, 7 " 8 « 9 " 10 " 11 " 12 •« 13 " 14 " 15 « 16 " 17 " 18 « 19 " 20 " 21 " 22 " 23 «' 24 " 25 " 1 1 2 11 29 96 129 138 212 204 140 133 95 43 33 8 8 4 5 14 26 47 50 76 79 58 38 21 9 5 1 5 6 10 13 9 16 8 4 2 10 19 63 85 97 76 57 26 23 4 3 8 21 32 24 11 18 . 10 8 1 1 4 10 20 20 38 41 20 20 12 4 2 1 7 18 34 40 55 77 81 72 35 26 24 14 2 1 i 15 27 35 13 6 2 1 Total, . . 1285 342 68 450 137 200 487 100 100 i According to this table, the greater number of first menstruations occur, at Paris, between the ages of fourteen and fifteen years ; but it may be remarked, that the most common variations fall between the ages of eleven or twelve, and seventeen or eighteen years. Warm climates, a residence in cities and the habits which are contracted there, together with robust constitutions, seem to favor the precocious development of puberty ; a low temperature, residence in the country, a feeble and delicate constitution, appear, on the other hand, to retard the appearance of the menses. Numerous exceptions to the averages above indicated are mentioned by authors. Thus, as examples of tardy and precocious menstruation, we see by the table that five women menstruated for the first time at the age oi twenty-three years, six at twenty-four, and two at twenty-five. In some very rare instances, the first appearance has been delayed for a much longer time ; thus, M. Kleeman mentions the case of a woman who was married at the age of twenty-seven years, and who did not menstruate until two months after her eighth confinement; she then continued regular until the age of fifty-four years. Pecklin speaks of a strong and healthy married woman,, who had never menstruated, although she was forty years of age ; her courses made their appearance upon one of the first nights succeeding her second marriage, and recurred regularly for two years, at the expiration of which time she became pregnant. If we compare these cases of tardy menstruation with the nume ous instances of women who become mothers without ever having menstruated, aud of nurses in whom the suppression of the menses did not prevent con- 106 FEMALE ORGANS OF GENERATION. ception, we shall find a full confirmation of what was stated in the preceding chapter, in relation to the secondary importance of the menstrual discharge. Regarded as a phenomenon attendant upon the changes going on in the ovary, it may be absent even though the Graafian vesicle should undergo all its phases of development; nor can its absence be now considered as indicative of the impossibility of fecundation. We cannot accept all the observations of very precocious menstruation ; but, laying aside the numerous cases in which the nature of the discharge has not been so well determined as to allow of their reception without ques- tioning, there are some whose genuineness is undoubted, inasmuch as the appearance of the discharge was attended with all the attributes of puberty. Thus, Dr. Susewind knew of a child of seventeen months, which had men- struated since she was a year old ; the hemorrhage returned regularly every month, and the breasts and mons veneris were those of a girl of fourteen or fifteen years of age. The child observed by Lenhossek menstruated when nine months old, and at two years she presented all the external signs of puberty. The girl mentioned by D'Outrepont, who had four teeth when two weeks old, was regular from the age of nine months ; she had at that time long black hair and prominent breasts. A woman observed by Carus, menstruated when two years old, became pregnant at eight, and died at an advanced age. In a memoir by M. Dezeimeris, many other similar facts, derived from Schcefer, Louis Robert, Le Beau, Descuret, Comarmond, Clarke, Lobstein, &c, wn increased weight, as also by the augmented pressure of the intestinal mass upon the larger surface, created by the change in the fundus. Hence, both its increase of volume and its weight, augmented by the pressure of the intestinal mass, which now has an extensive point oVappui on the fundus, contribute to produce the first change in position. At the same time, the uterus remains in the sacral cavity from the greater space found there, and, the fundus being turned a little backwards, causes the neck to advance slightly. Besides, the presence of the rectum on the left most generally obliges the organ to deviate towards the right, and the neck, in a corresponding manner, to the left; consequently, during the first ORGANIC CHANGES DURING PREGNANCY. 127 three months, the cervix is directed downwards, forwards, and a little to the left. About the third month and a half, or the fourth month, the uterus, no longer finding sufficient room in the excavation for its continued develop- ment, rises above the superior strait, then to the level of the umbilicus, and reaches the epigastric region towards the end of pregnancy. In tracing out the gradual elevation of the fundus uteri, it will be found, at the fourth month, to rise two or three fingers' breadth above the pubis ; at five months, it is within one finger's breadth of the umbilicus ; and from the fifth to the sixth month, it approaches and passes the umbilical depres- sion, so that at six months it is half an inch above this ring ; three fingers' breadth at seven months; and four to five at eight months; it still continues ascending in the commencement of the ninth, but in the last fortnight of gestation, the womb seems to sink down, being, in fact, on a lower level than before. This last is a remarkable occurrence, though it has been said in explanation that the uterus, as if overburdened with the weight of the foetus during the latter period, collapses to some extent, and enlarges in the transverse and the antero-posterior diameters. This may be true as regards some females who have previously had children, for not unfrequently they say to us at this time, " It has all gone to the sides ;" but I believe a more general explanation of the fact may be given ; for, in the great majority of cases, if females be " touched " near the end of pregnancy, a voluminous tumor, covered by the inferior and more especially by the anterior part of the uterine body, will be readily felt occupying the excavation. This is the head of the foetus, which has descended in consequence of its own weight, carrying the wall of the uterus before it, and become engaged in the excava- tion, sometimes even as low down as the floor of the pelvis. Now, does not this circumstance, which may be remarked whenever the head presents regularly, and when there is no malformation of the pelvis, furnish us a sufficient reason for the depression of the entire uterus? How, in fact, could the superior do other than follow the inferior part of the organ ? D. Direction. — In passing up into the abdominal cavity, the uterus is obliged to follow the direction of the axis of the superior strait, and being thrown off by the lumbar column, and finding much less resistance from the anterior abdominal wall, it necessarily inclines forward ; but, owing to the lumbar projection, it cannot possibly remain on the median line, and hence it leans towards one side of the abdomen, the right one, remarkable as it may seem, at least eight times in ten. Most authors, since the days of Levret, have endeavored to explain this great frequency of the right lateral obliquity. Levret himself taught, that the uterus always inclines towards the side where the placenta is inserted ; for this point, he said, being the thickest and most vascular part of the whole organ, is also the heaviest, and this increased weight augmented by that of the placenta, must necessarily draw the organ to that side; but experience has shown that the placenta is far from being always inserted on the one side towards which the uterus is inclined. Again, according to Desormeaux, the presence of the iliac portion of the colon, which is usually filled with fecal matter, prevents the womb from leaning to the left, when I 128 PREGNANCY. it commences ascending out of the excavation, and thrusts into the rignt iliac fossa, whilst the mass of the small intestines is pushed to the left side by the ascent of the womb (where the direction of the mesentery would naturally draw them), and this assists both to maintain and to increase the inclination of the uterus to the right. But, as M. Paul Dubois has justly remarked, any influence which the colon, placed on the left, may have, is fully compensated by the presence of the ccecum on the right ; and, from the observation of M. Velpeau, the mesentery is directed from left to right, and not from right to left as Desormeaux has it, doubtless by mistake. The habit of using the right arm, and of lying upon the right side, has also been brought forward in explanation of this right lateral obliquity, but subsequent observation has not sustained the assertion ; thus, for instance, in seventy-six females, all of whom had the uterus inclined to the right, thirty-eight rested on the right side, twenty on the left, fourteen alternately on both sides, and four on the back. And we may further remark that, down to the present time, it has not been observed that the uterus is placed upon the left side of the abdomen more frequently in those women who habitually use the left arm than in others. Madame Boivin has given an entirely different explanation of this fact ; she asserts that the round ligament of the right side is shorter, stronger, and contains more muscular fibres than that of the left, and she attributes tho right inclination of the organ to the more powerful action of this ligament. Professor Cruveilhier thinks that the shortness of the round ligament on the right, is the effect and not the cause of the uterine obliquity ; " for I have frequently had occasion," he remarks, "to observe that the shortening which occurred on the left, in left lateral obliquity, was constantly accom- panied by a remarkable increase of volume." I must confess that I do not comprehend upon what M. Cruveilhier founds this opinion. [In order to test Madame Boivin's explanation, M. Pajot, in connection with Dr Rambaud, former prosector to the hospitals, undertook new measurements of the length of the two round ligaments. From their investigations it would appear, that even in women who have been delivered, the left round ligament is not so often the longer as has been supposed, and more especially is this greater length far less common than the right lateral inclination of the womb during pregnancy. All the explanations of the fact being then so unsatisfactory, M. Pajot comes to the conclusion that the inclination of the pregnant uterus is due to the mode of evolution of the organ itself. Beside this lateral inclination, the entire womb undergoes a rotation upon its axis, which carries its anterior surface a little to the right, whilst the posterior surface looks backward and to the left. From this it results, that, if during an autopsy the abdominal parietes be removed without disturbing the womb, the annexes of the uterus and the ovary of the left side are found in front, whilst the same parts belonging to the right side are concealed behind near the right sacro-iliac symphysis.] E. Relations. — At term, the uterus is in relation — 1. In front, with the vagina, the posterior face of the neck and body of the bladder, and mperiorly, with the anterior abdominal wall. This last is not always ORGANIC CHANGES DURING PREGNANCY. 129 immediate, for occasionally a portion of the intestinal mass slips between the uterus and the ventral parietes, as occurred in the woman upon whom M. Dubois practised the Cesarean operation in 1839; and, as the professor has remarked, the operator should be very prudent in making his incisions, from the possibility of encountering this anomaly. 2. Behind, with the rectum, sacro-vertebral angle, and vertebral column below, and with the mesentery and intestinal mass above. 3. On the right, with the correspond- ing side of the pelvis, the iliac vessels, psoas muscles, coecum, and right abdominal wall. 4. On the left, with that part of the pelvis, the iliac vessels and aorta, the sigmoid flexure, the psoas muscles, and the whole body of intestines which separate it from the abdominal wall. F. Thickness of the Parietes. — The earlier authors on this subject enter- tained very different views concerning it: some, judging the thickness of the body by that of the neck during labor, concluded that the uterus could not be distended without a great diminution in the depth of its walls; others, having had better opportunities of examining the wombs of females who died soon after the accouchement, observed the very considerable thickness exhibited by the uterine parietes at that time, and therefore adopted the opinion that the latter become much thicker during gestation. Both sides were in error, for numerous autopsies, made since that period, of women who died during gestation, have established the truth of the following propositions, namely: 1. In the three first months, the uterine walls augment a little in thick- ness, doubtless in consequence of the development of their vascular and muscular apparatus. 2. Towards the fifth month, they are about the same as in the normal state, 3. At term, the parietes are thicker than in the natural condition, at the point corresponding to the insertion of the placenta, thinner at the neck, and they present but very little difference throughout the remainder of their extent. We may here notice some further exceptions: thus, M. Moreau, having measured the thickness of the walls in a woman deceased at term, found it one-sixth of an inch at the fundus, one-fourth of an inch at the insertion of the placenta, and one-third of an inch at the neck. This singular anomaly may be explained, says M. Moreau, 1st, as regards the thinness of the fundus, by the enormous distention the uterus had undergone (being a twin preg- nancy). And 2d, the greater thickness of the neck resulted from the con- siderable retraction this part had sustained from the escape of the amniotic liquid before death. In one instance, Saviard found it one-third of an inch at the placental attachment, and only a line in other parts. My friend, Dr. Iiipault, in performing the Cesarean operation, found the uterine wall only one or two lines thick. [At an autopsy made near the end of pregnancy, I found the walla of the uterus remarkably thin, from T 'y to -p v of an inch, throughout the greater part of their extent; M. NAlaton, who was present, confirming the observation. This thinning is, therefore, not very unusual, and I am even inclined to think is the most frequent condition. la many pregnant women, the parts of the child may be felt very easily; in some y 130 PREGNANCY. eases the hand appearing to bo separated from them by a layer of but a few lines in thickness. Notwithstanding all this, it is nevertheless true that the entire bulk of the uterine walls undergoes considerable increase during gestation in consequenee of the great extension in surface. To prove this, it is only necessary to weigh the uterus of a woman dead at the end of her pregnancy, when it will be found that the weight of the organ, after separation from the neighboring parts and removal of its contents, will vary from three to almost four pounds. In the case of M. Moreau, above cited, it was nearly four pounds. The uterus, therefore, increases at least twenty times in weight during preg nancy, a fact surely sufficient to prove the occurrence of hypertrophy under these conditions.] Again, the thinness may be partial ; thus Hunter describes a uterus, the posterior walls of which exhibited this phenomenon in a remarkable degree. G. Density of the Walls. — The uterine parietes, in the non-gravid state, are very hard and resisting, and have nearly the consistence of fibrous tissue, but during pregnancy this density diminishes and the walls become soft and flabby. The ramollissement begins to show itself as early as the first month, and constitutes at that period one of the best signs for proving a commencing pregnancy (see article on Diagnosis), because, instead of presenting the fibrous density of the ordinary state, the walls have a clammy softness closely resembling that of caoutchouc softened by ebul- lition, or that of an oedematous limb. This decrease in the consistence of the uterine walls constantly advances, so that, at a later period, a light pressure made on the anterior abdominal parietes will easily depress or deform them ; consequently, the extremities and other inequalities of the foetus may be detected, and its movements may even cause an elevation of some part or other; the child, therefore, is. not placed in a cavity having immovable walls. The diameters of this cavity will vary with the position taken by the foetus, which can, in some cases, continue to chauge them until the end of gestation, the flexibility of the walls permitting its long diameter to pass through the small ones of the organ ; and we can readily comprehend how this flexibility, this suppleness of the fibres of the womb, will aid in pre- venting the disastrous consequences which otherwise might result to the child from any violent blows on the abdomen, or from the shocks expe- rienced by the mother. § 2. Modifications in the Neck of the Uterus. The modifications which the neck undergoes during pregnancy, arc referable: 1, to the consistence of its tissue; 2, its volume; 3, its form; 4, its situation and direction. 1. As the softening of the tissue of the neck of the uterus seems to be an all-important fact, we therefore give it the first place. Now, everybody knows, that, in the non-gravid state, the uterine tissue resembles the fibrous in its consistence; but immediately after conception, and from the sole fact of the active congestion which the genital organs then experience, this consistence begins to diminish, although, from being coincident with the hypertrophy of the uterine walls, it is scarcely sensible ORGANIC CHANGES DURING PREGNANCY. 131 during the first few days, whatever may be the extent of the neck exam- ined. But towards the end of the first month we may ascertain that, inde- pendently of this original general modification, the most inferior, or rather, the most superficial part of the lips of the os tincse, begins to soften. It resembles more a swelling of the mucous membrane than a true "ramol- lissement" of the proper tissue of the lips; so that by pressing slightly on this thickened membrane the finger first detects a fungous softness, but soon reaches the proper tissue of the neck, which still maintains its normal consistence. The sensation then experienced by the finger greatly resem- bles that communicated when it is pressed on a table covered by a soft and thick cloth, or, better still, a sheet of India-rubber ; and it is only towards the end of the third, or beginning of the fourth month, that the lips of the os tincse are softened throughout their Avhole thickness to the extent of a line or a line and a half. At the commencement of the fifth, the softening increases from below upwards, and at the sixth embraces the moiety of the sub-vaginal portion. During the last three months it invades the superior part by degrees, and last of all the ring of the internal orifice, so that, at the end of gestation, the neck is so soft in certain females, that I have frequently seen students have great difficulty in distinguishing it from the walls of the vagina. This modification of the neck, which authors have scarcely spoken of, is one of the most important signs ; because, after a little experience, it affords us one of the best means for ascertaining the different stages of pregnancy ; being constant, and found in all females, unless the neck should be the seat of some pathological alteration. It is worthy of notice, however, that the softening is not so well marked, and is much slower in its progress in primiparse, than in women who have previously had children ; but in all, it steadily proceeds from below upwards. A.s before remarked, we may judge very nearly of the probable period of pregnancy by the extent of softening, as it progresses from the inferior to the superior part of the neck; though there is one important remark to be made on this subject, namely, that whenever females have had a great number of children, the sub-vaginal portion of th^ neck loses the greater part of its length ; the extremity then projecting into the vagina, and capable of exploration by the finger, being much shorter. Now, as the softening of the supra-vaginal portion of the neck is of much more difficult detection, it may be thought to be much less extensive than it is in reality, whence we may expect to find a great difference in the extent of the soft- ened part, if a comparsion be made between the necks in two females, both advanced to the sixth month, one of whom is pregnant for the second time, and the other had previously borne ten children. Wherefore it is necessary, in making this appreciation, to bear in mind the number of former preg- nancies, as also the real length of the sub-vaginal portion >f the cervix. 2. Volume. — Some singular idea- on thissubject have been promulgated by many authors, but the following appears to be the mo^t constant rule: the neck doubtless participates in the hypertrophy of the uterine wails during the earlier months, though its development is far less considerable The neck becomes thicker and grows more volumin >us, especially at th< 132 PREGNANCY. superior part, but I have never observed its elongation to the extent of two inches, as Madame Bjivin apparently believes, or to two and three-quarters and throe inches, as M. Filugelli has more recently advanced ; for, aa elsewhere observed, these opinions result, in my estimation, from an error. The neck, in the commencement, being much lower, and directed more in front than in the ordinary condition, the finger can easily explore a larger extent of it, and thus an impression is created of an increase in its length which really does not exist; for frequent post-mortem examinations cf females who died in the early months of pregnancy, have convinced me that, even if the neck is increased in thickness, its length does not undergo any appreciable augmentation. At the commencement of the fifth month, according to most writers, the cervix begins to diminish. In the sixth month (they say) it begins to spread out at the superior part, so as to aid in the enlargement of the body of the womb, and tins spreading at the upper part continues to advance in pro- portion as the term of gestation approaches, and consequently the length of the neck decreases from, above downwards, so as merely to present at last, at the close of the ninth month, a ring of variable thickness. In fact, the diagnosis of the different periods was based on this gradual shortening, and, agreeably to the majority of the French accoucheurs who have adopted the opinions of Desormeaux, the neck has lost at the fifth month about one-third of its length, one-half at the sixth, two-thirds or three-quarters in the seventh, three-fourths or four-fifths in the eighth, and the remainder is effaced during the course of the ninth month ; and yet, I do not hesitate to pronounce all this an entire error, which was first pointed out by M. Stoltz, in 1826, and to which I also have constantly asked attention since the year 1839. No ; the neck does not shorten in the way which has so long been described; it preserves its whole length until the last fortnight of preg- nancy ; and it is an easy matter, especially in women who have previously borne children, to verify this remark, as we shall presently demonstrate. But during the last few weeks, its length, which until that time was intact, diminishes very rapidly, and even disappears by a total effacement ; and we shall in due season explain the simple mechanism of this phenomenon. But to return ; I have frequently been enabled to prove, in primiparoo, the truth of M. Stoltz's assertions ; for in these women the neck does diminish a little in length, during the last three months, although by a process entirely different from that described by Desormeaux. Thus, towards the seventh month, the ramollissement has invaded the whole intra- vaginal portion ; the parietesof the neck, having lost their consistence, are easily separated by the liquids secreted upon their internal face, and the upper part of this por- i sei'tiuii, showing the ... . , , i • i „cck of the ntenw; the tion being turned outwards, enlarges in such a mannei »nterior nnd posterior lips ag ( () cause the whole neck to resemble a spindle in ita ii'".r shape; the superior extremity of which is formed by the by the fusiform cavity of internal orifice (still closed), and the inferior is con- stituted by the external one, which is scarcely opened in ] rimipane, even at the end of gestation, as we shall hereafter show ORGANIC CHANGES DURING PREGNANCY. 133 Now, it is easily understood how this bulging of the middle part of the neck can only take place just in proportion as the two extremities of the latter ap- proach each other ; thus, of course, detracting so much from its total length. I do not believe, however, with M. Stoltz, that the approximation of the two orifices can be so great as to cause a material shortening of the neck, though this eertairly does exist to some extent. The shortening of the neck is therefore real, though slight, in primipane ; being accomplished, however, by a different mechanism from that taught by most authors. Its upper part does not spread out so as to contribute to the enlargement of the cavity of the body, but suffers a sort of collapse, which brings the two orifices nearer together, at the same time increasing its central cavity, and extending its transverse diameters at the expense of the vertical. What has been said concerning the rapid effacement of the neck during the last few days in multipara?, equally applies to primiparse ; the process taking place by the same mechanism. 3. Form. — The principal modifications in the shape of the neck have already been presented, but they ought to be studied in a more special man- ner, according to whether they are found in prirni parse, or in women who have previously been mothers. A. At the commencement, in primiparse, the cervix appears more con- tracted and more pointed, resulting, perhaps, from the augmentation of its superior part in volume ; the orifice of the os tincse, which, before conception, presented a simple linear and transverse fissure, now assumes a circular form, constituting, as it were, a small lenticular fossa. A little later, as mentioned above, the middle part of the cavity of the neck enlarges, so as to give to the whole cervix the form of a somewhat elongated spindle, rather than that of a cone, which it previously had. It continues smooth and polished on the exterior surface, and the periphery of its orifice is rounded, without any irregularities or fissures; sometimes presenting a soft circum- ference, at others a thin and sharp border: the latter rarely happens, how- ever, before a very advanced stage. At this time, it is very easy to ascertain what changes the neck has undergone, for although the external orifice is constricted, it is very much softened, and sometimes allows the finger to pass with a very slight effort and enter the cavity of the neck. The base of the last phalanx is then felt to be grasped quite tightly by the external orifice, whilst the extremity of the finger is at full liberty in the fusiform cavity of the neck. It may also be readily observed that the two orifices are still widely separated, for the entire length of the first phalanx and some- times more, are capable of being contained in the cavity. Fig. 40. Pio. tl. Fio. 42. Tlic-r three ftgui ua give ,"< id if tin' gradual dilatation winch ill vjiri hum perlodu of preguuiicy. nciU iimli'i goes at 134 PREGNA.VCY. B. The form of the neck is altogether different in women who have had ihildren ; thus the inequalities and protuberances exhibited by the inferioi part will scarcely permit us to ascertain whether it becomes more pointed or not, and it is equally difficult to determine whether the external orifice has become more rounded ; because, having been somewhat patulous before pregnancy, this orifice, in consequence of the numerous cicatrices found on it, presents a very irregular opening. The only point capable of demonstra- tion in the early periods is, that the partially opened orifice will dilate still further, so as to admit readily the extremity of the fore-finger. This spreading out of the os tinea;, and the inferior part of the neck, con- stantly increases from below upwards, as the gestation progresses; it reaches the middle part of the cervix about the seventh month, and nearly gains the internal orifice by the ninth. The enlargement of the cavity of the neck advances simultaneously with the softening of its walls ; and we can easily prove by experiment that the ringer will each month penetrate deeper into it. The shape of this cavity resembles in some women that of a thimble, in others, of a funnel, with the hase below and the apex above, the difference being due simply to the depth and number of the ruptures which had existed on the external orifice before pregnancy. The part of the neck not yet softened and dilated constitutes the summit of the cone: that is, every portion of its length contributes in succession; so that the first, and often even the half of the second phalanx of the finger can penetrate into its cavity towards the ninth month, the extremity of the finger being only arrested by the internal orifice, which is still closed and puckered like the knot of a purse. The ring at this orifice finally softens, becomes dilated, and permits the finger, which has passed through a canal an inch to an inch and a half in length, formed by the cervix, to come into direct contact with the naked membranes. If the length of the external surface of the neck be compared at this period with the canal in which the finger is introduced, the neck will be found much longer internally than exteriorly, for it is self-evident that the finger is arrested on the outside by the vaginal insertion, whilst within it traverses the whole space between the two orifices. The internal orifice sometimes opens too soon; thus Desormeaux declares that he touched the membranes at the end of seven months, over a space of an inch and one-third in extent. I also have verified the same fact, but only in women who were subject to floodings, or in those who submit to "the touch," in our public lessons, fur, in these latter, the frequently repeated and careless introduction of a great number of fingers, has appeared to me to greatly accelerate the softening and dilatation of the neck. < >n the whole, therefore, the neck is fusiform in primiparse, the external orifice is rounded, and so little dilated as to prevent the introduction of the finger without some considerable effort. In females who have had children, 'he external orifice is widely open, ami the cavity in the neck is funnel- shaped, the base being below, and continues to increase until its ape: reaches the internal orifice. This latter remains closed in both, in a vas: majority of cases, until the beginning of at least the last month of pregnancy ORGANIC CHANGES DURING PREGNANCY. 135 These differences in the form of the neck in primiparae and of multipara, are readily accounted for when we take into consideration the condition of the external orifice before pregnancy in both cases. The os tincse of women who have already had children, has the continuity of its circumference interrupted by a greater or less number of ruptures, so that as soon as a small part of the neck has become softened, each of the divisions of the circumference being fixed only by its upper part, is turned outward, so as i ) give to the orifice the form of the large extremity of a trumpet. In the primiparous woman, on the contrary, the integrity of the ring is complete, and the os tineas may become softened without its orifice being much enlarged in consequence. We have stated that the whole length of the neck disappears at the last, by being confounded with the cavity of the body. The mechanism of this fusion is very simple ; the ring at the internal orifice having at length lost all power of resistance from its ramollissement, opens so as easily to admit the extremity of the finger (see Fig. 42), and this dilatation gradually augments under the influence of those feeble contractions by which the uterus, in the last fortnight of gestation, seems to prelude the labor of child- birth, and as soon as this is sufficiently advanced to permit the inferior part of the ovum to engage in the cavity of the neck, we can understand that the latter is promptly trespassed upon. Again, there is no projection found at the upper part of the vagina, unless, perhaps in those who have had children, a collar of variable thickness and softness, circumscribing an opening large enough to permit the finger to reach the membranes ; whilst in primiparae, only a sharp, thin ring, in the centre of which is a much more contracted orifice, will be encountered. 4. We have but little to remark concerning the situation and direction of the uterine neck during pregnancy, and our opinions do not differ from those held by the majority of writers on this subject ; hence we shall merely state, in a few words, that during the first three months the neck is lower, is directed more in front, and a little to the left ; and that this position is the necessary consequence of the inverse movement of the body of the organ, by which its fundus is carried backwards into the sacral cavity, and pushed to the right by the tumor, which the rectum, habitually distended with fecal matters, forms behind and at the left part of the excavation. In the last six months, the cervix, necessarily following the ascent of the body, mounts upward, and, at the same time, most generally looks back- ward and to the left, whilst the fundus is nearly always carried forwards and to the right. I cannot pass over, however, a disposition of the neck occasionally met with at the end of gestation, that sometimes embarrasses persons qo1 familiar with this kind of exploration : namely, in the last month, the head (if that is the presenting part) frequently presses before it, in engaging in the excavation, the anterior inferior portion of the uterus, and in case the female has a large pelvis, this descends even perhaps down to the inferior floor. The neck will therefore necessarily be carried behind the tumor which then tills the pelvis, and the plane of its orifice will look towards the anteiioi face of the sacrum, and, of course, in order to penetrate its cavity, the linger 136 PREGNANCY. must be bent like a book and be introduced from bebind directlj forwards This posterior obliquity of the cervix, which differs essentially from that produced by an anteversion of the womb, sometimes renders it very difficult of access, even when the labor is somewhat advanced. The difficulty ia still further increased, in some cases, by the softening of the neck through- out, in consequence of which it becomes flattened and applied to this tumor forming a kind of fold or doubling on its posterior part. Summary. — From what has been stated, we may now d?aw the following conclusions: 1st. That the tissue of the neck begins to soften at the very commence- ment of pregnancy, and the softening, although not very apparent in the earlier months, and limited to the most inferior part, gradually ascends, so as to invade successively the whole neck from below upwards, though it is sometimes less marked and less rapid in its progress in primiparse than in other females. 2d. The cavity of the neck dilates simultaneously with the softening of its walls ; and further, this enlargement causes it to be spindle-shaped in primiparse ; and, in females who have already borne children, to resemble a thimble, the finger of a glove, or a funnel with its base below. 3d. The external orifice remains either closed, or else very slightly open, in primiparse, up to the very term of pregnancy, whilst in others it is widely open, and constitutes the base of the funnel 4th. The whole length of the neck disappears in the last fortnight, being lost in the cavity of the body. The effacement beginning by the interna] oritice and gradually involving the neck from above downward as far as to the external orifice. 5th. Contrary to the opinions generally adopted before the time of M. Stoltz's publication, the neck preserves its whole length until the last fort- night ; it does not shorten from above downward during the last four months, but the fusion of the neck with the body takes place only within the last few weeks of gestation. § 3. Modifications in the Texture of the Uterus. Among the many changes which the womb undergoes during pregnancy, the most curious of all are those exhibited in its texture; and we shall Btudy these by successively examining the different parts of its constituent elements. 1. Serous Coat. — The peritoneum, forming the external membrane of the uterus, spreads out in all directions. The various folds formed by it in the neighborhood of the womb, a species of mesentery, as M. Dubois calls them, Buch as the broad ligaments and the anterior and posterior ligaments, are double. Many anatomists believe this doubling is even sufficient to accommodate the enlargement of the organ. But, to refute this opinion, it is only necessary to examine that portion of it comprised between the com- mencement of the two tubes, which cover the fundus; for this will afford a convincing proof that it cannot be furnished by the accession of neighboring parts of the peritoneum, because, as Desormeaux remarks, the insertion of the tube and ligament of the ovary upon each side presents an obstacle thai ORGANIC CHANGES DURING PREGNANCY. 137 will prevent the gliding of the adjacent membrane. The peritontal tissue, however, undergoes a considerable extension, and a more active nutrition must necessarily take place to prevent its attenuation, since that which covers the uterus during gestation quite equals in its thickness the serous membrane of the unimpregnated state. This extension of the peritoneum, without a decrease in thickness, is not a new fact in pathology, and it may be seen in every hernia of considerable size. The tissue uniting this membrane to the muscular substance appears to have diminished in density ; for the peritoneal coat is movable on the muscular walls, according to M. Dubois, who has met with difficulty from this cause every time he has performed the Csesarean operation. 2. Mucous Coat. — Although the existence of this coat in the non-gravid state has been denied by many anatomists, it becomes very apparent during pregnancy. It then grows redder and more vascular, and its folds dis- appear ; but this unfolding will not alone account for the extension which it undergoes, and it must, whatever be said to the contrary, receive, like the peritoneum, a more active nutrition. All the elements which we have mentioned (page 80) as entering into its composition undergo, in reality, a considerable development. The nature of this work does not allow us to enter into all the details which the subject demands, and we prefer referring the reader to the excellent work published by M. Robin, in the Archives, for the year 1848, Vol. XXV. of the Memoires de VAcadimie de Medecine, and in the Bulletin de I'Academie de Medecine, 1861. The glands of the body of the womb share in the general hypertrophy, and we shall be obliged to recur to this subject when we come to treat of the decidua, which is nothing else, as must be finally acknowledged, than the mucous membrane of the uterus modified by the progress of gestation. (See Decidua.) m It is easy to convince ourselves, after the accouchement, that the mucous membrane of the neck itself is also hypertrophied, though much less so than that of the body. Its glands, also, have undergone an enlargement, their secretion is much increased, and to it is due the gelatinous plug, that is to say, the elastic, dense, semi-transparent, and almost insoluble mass of mucus, which closes and fills the cavity of the neck during pregnancy. That such is the case may be demonstrated by examination of the bodies of women who die during pregnancy, when, if the mass be detached, pro- longations will be found passing from it, and entering the orifice of the glands. (Robin.) 3. Middle Coat. — [The middle coat of the uterus is formed of muscular fibres of organic life, as stated whilst describing the normal anatomy of the organ. In the unimpregnated condition these filires are hardly recognizable, but. during pregnancy they become very evident. Numerous microscopic researches have shed still more light on the subject, revealing the most intimate changes which the muscular tissue undergoes. According to M. Ch. Robin, whose opinion is stated by M. Pajot, the muscular or cell fibres of the uterus are, in the empty uterus, remarkable for their small size and grayish color, making it difficult to distinguish them by the raked eve from the cellular texture which surrounds them. During pregnancy tlie\ enlarge in everv way, particularly in length, and new fibres are formed beside the old ones, especially in the innermost, layers of the middle coat l: PREGNANCY. "We quote the text in which Kulliker treats of the subject, viz.: " The muscular coat undergoes an increase in bulk, to which the enlargement of the uterus is principally due, an increase resulting from the concurrence of two phenomena: the increase in size of the pre-existing muscular elements, and the formation of :ieic ones. The first of these is so marked that the contractile fibre cells, instead of being from 05 to .07 of a millimetre 1 in length, and .005 in breadth, which is their usuil >!ze, measure in the fifth month .14 to .27 m. m. in length, and .0055 to .014 and even .02 in. m. in width ; in the second half of the sixth month .2 to .52 m. m. in length, .009 to .014 m. m. in width, and .005 to .000 m. in. iu thickness; so that they are about from seven to eleven times longer, and from two to seven tinier \\ idcr than at first. " 'J he formation of new muscular fibres is especially noticed during the first half i>f pregnancy, and in the internal layer of the muscular coat. Iu this situation are found a multitude of young cells of from .02 to .04 m. m. in diameter, presenting all the transition forms of cell fibres of from .05 to .07 m m. in length; nothing similar to this being observable in the external layers. " This generation of muscular fibres appears to cease at the sixth month ; at least I have been able to discover in the uterus during the twenty-sixth week of preg- nancy only enormous fibre cells with no traces of preceding forms. " To this increase of muscular fibres corresponds that of the connective tissue which unites them; toward the end of pregnancy the latter exhibits in some places a distinct fibrillation." (Human Histology.) In short, the increase in size of already existing muscular elements, and the forma* ♦ion of new fibres, concur in the production of the uterine hypertrophy. AVe have next to exhibit the arrangement and direction of the muscular fibres, and in so doing shall state successively the result of the dissections of Madame Boivin and of MM. Deville and Helie.l Fig. 43. A. According to Madame Boivin, there are two planes of fibres in the body of the uterus — the one exterior, the other interior; the external plane is composed of fibres which run from the middle line outwards and downwards to the inferior third of the organ, where they terminate upon and aid in forming the round ligaments situated there, while the most superior ones are distributed to the Fallopian tubes and the ligaments of the ovary. An exact idea of the radiated disposition of the external fibrous planes, at the superior and lateral parts of this organ, may be formed by im- agining the long hair of the human head to be parted along the whole middle line of the cranium, and then combed smooth on each side in front, and tied very tight opposite each ear. Another muscular plane is found internally, having an entirely different arrangement; these fibres are circular and situated at the superior angles of the womb. They surround the internal orifice of the tubes (a a, Fig. 43), describing concentric circles, at first very Muscular Bbree of the uterus, a a. The internal orifices of the Fallopian 1 A millimetre is .0.039 of an inch. ORGANIC CHANGES DURING PREGNANCY. 139 small and dose, but gradually separating as the distance from the angles increases, so that the last and largest border upon the, median line, and spread out in the direction of its length. Between these two planes, the external one composed of longitudinal, and the infernal one of horizontal fibres, some other muscular fibres are found, the course of which it is impossible to trace. Only a single order of fibres, which are semicircular, exists at the inferior part. They commence at the median line of this region, and reunite on the sides near the round ligaments. I will remark, in terminating this short account of the uterine structure, its great resemblance to that of all the hollow organs, in having, for instance, its longitudinal fibres on the exterior, whilst the circular and horizontal ones are internal. The fundus uteri is the part particularly concerned in the expulsion of the foetus, and it is there also that the muscular appa- ratus is the most developed ; its disposition is such, that all parts of the uterine surface tend towards the centre during contraction. Lastly, at the inferior part, where the resistance should be least, there are only the hori- zontal fibres, constituting a sort of sphincter muscle, which may be com- pared, on more than one account, to the sphincter of the rectum or of the bladder. B. Quite recently, M. Deville, prosector to the hospitals, has studied the muscular arrangement of the uterus in a great number of cases of females who died a few days after labor, and the results at which he has arrived differ much from those previously acknowledged. This subject, in my estimation, requires further examination ; but whilst awaiting an oppor- tunity of dissecting for myself, the preparations of M. Deville appear so satisfactory, that 1 have obtained a drawing of them, and introduce here the description furnished by that skilful anatomist. Examined on its external surface, after the removal of the peritoneum and the compact resisting layer that separates this serous coat from the muscular fibres, the uterus seems to be composed of two orders of fibres, which are essentially muscular, one being transverse and the other longitudinal. The transverse fibres arise (this word to be received in a purely descrip- tive sense) from three sources : the round ligament, Fallopian tube, and the ligament of the ovary; also from the wings of the corresponding broad ligament. The mere removal of the delicate peritoneal envelope of these organs suffices to bring the transverse fibres into view, and at the same time to reveal their muscular character. The transverse fibres, together with certain vessels and nerves, constitute the intimate structure of the round and ovarian Ligaments, as also the middle layer of the Fallopian tube, which is therefore essentially muscular, like the internal membrane, improperly called dartoid, of all the excretory canals. The presence of a great number of transverse uterine fibres King in the thickness of the folds of the. broad ligament, and extending to its base, i.^ an important fact to be borne in mind ; and the question arises, where do they terminate? I confess that I have not been able to determine this in a satisfactory manner. 140 PREGNANCY. Howevei the truth may he, the transverse fibres coming from these divers origins spread out in a radiated manner over the whole exterior surface of the uterus, the anterior and posterior ones transversely, or a little down- wards in an oblique direction, and the superior, obliquely upwards, so as to cover the organ completely. Near the median line these fibres are crossed perpendicularly to their course by a longitudinal fasciculus, more or less sinuous in character, and three-eighths to three-fourths of an inch wide, which arises near the point of union of the body with the neck, ascends upon the fundus of the organ, and descends on the posterior face, to be lost at its inferior part opposite to or a little below the point of beginning, that is, near the union of the body with the neck. A positive continuity will be observed between the transverse fibres of each side and the middle longitu- dinal fasciculus, if the line of contact be carefully examined. As the transverse fibres arrive near the median line, some curve down- wards, others upwards, so as to become longitudinal, and thus constitute the median layer. This is particularly evident at its termination, both in front and behind, for the whole fasciculus divides there into two portions, one of which curves to the right, the other to the left, and becomes con- tinuous with the most inferior transverse fibres of the body. This continual exchange of the two series of uterine fibres takes place with such great uniformity, that the longitudinal fasciculus has nearly the Bame thickness everywhere; but if this lamina be more patiently examined, it will be found to be composed of very FlQ - 44 - short longitudinal fibres, forming the cen- tral part of a letter X, which the uterine fibres describe, as I have verified on many of my preparations, in the following manner. Let us take a layer of transverse fibres on the right side of the uterus, at the an- terior inferior part (see Fig. 44); this fasciculus nearly approaches the median line, then curves upward and becomes confounded with the longitudinal lamina; then, after a vertical course, varying from one-third of an inch to two inches, it again curves to the left, to reassume a transverse direction, thus representing a Z, or still more exactly, a branch of the letter X. Thus, the longitudinal median layer is produced by the union of the central and vertical branches of the X. described by the uterine fibres. It sometimes happens, however, that the transverse fibres pass directly from right to left without forming the vertical branch, which fact should be borne in mind lest this arrangement existing on the surface might give rise to a belief of the absence of a median longitudinal fasciculus; whereas, if the latter is not evident, it will only be necessary to raise carefully this layer of median transverse fibres, to bring it into view. The uterus exhibits The disposition of the muscular fibres on the anterior face of the womb. ORGANIC CHANGES DURING PREGNANCY. 141 The disposition of the muscular fibres on the posterior face of the womb. the same disposition of muscular fibres on the internal face, which will readily account for the error of Madame Boivin, Avho described them a? circular. Notable differences, however, exist be- Fro. 45. tween the fibres on the two surfaces of the >rgau. The most remarkable on the ex- terior is the extreme breadth of the longi- tudinal fasciculus, which covers the whole fundus, extending from the orifice of the Fallopian tube on one side to the same point on the other. When this fasciculus reaches the anterior and posterior faces, it is intersected at right angles by the transverse fibres occupying the lateral portions just below the orifice of the tubes, which act there as on the exterior surface : that is, some of the fibres curve upwards, others downwards, becoming con- founded with the longitudinal layer. Lower down, near the junction of the body with the neck, the longitudinal fasciculus is very irregular. Sometimes it exists; sometimes, though more rarely, it does not. At this point, in fact, the continuation, or inter-crossing of the transverso fibres from one side to the other, occurs in an irregular manner, either forming the vertical branches of an X, fio.46. or taking an oblique direction, or again going directly across, the fibres preserving a transverse course. A third layer exists between the two just described, but I am not sufficiently acquainted with the disposi- tion of its fibres to give an exact account of them. All these particular details do not interfere with the general law of inter-crossing, or passage of uterine fibres from one side to the other, and in this respect, the uterus may justly be ranged in the same class with all the other hollow muscular organs whose structure is also regulated by the fundamental law of muscular inter-crossing. Hence, it would not be difficult to de- monstrate that the human uterus, as just described, approaches in its structure quite as well, perhaps better, to that of the same organ in other mammiferse, than the arrangement pointed out by Madame Boivin. But such a discussion would be out of place here. In conclusion, I will observe, that the same dispositions in the muscular arrangement are found in the neck and inferior part of the body. Inter- crossings occur there also, the fibres passing directly from one side to the other, or becoming more or less oblique at the moment of crossing, and .-till oftener forming the branches of an x with the median vertical parts. This last disposition gives rise to the peculiar formation, which has improperly bven called the arbor vitas. Shows the Inter-crossing of the uterine fibres. 1 12 PREGNANCY. [c. Lastly, M. Helie, Professor in the Medical School at Nantes, lias, in a remarkable memoir written after long and skilful dissections, discussed anew the Bubject of the muscular structure of the uterus. A.8 M. Hedie seems to represent the true state of the case, and gives a better and more complete exhibition of the arrangement of the muscular fibres than has hitherto been done, we shall follow his description whilst pointing out the principal results at which he lias arrived. The fibres of the uterus, like those of the heart, are disposed in layers, which cover and envelop each other successively. Fibres pass frequently from one layei to the other: their arrangement is intricate, and their dissection very difficult. These superposed layers form the muscular structure of the uterus, and we shali describe successively the external, the internal, and the middle layer. The external layer is composed of several alternate planes of longitudinal and transverse fibres. The most superficial plane is longitudinal, and is formed of a median fasciculus whose middle part is curved like a loop upon the fundus of the uterus, whilst its two extremities descend, one upon the posterior and the other upon the anterior surface of the organ. This loop-like fasciculus (Figs. 44 and 45) always descends further behind than in front. Behind, it begins where the neck joins the body, and is composed of fibres which, from being at first transverse, by a sudden change of direction become vertical, as shown by M. Deville. As it ascends, the fasciculus is reinforced by other fibres bent in like manner. As it approaches the fundus, the lateral fibres curve outward toward the Fallopian tubes and broad ligaments upon which they disappear. The middle fibres of the fasciculus are, therefore, the only ones which bend over the fundus of the organ, and descending upon the anterior surface curve successively outward to reach the broad and round ligaments. A portion of the fibres which thus emerge from the loop-like fasciculus, reach the lateral parts of the organ only after having traversed its median line and passed from one side to the other. From the right side, they proceed to the left angle or to the left side of the anterior surface ; those, which at their origin belong to the left side, go to the right angle, or to the right side of the anterior surface of the organ. These crossed fibres follow, therefore, precisely the Z-like direction described by M. Deville. M. Helie, however, regards the crossings as far from constant, besides being limited to very few fibres ; the greater number of the looped ones beginning and ending upon the same side without crossing the median line. The loop-like fasciculus is almost never limited to one plane only. It is always thick upon the posterior surface of the uterus, sometimes, though rarely, forming a single plane. At other times, and most commonly, its fibres are divided into two planes separated by a layer of transverse fibres, the superficial layer being then thin, and the deeper one much thicker. Let us study next those transverse fibres which, witli the preceding fasciculus, form the surface of the body of the uterus. They constitute the greater pari of the external muscular layer, and contribute to the formation of the loop-like fasciculus as already stated; the greater part, however, being foreign to its formation remain upon the median line, passing below it and between its two layers, sometimes even upon its superficial posterior layer. They go from one side to the other, extend outwardly into the broad ligaments, and especially into the ligament of the ovary, the round ligaments, and upon the Fallopian tubes. If we follow them in the opposite direction, they may be said to proceed from all these points, and after reaching the sides of the uterus to divide into two layers, one of which passes upon the anterior, and the other upon the posterior surface of gan, the uppermost covering the fundus and making arch-like curves upoD f ,he anjrles. ORGANIC CHANGES DURING PREGNANCY. 1 13 Via. 47. O T Some of the fibres leave the external layer ami pass into the middle cne. It should be observed that the anatomists who have studied the muscular structure ?f the uterus have failed to treat of the sides of the organ, mentioning only those fibres which extend to its annexes; an omission which M. Helie has supplied. If the two layers of the broad ligament with the muscular fibres distributed to it be separated, trans- verse muscular fibres going from one surface to the .other, are per- ceived throughout the entire ver- tical extent of the sides of the uterus At the sides of the uterus, these fibres are so curved as to reach the surface opposite to the one from which they took their departure. Such at least is their T general arrangement, though their course is a very complex one. They separate to afford passage to the vessels, and do not keep to their primitive plane throughout their course. Thus in front they are superficial, but are more deeply situated behind, and vice versa. Above, and on a level with the Fallopian tubes, the fibres of the sides of the organ are arranged still differently. The transverse ones which describe large curves upon the fundus from one angle to the other, descend and curve ag^in -;pon the sides of the organ. A portion of these go to the Fallo- pian tube, and to the round and ovarian ligaments, the major portion, however, descend upon the sides of the uterus. In their descent they meet the vessels which interrupt their regularity, then they { ass more deeply and curve forward or backward to become transverse upon one surface or other of the organ. In the neck, the arrangement of the fibres is more simple, for no trace of the loop-like fasciculus is found. Almost all the fibres pass somewhat obliquely down- ward from the sides of the uterus toward the median line, where they interlace with similar fibres from the opposite side. They pass upon the sides (if the neck and curve round from one surface to the other in the same way as on the body, the most superficial passing outward with the vesico-uterine and recto-uterine folds, as also with some fibres of the bladder, and still lower with the muscular fibres of the vagina. Internal Layer. — When the uterus of a woman deceased just after delivery is Opened, the muscular fibres of the body are found deprived of tin' mucous membrane which had covered them, and which had been transformed into the decidua. As the mucous membrane had not undergone this change in the neck, it there still covers the muscular fibres, and is closely united to them. When the uterus is opened by incision, the middle of the posteriorwall is found to present uniformly a slightly projecting triangular fasciculus, the base of which extends from one Fallopian tube to the other, whilst the apex reaches t" the interna! on (he neck. Second plane of the anterior muscular layer. A. Superficial layer divided and folded over upon the side* of the uterus. B. Deep layer of the loop-like fasciculus C. Transverse fibres emerging from the loop-like plexus. D. Fibres of the neck. 0. Ovary. It. Rectum. T. Fallopian tube. V. Bladder. 144 PREGNANCY. B This triangular fasciculus is funned as the loop-like one: of horizontal fibree which curve suddenly upward, and what is singular, the new fibres which reinforce it are always added to its left side, whilst from its right side fibres successively emerge which become transverse by passing to the right side of the womb. These fibres have precisely the form of the letter Z. In approaching the Fallopian tubes, the triangular fasciculus divides into two small thin ones, of which one on each side has its acute point inserted into the corresponding Fallopian tube, where it suddenly comes to an end. Finally, transverse fibres extended di- rectly from the orifice of one tube to the other, complete the triangular fasciculus by forming its base. (D. Fig. 48.) A precisely similar triangular fasci- culus exists upon the anterior wall, with the single difference that the transverse fibres whilst curving to a vertical direc- tion enter its right side, whilst from its left side fibres emerge which assume a horizontal direction in order to reach the left side of the womb. Upon the sides of these triangular fasciculi, throughout the whole vertical extent of the body of the uterus, the muscular fibres of the internal layer have a transverse direction, and pass from one surface to the other. As they approach the middle of the anterior and posterior walls, some undergo an in- flexion to form the triangular fasciculus, whilst others in much greater number pass beneath it, and continue their trans- verse direction. At the internal orifice of the neck the transverse fibres form a projecting fasciculus, which defines sharply the cavity of the body and that of the u°:k. At the fundus of the uterus, that is to say, above the orifices of the Fallopian tubes, the muscular fibres form arches directed from before backward, which con- stitute the vault of the cavity. Descending thus upon the anterior and posterior su! faces, they pass beneath the transverse band of the triangular fasciculus which covers them, and finally curve and become blended with the horizontal fibres. At the orifices of the Fallopian tubes, the fibres of the internal layer are dis- posed in concentric rings; the smaller being in contact with the orifice, whilst the larger, often imperfect, are continuous with the arches of the vault, touching back to back those of the opposite side as described by Madame Boivin. At the neck, it is necessary to remove the mucous membrane in order to see dis- tinctly the muscular fibres. It is then evident that the projection of the arbor vitce is formed by muscular fasciculi whose fibres separate on each side to form superposed arches. Near the external orifice the fibres of the neck are almost all annular and interlaced. Middle layer.—- When the progress of the dissection has removed successively the loop-like' fasciculus and the different planes of transverse fibres which compose the external layer, the middle layer, presenting an entirely different arrangement, is reached. Internal muscular layer. (Anterior wall.) A. Section of the uterine walls. B. Triangular Fasciculi. C. Fibres passing to the Fallopian tubes. D. Openings of the Fallopian tubes. E. Transverse libres. V. Vagina. ORGANIC CHANGES DURING PREGNANCY. 145 Between these two layers, however, there is no precise line of demarcation, the Jeep fibres of the external layer assuming gradually the arrangement peculiar to the middle layer. Therefore, only after the removal of tliese intermediate laminae, can the middle layer with all its peculiarities be clearly distinguished. The same observation applies to its exhibition by the entire removal of the deep layer. The middle layer, first indicated by the great number of vessels which it con- tains, is always thicker in the part corresponding to the insertion of the placenta. It is composed of bands of variable width, crossing each other in all directions, some being transverse, others oblique, and some again longitudinal. Large orifices traversed by the veins or sinuses separate these bands from each other or even the fibres of the same band. The muscular fasciculi are curved in loops around the uterine veins, each loop being crossed by another forming with it a complete ring which surrounds the vein ; a succession of rings forming a canal for the vein. Large rings produced in the same way inclose several veins, each of which has its special rings within the principal one. Most frequently, the loop-like fasciculus forms but the half or two-thirds of a circle, another fasciculus completing it by crossing its extremities, at the same time becoming closely attached to them. Each vein is therefore surrounded by annular contractile fibres, and traverses a true contractile canal in its course through the middle layer. The arteries, like the veins, are surrounded by muscular rings, with this difference, however, that the arteries are free within the rings, whilst the veins, reduced to their internal membrane, adhere to the muscular fibres. According to M. Helie, the middle layer is found only in the body of the uterus and is absent in the neck. The latter, therefore, is formed simply by the super- position of the external and internal layers.] 4. Vascular Apparatus. — Towards the end of pregnancy, the uterus ex- hibits an astonishing development of its vascular system. My friend, Dr. Jacquemier, has for fifteen years paid much attention to this subject ; the results of his labor as found in his work are important, and from them I draw largely. "In studying the development of the vascular system in its whole extent, we shall find," he says, "that the augmentation in the size of the arteries only becomes considerable as they approach the uterus. Whilst advancing between the peritoneum and the external face of the organ, and before giving off their first divisions, they dilate and swell up, and then they furnish branches to the anterior and lateral parts, which ramify ad infinitum; they are not situated immediately below the peri- toneum, but are separated from it by a delicate layer of muscular tissue. All these ramifications anastomose freely and penetrate through to the internal surface, where they generally terminate ; but a large number of those, corresponding to the placental insertion, traverse the mucous mem- brane and enter the placenta. The ramifications of the arteries are con tinuous with the capillaries, which in their turn give origin to the veins. That the capillary vessels become enlarged during pregnancy has been proved by Virchow ; and Jacquemier found that they wore more readily injected than capillaries are under ordinary circumstances. This fact ex- plains the activity of the uterine circulation, as also the rapid and profuse discharge of blood from the arteries into the sinuses. If the venous trunks be examined, from the point of quitting the uterus to their terminations in the hypogastric vein and in the vena cava interior. a groat increase in capacity will be noticed for the ovarian veins are 10 146 PREGNANCY. almost as large as the external iliaes, and the uterine are hut little less, In the substance of the womb, the venous system presents itself as a series of canals, situated in the centre of the muscular tissue, at nearly an equal distance from the internal and the external faces: at this point, the uterus is traversed by a great number of canals coming from all directions, which anastomose, and form large sinuses at their junction ; the whole constituting a giand plexus, several divisions of which are large enough to receive the extremity of the little finger These canals are much larger opposite the insertion of the placenta than elsewhere, and they diminish in size as they recede from it. There is a certain portion of the uterine walls, determined by the placental insertion, where the venous canals of the uterus traverse the mucous membrane in order to be distributed to the placenta. (See Decidua and Placenta.) There, in the thickness of the inter-utero placental decidua itself these vessels form, through an enormous dilatation of all their branches, the large sinuses which exist at the aiherent surface of the placenta. These sinuses communicate so freely with each other as to form, so to speak, a pool of blood, divided up by numerous partitions. A proportionably small num- ber of orifices exist at intervals, through which this reservoir of blood communicates with the sinuses of the muscular walls. When the after- hirth is detached, the whole placental surface of the uterus is found to be riddled with holes, which look as though they had been made with a punch. These orifices, which are oblique, like the section of a quill in making a pen, close of themselves through the depression of one of the membranous lips of the opening against the other. (See Placenta.) When we come to treat hereafter of the decidua, we shall find that the arrangement of the vessels of the mucous membrane properly so called, undergoes changes during the course of gestation ; the vascular network of the internal surface, which Is highly developed in the early stages, show- ing signs of a commencing atrophy at the end of the second month, and diminishing to vessels of very small calibre by the end of the pregnancy. A very delicate yet distinct web of areolar tissue envelops the uterine arteries. The veins, on the contrary, have only their internal coat, which adheres intimately to the muscular substance, and no valves are found in their interior. So great an enlargement of the arteries and veins must be due to some- thing more than a mere unfolding, since they preserve their flexuosities which are increased rather than diminished. They must, therefore, undergo a change analogous to that which takes place in the fleshy tissue of the organ. From what has been stated, it is evident that the blood flows to the uterus in very large quantities, and consequently its nutrition is augmented, for such an amount of blood must certainly contribute to the growth of its walls. But the question then arises, is the circulation much more active, as many authors have thought? In reply, it would appear from the late researches of M. Jacquernier, that the venous circulation especially must exhibit an unusual slowness, but I confess the reading of this last part of his memoir has nol convinced me on that point. (See art. Hemorrhage.) ORGANIC CHANGES DURING PREGNANCY. 147 The lymphatic vessels also accmire a very considerable calibre and form several planes in the uterine substance, the superficial of which are the most developed ; they divide into two groups, those of the neck, which run to the pelvic ganglia, and those of the body, going to the lumbar ganglia. The hypogastric absorbent trunks, according to Cruikshank, who has described and figured them, are as large as a goose-quill, and the vessels themselves so numerous, that, when injected with mercury, the uterus appears to be a mass of lymphatic vessels. A common dissection, made a few days after delivery, will afford convincing proofs of their volume and number. 5. The nerves of the womb have, of latter time, been the subject of numerous researches, among others, by Drs. Robert Lee, Jobert, Rendu, and Boulard. Agreeably to the latter anatomists, whose conclusions closely correspond with those of the English accoucheur, the nerves are derived from three sources: 1st. From the ovarian plexus — few in number, and distributed to the angles and fundus uteri. 2d. From the hypogastric plexus — these are specially destined to the neck; and 3d. Some filaments of the great sympathetic, which accompany the uterine arteries, and are apparently lost upon the neck and lateral parts of the womb. Among the filaments constituting the ovarian plexus, there are a few which seem to follow the course of the blood-vessels passing near the ovary, and reaching the border of the uterus at its superior part. The filaments then penetrate into its substance along with the vessels, apparently for distribution to the muscular walls. The hypogastric plexus furnishes some nervous filaments as the urethra crosses its anterior part ; these nerves are few in number, and ascend along the lateral portions of the neck (but not following the vessels), giving off branches here and there which enter the uterine walls, but M. Rendu has not been able to trace them beyond the neck. These nerves differ essen- tially from the preceding, both in origin and distribution, for they come from a plexus whose branches are not distributed with the vessels, and which has frequent anastomoses with the sacral nerves or nerves of animal life. The whole body of the uterus, therefore, receives the nerves of organic life exclusively, whilst the nervous apparatus of the neck alone has com- munications with the spinal nerves. Like the lymphatic and sanguineous vessels, the nerves, according to some authors, undergo a considerable development during gestation. In the preparations exhibited by Robert Lee to the inspection of the Royal Society, and also in the two figures given by him, large nervous bands are seen below the serous tunic, and these bands are so voluminous that many anatomists have doubted their true structure, and regarded them as furnished by a gelatinous or cellular mem- brane, placed between the peritoneum and the muscular coat. Consequently, in accordance with this view, the uterine nerves do not form an exception, as was for a long time supposed, to the hypertrophy seen in all other parts of the organ during pregnancy — for they likewise are developed in every way, and return after the delivery to their normal size. (See, for further details, the memoir of Dr. Robert Lee, " On the Ganglia and the other Nervous Structures of the Uterus") It is generally admitted, however, thai the neurilema is the part chiefly affected by the hypertrophy. 148 PREGNANCY. The preparations deposited by M. Boulard in the Museum of the Faculty, and the works of Robert Lee, Ludovic Hirschfeld. and Riehet, have con- vinced us, that exceedingly fine filaments are prolonged even to the lowest parts of the os tineas, and, consequently, that no portion of the organ is entirely destitute of them. ARTICLE II. CHANGES IN THE PROPERTIES OF THE UTERUS. [Sensibility. — The sensibility of the uterus undergoes little alteration. It is well known that in the unimpregnated state the neck may be touched almost with- out the woman being aware of it, and it may even be cauterized without giving rise to definite pain. The same observation is almost applicable to the organ in the pregnant condition, so that it were wrong to suppose that its sensitiveness is much increased during gestation. The sensibility varies, however, with the cause which excites it; a forced distention, for example, seeming to us to give rise to considerable pain. To avoid exaggeration, it may be said that sensibility exists in the neck, but is obscure during as well as before pregnancy.] The body of the uterus appears to be even less sensitive than the neck. I am aware that most women feel the motions of the child, but are these movements perceived by the walls of the abdomen, or by the uterine parietes? The fact that in women affected with ascites, the active motions are much more obscure than in other females, tempts us to accept the former hypothesis. I have, besides, frequently known women to pass through the whole course of gestation without feeling the motions ; for instance, I saw a patient at La Charite, in August, 1839, who, although advanced to seven months, doubted her pregnancy because she had not felt the child stir. I saw her frequently afterward between this time and near the last of October, when her labor occurred, yet, although the child was quite strong and healthy, she had never observed its motions. [The body of the womb must not, however, be regarded as entirely insensible, for the contractions of labor or the introduction of the hand give rise to quite severe pain. We shall recur to this subject when studying the subject of the pains of labor. (See Phenomena of Labor.) Irritability. — Having treated of its sensibility, we have a few words to say of the irritability or organic sensibility of the womb, meaning thereby the vital activity peculiar to the. nervous system of the uterus, and other parts supplied from the same source.] This irritability is notably increased during gestation: to it is due the kind of sympathetic relation which is established between the fibres of the neck and those of the body of the uterus, and in consequence of which, any rather active and prolonged excitement of the neck of the organ reacts upon the fibres of the fundus. Even the premature expulsion of the foetus is often a consequence of con- tractions produced by excitations of the cervix, and it is owing to this cause, according to Delamotte, that repeated coition has frequently caused abortion. and that females who are used in our amphitheatres for practising " the touch," are so often delivered before term. This irritability of the cervix, and its influence upon the contractility of ORGANIC CHANGES DURING PREGNANCY." 14!) the body is in some cases turned to profit in the practice of our art ; thus it is well known, that one of the surest and most generally employed methods of inducing pr< .mature labor, consists in the introduction and retention of a foreign body in the neck of the womb. [Contractility. — By this is meant the power with which the fibres of the -womb are endowed of closing upon the body which it contains for the purpose of expelling it from its cavity. It is a true contraction, precisely similar to the muscular con- traction of all hollow organs, such as the bladder, rectum, or stomach. The power of contraction exists even in the unimpregnated condition, especially at the menstrual periods ; at which time, in exceptional cases, it gives rise to the severe pain experienced by those who suffer from dysmenorrhoea. During preg- nancy, the uterine contractility becomes more evident though still feeble and pain- less ; during labor only does it acquire its full energy, and is then productive of intense suffering.] The pain which, during labor, accompanies the uterine contraction, is usually very great in the human species, but does not exist at all in wild animals, and is only observed to a very feeble degree in our domesticated ones. As a general rule, the uterine contraction is not painful in the differ- ent species of animals, unless an accident or some disease renders a greater energy of action necessary on the part of the organ, and the pains then experienced by the female are altogether similar to those of women. If, therefore, the contraction is only painful accidentally, as it were, in animals and merely in consequence of a particular morbid condition of the uterine fibre, are we not justified in referring the pain in the human species to the same cause ? Now can this predisposition be the result of the refine- ments of civilization ? It would of course be impossible to prove this, but there are strong grounds, at least, for believing that such is the fact, when we reflect that our domestic animals, which, like ourselves, have been trans- lated from their primitive normal condition, often surfer much more during parturition than those in a savage state. This contractility resides in all the muscular fibres of the womb, both body and neck, though the great development of the muscular layers of the body causes the contraction to be most powerful in that portion. Its inten- sity is exceedingly variable in different females, being very strong in some, and scarcely existing in others; but its energy bears no relation to thai of the external muscular system, for some strong muscular women have extremely weak contractions during labor, and oftentimes the contrary is observed. The exercise of this function takes place independently of the will, at least in a great majority of cases, which indeed we can readily understand must be the fact, from the origin and nature of the nerves distributed to the body of the uterus, since we have just learned that its fundus receives filaments from the great sympathetic alone. I am well aware the books furnish some cases of women who had the power of suspending the contraction at will; but if the facts have even been well observed, they have failed perhaps to receive the most rational interpretation. In the eases related by Baude- Iocque and Velpeau, in which the labor ceased when the students were sum- moned to witness it and began again when these numerous observers retired, 150 PREGNANCY. the will had probably less to do than the imagination and modesty, with the alternations of retardation and acceleration ; for though the influence of the will may be reasonably doubted, it cannot be denied that moral disturbances appear to affect the contractility of the uterus; thus, a violent emotion has often sufficed to arouse it long before the ordinary term of gestation, and it is not at all uncommon for the contraction to diminish or disappear for several hours, or even days, under the operation of such causes. Dewees knew the pains to be suspended in this manner for two weeks in a woman who was greatly affected by his sudden and unexpected arrival. Betschler cites a case in which the pains were suddenly suspended by a violent tempest, so that the neck, though widely dilated, closed again, nor did the labor recommence until nineteen days had elapsed. Everv day, indeed, we witness a suspension of the pains for half an hour, and sometimes even for several hours, upon visiting women whose modesty is shocked by our presence. The exercise of this function is seldom of long duration, lasting for a few seconds only — rarely beyond one or two minutes, and then the organ which was so strongly contracted and hardened, gradually regains its primitive state, and remains in repose, until, under the influence of the same stimulus, it is again thrown into action. The organic contractility, like all mus- cular power, is expended by a prolonged exercise, and hence we can under- stand why the pains so often become at once more slow and feeble or even cease altogether after a prolonged labor. Lastlj r , opiates have a marked influence over them ; for by employing these preparations, we may suspend the uterine contraction nearly at will, for several hours during labor at term, and indefinitely, in a case of premature delivery or abortion. This contractility may be excited by natural, accidental, or artificial stimuli : thus, all the causes of labor constitute the first ; the second are those of abortion and premature labor ; and the third comprise all irrita- tion whatever of the neck or body of the womb ; as electricity, ergot, and, in a word, all the means employed when it is desirable to deplete the organ. On the contrary, it may be weakened by an over-distention of the uterus, by prolonged contractions, or vivid moral impressions. An observation of M. Brachet's might lead to the supposition that the contractility of the uterus would be weakened, or even totally destroyed, by lesions of the spinal marrow. Experiments upon animals have, besides, shown that complete destruction of the cerebro-spinal axis abolishes the senso- motor functions of the great sympathetic nerve. The uterus would, there- fore, be paralyzed in an experiment of this kind. It is, however, proved by numerous cases of paraplegia in females, as well as by experiments on ani- mals, that labor is in no respect impeded by alterations of the cord, that the uterus continues to contract, and that the want of action of the voluntary muscles is largely compensated for by the paralysis of those of the perineum, the slighl resistance of which renders the last stage of the fetal expulsion both more easy and rapid. This result might indeed have been anticipated from the known absence of all nerves of animal life from the body .if the uterus. The contractility of the uterus, like that of all the viscera of organic life, ORGANIC CHANGES DURING PREGNANCY. 15] is retain^ for some time after death, and thus serves to explain tne oeca sional expulsion of a foetus several hours subsequent to the decease of a mother, as also the posthumous contraction of the uterus in Csesarean opera- tions performed immediately after the mother has expired. [Retractility. — The term retractility seems both to myself and M. Pajot much preferable to that of contractility of tissue, by which it has often been designated. Retractility is a property in virtue of which the uterus, when relieved partly or entirely of its contents, subsides upon itself. It is a sort of elasticity, differing from contractility in being permanent and keeping the walls of the organ closely applied to the ovum, whilst the latter is intermittent and temporary. A principal office of chis retractility is that of closing the open orifices of the utero-placental vessel* after labor, which without it would give rise to mortal hemorrhage.] The retractility exists chiefly in the fibres of the body. Dewees supposed it to be seated more especially in the circular ones that constitute the internal plane of the uterine muscular layer, and it is scarcely observable at the inferior parts and in the neck. It was certainly a wise provision on the part of nature to place it in a region where the habitual attachment of the placenta causes a more considerable development of the vascular apparatus. This holds so true, that it is easy to detect the retracted fundus in the hypogastric region after delivery, as a hard, irregular tumor, whilst to the vaginal touch, the neck appears soft, flexible, and not the least con- tracted. Therefore, whenever the placenta is inserted on the neck, a hemor- rhage is not only to be dreaded during labor, but also at the time of, and for a short period subsequent to, the delivery of the after-birth. In most female-, the retractility accompanies the contractility, and these two properties are successively in action at the period of labor, and during the gradual deple- tion of the uterus. In fact, if after the contraction which has caused the expulsion of a certain part of the body inclosed in the uterine cavity, the walls of this organ did not retract promptly to fill up the void, it would constitute inertia of the womb. The retractility acts slowly and continuously, and is prolonged throughout the period of the getting-up. When it takes place in a regular manner, it is unaccompanied by pain, as we see in. the cases of many primiparous women, in whom the retraction is accomplished without their being aware of it. The retractility is not, however, always equal to this effect, at least during the first days after labor. Its insufficiency may perhaps be due to over- distention, or to a protracted or too rapid labor, in which cases the uterine fibre loses its elastic property, as Leroux expresses it, or else it may be that the presence of a foreign bod) - , whether solid or fluid, requires the interven- tion of a more active force. Here, then, the contractility is called into exer- cise, and the retraction of the uterus is effected by a true intermit tent and painful contraction. This diminution of the retractility is generally, however, of short lu rat ion, for after four or six days at the furthest, the contractility is no longer required, unless a new clot should happen to form in the uterus. The elasticity of the uterine fibres, assisted by the process of absorption, which goes on unceasingly, and also by the lochia! discharge, are thenceforth sufficient to restore the organ to its normal condition. 152 pregnancy. The retractility is far from being equally powerful in all women, nur is it always easy to give a good reason for the difference. For example, it is much less active in multipara? than after a first labor, and this explains why after-pains are much more common with the former than in the latter case, for the pains are a consequence of the exercise of the contractility, and the uterus returns more slowly to its habitual volume. Great over-distention of the womb, and a too rapid or too prolonged expulsion, also seem to diminish its action. If it be indisputable that there are circumstances which diminish the elasticity of the uterine fibres, it is also fully proved that we possess certain agents capable of exciting its action. Thus, external or internal irritations acting on the neck and body (such as cold or frictions), and the adminis- tration of ergot, often have this happy effect. ARTICLE III. CHANGES IN THE NEIGHBORING PARTS. We can readily imagine that the modifications just studied do not take place in the uterus without affecting the neighboring parts, and the changes in these will next engage our attention. 1. As the uterus gradually rises in the abdomen, its surrounding peri- toneum is carried along with it ; the folds, called the broad ligaments, then disappear, and consequently the Fallopian tubes and ovaries are drawn nearer to the body of the uterus, where they lie very nearly in a vertical direction; the fundus becomes rounded, its angles diminish and finally disappear. The Fallopian tubes, which in the unimpregnated state are inserted at the apex of the angles, and on the same horizontal line with the fundus, are no longer implanted upon the highest part, but correspond to the upper fourth, or even to the middle of the total length of the organ. The round ligaments are then composed of short linear fibres, among which a great number of muscular ones, prolongations of those of the uterus, and having the same contractility, may be distinguished. M. Velpeau asserts that he discovered and watched their contraction in three different females, during the efforts of the uterus to expel the after-birth. The greater devel- opment of the anterior than of the posterior wall of the uterus, removes the insertion of the round ligaments from the lateral position which they occupy in the unimpregnated organ, to a point so much farther in front, that they are implanted at about the union of the anterior fifth with the posterior four-fifths of the antero-posterior diameter. 2. As the womb and upper part of the vagina are intimately associated, the latter is necessarily shortened as the former enlarges in the early periods of pregnancy, whilst the vagina becomes longer when the womb rises above the superior strait. The venous system in the vaginal walls is considerably developed, owing to the greater activity of their circulation. This dilata- tion of the veins is, doubtless, the consequence of a greater vitality in the genital organs, but it is also due in part to the stasis of the blood, which is impeded in its course by the uterine development. The varicose stale, and the nodosities frequently encountered by the finger on the vulva and vagina towards the end of pregnancy (described OUliANIC CHANGES DURING PREGNANCY. 153 by M. Deneux under the name of thrombus), which certainly predispose females to hemorrhagic accidents, may probably be attributed to the same cause ; and this congestion even affects the capillaries , for otherwise it would be difficult for me to explain the livid spots or discolorations, resem- bling wine-lees, presented by the vaginal mucous membrane, aud to which attention has again been recently called as affording a sign of pregnancy. 1 But unfortunately this sign can only be serviceable in a medico-legal case, because in private practice very few females would permit such explorations. In practising the "touch," the finger frequently detects some arterial pulsations at the upper part of the vagina, though they are more frequently found on some point of the supra-vaginal portion of the uterus, and are evidently due to the great hypertrophy of the vaginal and uterine arteries. Doctor Osiander, of Gottingem attaches great importance to this as a diag- nostic sign, and has called it the vaginal pulse? It is not uncommon to find the mucous membrane of the vagina covered, about the seventh or eighth month, throughout its whole extent, with myriads of little pimples as large as a pin's head. These small granula- tions, which I have frequently met with, always coincide with a marked increase of the vaginal secretion, and have given rise to the term granular vaginitis of pregnant women. The vaginal mucosities are always secreted abundantly during preg- nancy, but the time of their appearance is very uncertain. Usually, how- ever, they are more copious in the advanced stages, and the women then say, "they are losing the milk;" an opinion unworthy of refutation. In some, this flow appears in the early months, then ceases, and again reappears several times ; though perhaps not at all, or else only at a very late period. 3. The bladder is gradually pushed above the superior strait, the meatus urinarius is drawn out and elongated, and its orifice, from being so high up, is concealed behind the border of the symphysis pubis, thereby rendering the introduction of an instrument very difficult. The urethral canal is more curved than usual, and the curvature is sometimes so great that the male catheter can more readily be used ; because the bladder being strongly pushed forwards, and above the pubis, by the developed uterus, draws this canal upwards, and causes it to be applied against the posterior face of the pubic symphysis, thus producing a curvature of the urethra having its con- cavity in front. Lastly, as the upper part of this canal is compressed by the enlarged womb, the circulation in its inferior parts is impeded, and the whole tube becomes greatly tumefied. It is placed behind the osseous pro- jection produced by the posterior part of the articular surfaces of the pubis, and these two superposed eminences form a considerable tumor in the 1 This discoloration is evidently owing to the greater activity of the circulation in the genital organs, and consequently it ought to be met with in all cases predisposing to a vascular congestion of the genito-urinary apparatus. Mr. Montgomery has de- tected it in a female at the menstrual period, and it is a well -known fact, that cattle- breeders ascertain whether an animal is in heat or not, by exnmining the orifice and internal surface of the vagina, which is almost as black as ink under such circumstances 2 'flic hypertrophy of the vessels of the vagina and of the vulva sometimes renders wounds of these parts very dangerous. Profuse hemorrhage lias been known to occur ?: ■ :k', J/ ;/;lil!0- s ■ % i f ^3| , A. Nipple. B. Sebaceous tubercles scattered over the surface of the true areola. C. Spots of the dotted areola. D. Markings due to distention of the skin.J | Here and there on the surface of the areola we find small elevations of about one-sixteenth to three-sixteenths of an inch, due to an hypertrophied condition of the twelve or twenty sebaceous glands already described. When they are pressed, a whitish fluid escapes which has been mistaken for milk. Toward the fifth month, another areola, known as the secondary, spotted or dap- pled areola, is formed around the first one. It extends much farther than the first one, often covering a large portion of the skin of the breasts. When this spotted areola is examined closely, we observe that the pigmentary coloration does not cease suddenly at the circumference of the true areola, but that the coloring matter is so deposited in the adjacent skin as to form a vanishing layer of greater or less extent in different women. This secondary areola is sprinkled with a considerable num- ber of small white spots which give it a peculiar appearance. The spots, which have a rounded form, are merely so many points devoid of pigment, each one exhib- iting in its centre a small black spot which marks the orifice of a sebaceous gland and the position of a minute hair discoverable by the assistance of a magnifier.] These changes usually persist during lactation, though when the woman does not suckle her infant they diminish after delivery, but do not wholly disappear. Consequently, they are more conclusive in primiparse than in others ; and although we must not always anticipate their existence in preg- nancy, yet, whenever they are fbu,nd, they constitute an almost certain sign of that condition. (See Diagnosis of Pregnancy.) ARTICLE V. [iNATOMICAL AND FUNCTIONAL CHANGES OF PARTS NOT IMMEDIATELY CONNECTED WITH THE GENERATIVE FUNCTION. The entire organism is deeply affected by the pregnant condition. Of the changes observable some are purely physiological and compatible with excellent health, whilst others are pathological. Although indispositions and diseases so often fall to the lot of the pregnant female, it were an exaggeration to say that pregnancy ifl a disease of nine months duration. Some women are never better than when p-egnant, in which case it is eminently a physiological condition. ORGANIC CHANGES DURING PREGNANCY. 157 Although it is difficult to draw the line between these two orders of phenomena we have nevertheless endeavored to indicate it as clearly as possible, and in this intent shall study at present only such anatomical and functional changes as are observed in healthy pregnant females, leaving all that is pathological for discussion in another part of the work. \ 1. Digestion. Nutrition. The digestive organs are almost always affected by pregnancy; but to those functional changes which are familiar to all, we shall add a description of some anatomical alterations of more recent observation. Disturbances of Digestion. — Sometimes immediately after impregnation has taken place, the digestive function indicates by unmistakable signs the impression pro- duced upon it thereby. We may adopt Professor Pajot's very natural classification of these changes, namely, stimulation, depression, disorder, and perversion. Stimulation of the digestive function, says this author, is the least frequent of these classes, though it sometimes occurs. The appetite is then greater, digestion easier, the circulation quicker, the face of a fresher color, and the mucous mem branes redder. Depression of the function is much more common, and is indicated by some emaciation, pallor, and alteration of the features. These are often followed by disorder and perversion of digestion, vomiting being the most noticeable phenomenon of all. Although the latter classes are so commonly attendant upon the pregnant condition as sometimes to have a real diagnostic value, they ought nevertheless to be regarded as diseases, and studied as a part of the pathology of gestation. Fatty Condition of the Liver. — The liver is found to be increased in size in almost all women who die during or shortly after labor. It was this fact which first drew my attention to this organ, and led me to the discovery of the fatty condition described in my inaugural thesis. The following is a brief statement of the facts concerning it. The color of the hepatic tissue is not uniform, its substance being sprinkled with minute yellow spots so numerous as to give it the appearance of granite. The spots also seem to form so many projecting points, of a size varying from that of a pin's head to that of a millet-seed. Sometimes they are disseminated, at others aggregated, forming in the latter case little insular patches, though sometimes the agglomeration is such as to give rise to a yellow spot of an inch <>r more in diameter. This appearance is not limited to the surface of the liver, but will be found in any section made through the substance of the organ. A microscopic examination of this tissue, made in connection with Dr. Vulpian, exhibited hepatic cells in good condition mingled with an abundance of fat globules. A fatty condition of the liver in pregnant women is therefore well determined, although its causes and significance are, as yet, but little understood. \ 2. Circulation. Throughout the period of pregnancy, but especially during the latter half, the fzeneral circulation becomes more active; an activity which modern research has shown to be connected with important changes in the composition of the blood and with hypertrophy of the heart. Changes in the Blood. — The conditions known as the plethora and hydremia of pregnant women have been successively admitted by the profession, but as they involve a question to be studied in connection with the diseases of pregnancy, we here confine ourselves to the statement, that both opinions, though perhaps excep- tionally true, are equally false in tin- majority of cases. Though the blood lit altered during pregnancy, we sec ii" reason for regarding the alteration as any- thing more than a physiological phenomenon. To MM. Andral and Gavarret is due the honor of having discovered the change? 158 PREGNANCY. which the blood undergoes during pregnancy, and their investigations have been followed up by Becquerel, Rodier, and Regnauld. As the experiments of all these observers coincide, we have but to give the results at which they arrived.] Now, if we admit with. MM. Andral and Gavarret, that the mean normal proportion of corpuscles is 127, or with MM. Becquerel and Rodier, that it is 141 for men and 125 for women, it will be seen that all the analyses made up to the present time give a much lower mean for a woman at an advanced stage of her pregnancy. Thus, of 34 bleedings examined by Andral and Gavarret, but one specimen exhibited, at the end of the second month, a proportion of corpuscles greater than the physiological mean, namely, 145. In one only, pregnant between one and two months, did the corpuscles reach the physiological standard of 128. In all the remaining 32 cases the corpuscles were below this point, ranging in 6 cases from 125 to 120, and in the other 26, from 120 to 95. The 34 bleedings gave different results as regards the fibrin, the mean physiological proportion of which is 3, according to the period of pregnancy at which the blood was drawn. Thus, from the first month to the end of the sixth, the amount of fibrin was always below the average ; the mean being 2-5, the minimum 1*9, and the maximum only 2 - 9. During the last three months, on the contrary, the proportion of fibrin exceeded the physio- logical average ; it was about 4, the maximum reaching 4'8. Toward the end of the last month, the average is 4*3. MM. Becquerel and Rodier analyzed the blood of nine pregnant women, two of whom were 20 years of age, two 22, one 25, one 27, one 29, one 34, and one 41. Five of these were of robust constitution, two were about the average in this respect, whilst the other two were weak and apparently lymphatic. Six enjoyed excellent health, two were not so well, and one was in the hospital on account of indefinite pains in the abdomen, and a cough of rather long standing, though not serious in character. One was 4 months pregnant, four 5, one 5 J, one 6, and two 7., The following represents the average composition of the blood, at least as regards its principal elements : — Corpuscles, Fibrin, Albumen, (The average in ncn-pregnant women is 70-5.) Water, . . . .801-6 (The average in non-preguant women is 791-1.) My colleague and friend, M. Regnauld, has the following table in his thesis, and I think it so important that I give it entire: — Average. Maximum. Minimum. 111-8 127-1 87-7 3-5 4- 2-5 66-1 68-8 62-4 ORGANIC CHANGES DURING PREGNANCY. 159 Table showing the Composition of 1000 Parts of Blood from 25 Women at various Stages of Pregnancy. s S a O J£ STAGES OF PREGNANCY. a g 3 a £ a £ s p u o U 2 I "3 ~ CO Water and v 1. 2d month, .... 20 2-60 70-50 1 25-35 11-75 789-80 2. End of 2d month, 21 2-80 70-18 126-40 9-30 991-32 3. 3d month, 32 2 70 67-30 122 60 10-20 797-20 4. 3 months, 27 1-98 70-25 126-22 8-65 792-60 5. 3 months \, 18 2-90 68 09 116-91 11-40 800-70 6. 4 months, 39 2-40 69-35 12718 10-50 790-57 7. 5 months, 31 2-43 69-40 123-90 8-75 795-52 8. 6 months £, 29 2-80 68-85 99 76 10-50 818-09 9. 7 months, 27 3-25 69-20 120 40 7-90 799-25 10. 7 months, 35 2-79 6830 107 92 9-75 811-24 11.7 months, 22 3-20 68 66 118-40 1020 799-54 12 7 months h, 23 416 69 18 9941 8 43 818-82 13. End of 7th month, 19 330 6907 112-50 965 805-48 14. End of 7th month, 25 2-78 65-43 100 77 10-20 820-82 15. Beginning of the 8th month, 29 3-31 6618 115-44 9-43 805-62 16. Beginning of the 8th month, 38 3-74 64-92 9936 11-20 820-78 17. Beginning of the 8th month, 20 4-16 67-20 103-10 9-50 815 74 18. 8 months £, . 22 4-47 66 82 95-60 10 95 82216 19. 9 months, 25 3-70 68-25 108 90 9-85 809-30 20. 9 months, 24 4-89 65-47 91-40 10-75 827-49 21. 9 months, 33 4-42 66-38 115-25 9-24 804-71 22. 9 months, 27 3-69 64 45 90-20 10-40 881-26 23. 9 months, 25 4-39 65-80 94-90 11-65 823 36 24. 9 months, 28 3-86 68-92 102-80 9-96 814-46 25. 9 months, 26 4-28 66-27 99-75 9 80 819-90 The table shows, evidently, that, conformably with the results already men- tioned : — 1. Corpuscles. — From the beginning of pregnancy, the proportion of cor- puscles is sensibly diminished ; but that, though the diminution is small for the first five or six months, since it yields an average of 121 '04. it is some- times considerable in the second half, and especially at the end of gestation, at which period the average is 104 # 49. 2. Fibrin. — The proportion of fibrin is not increased in the blood of pregnant women until about the sixth month, but from that time it increases until delivery. 3. Albumen. — Like MM. Becquerel and Rodier, M. Regnauld found a decrease of albumen, which is lowered from 70 - 5, the physiological standard in the non-impregnated condition, to 68*6 in the first seven months, and to 66*4 in the two last. 4. Water. — The proportion of water in the blood increases sensibly towards the end of the ninth month ; thus, the average of the first thirteen analyses, corresponding with the first seven months, is expressed by 81601. and that of twelve bleedings performed during the two last, by 817'70. 160 PREGNAXCY. We would also add with M. Regnauld, that not only is the serum more abundant relatively to the fibrin and corpuscles, but that it contains less solid matter, which of course helps to increase the total amount of water contained in the blood. [If the blood of a pregnant female be examined by the usual mode of bleeding, h contracted and buffy clot is sometimes obtained, all readily explained by the increase of the fibrin. Still, this appearance is less frequent than has been asserted, and than one might be led to suppose would be the case. Out of nearly two hundred bleedings practised at an advanced period of gestation, M. Jacquemier discovered the buffy coat but once in six, and even then its thickness was very slight. The same author also observed that most of the women whose blood was buffed had fever, and that but few were free from any apparent disease. The increase of fibrin in pregnant women continues for a certain time after de- livery. None of these facts should be forgotten whilst studying puerperal diseases, for without them one would lie liable to explain the excess of fibrin by the inflam- matory nature of the disease, whilst it is only the expression of a transient physio- logical condition. The causes of all of the changes in the blood which we have just studied elude our research. It does not seem to us, however, unreasonable to suppose that the increase of fibrin, by rendering the blood more coagulable, may have a tendency to lessen the hemorrhage which always accompanies delivery. We shall, however, have occasion to revert to this subject.] Hypertrophy of the Heart. — M. Larcher, long ago (1828), called atten- tion to hypertrophy of the heart as a result of pregnancy; and quite recently, in a paper read at the Academy of Sciences, produced new observations in support of his opinion. According to him, the walls of the left ventricle become at the least one-quarter, and at the most one-third, thicker during the latter months of pregnancy or shortly after delivery ; the right ventricle and the auricles preserving their normal thickness. He considers this the cause of the precordial murmur so common during gestation, and the con- sequence of the obstruction to the flow of blood towards the lower extremi- ties, occasioned by the development of the womb. [Numerous observations by M. Blot, confirm those of M. Larcher which have just been mentioned. He proved their correctness both by measurement, which is always very difficult, and by weight determined with the greatestcare. The results, which he has obligingly put in my possession, are as follows: The total average weight of the heart in 20 cases of puerperal women was about 9 oz. 38 gr. tr., whilst in the usual state the heart of a young woman weighs but from 7 oz. to 7 oz. 2 dr. tr. It would thus appear that the organ gains more than one-fifth upon its total weight during pregnancy. This hypertrophy affects the left ventricle almost exclusively, and is remarkable for being temporary like the hypertrophy of the uterus. (II. Blot.) | 3. CnANGES IN THE URINE. The urine undergoes great alteration during pregnancy — so that, beside glyco- suria, which will be studied in connection with the phenomena observed after delivery, ami albuminuria, which properly belongs to the diseases of pregnancy, we have now to treat of kyesteine whose presence in the urine appears to be a result of the oregnant condition.] ORGANIC CHANGES DURING PREGNANCY. 161 Kyesteine. — For several years past the attention of a number of physicians das been directed to the peculiar phenomena exhibited by the urine of pregnant women. Thus, M. Nauche, and after him, Messrs. Eguisier and Tanchou, in France, Dr. Letheby (London Med. Gazette, December, 1841), and Mr. Stark (The Edinburgh Med. and Surg. Journal, January, 1842), in Great Britain, and Dr. Elisha Kane, in America {Am. Journal of the Medical Sciences, July, 1842), have submitted the result of their observa- tions to the public, after arriving at the conclusion that pregnancy may be detected by the inspection of the urine alone. This question, however, is not of such recent origin as many seem to believe, for several of the ancient authors, Avicenna in particular, had previously described the characteristics of this fluid in gestation, and their writings frequently exhibit a special attention to the subject. But we may add, that their observations were far less precise, and, in fact, had become altogether forgotten, when M. Nauche undertook his researches. We shall now present the principal results which have been recently obtained. If the urine of a pregnant woman be received in a wineglass, and then be permitted to settle in a light, airy place, the following peculiarities will be observed: When first excreted, the urine is acid, whitish, somewhat clouded, and of a nauseous odor; frequently little white corpuscles, readily distinguishable by a glass, are held in suspension, but, in a few moments, these subside in the form of cloudy flakes, either on the bottom or sides of the glass, the urine meanwhile becoming more limpid and transparent. Agreeably to the observations of Dr. Kane, this primary deposit does not always occur, nor is it peculiar to the pregnant state, for it cannot be dis- tinguished from the mucous deposits so often seen in the ordinary urine. No change is visible on the surface during this period, but, in the course of eighteen or twenty-four hours, a number of small, brilliant, crystalline granules, irregularly isolated, appear there, in numerous cases ; and in some instances, these granulations unite so as to constitute a thin, trans- parent, and iridescent layer, which is only visible in certain positions. The urine remains in that state for several days, though it soon begins to manifest the peculiar signs of gestation; thus, upon the second day, or during the course of the third, according to M. Eguisier, sometimes sooner, but rarely later, its transparency diminishes, the original clouded appear- ance returns with increased intensity, the odor becomes stronger, and a pellicle may be discerned forming, at first like a nebulous streak, but soon acquiring larger dimensions. All of these characters are more evident on the third and fourth days, and some small debris fall from the pellicle to the bottom of the glass. By the fifth or sixth day the pellicle is almost entirely destroyed ; its debris precipitate and form a white crust upon the sediment. It is, however, replaced successively by new pellicles less white than the former, and studded with minute brilliant points having a crystal- line lustre; a greenish tint also supplants the milky appearance. In the succeeding days, as the evaporation of the urine progresses, its turbidity and green color increase; putrefaction commences, and the second pellicle is destroyed to give way in its turn to a third, which resembles more or less that which putrefaction engenders upon ordinary urine. 11 lUl? PREGNANCY. Dr. Kane, who has ohserved these changes almost hourly, furnisnes the following account of their progress: The pellicle appears at a variable period ; I have seen it sometimes at the end of thirty-six hours — at others, as late as the eighth day; it is scarcely perceptible at first, but soon a light cloud of a milky or bluish-white appearance is seen at the centre or sides oi the glass; at the beginning, in some cases, it is uniformly deposited on the surface, constituting there a transparent layer, which becomes more and more distinct; at other times, it is not so well characterized in the early , presenting only a tew striated, irregular circular lines, resembling a web, but these strire become condensed, and about the fifth day are resolved inio a true pellicle. It now presents a creamy, opaline layer, of a light- yellow color, which grows thicker and thicker; its external surface is rendered unequal and ragged by the presence of small granulations, which are whiter in color and crystalline. The pellicle then resembles the layer of fat that floats on the surface of cold broth, and it retains these characters for a long time. On the subsequent days, the sides of the glass are covered with small whitish streaks, varying from a line to a fourth of an inch in extent, which attest the descent of the pellicle during the evaporation. The pellicle, especially when thick, gives off a strong cheesy odor, accord- ing to Dr. Bird, and thus facilitates the diagnosis ; but Dr. Kane has verified this observation in only seven cases out of twenty-five, and he has not remarked that any relation exists between the thickness of the pellicle and the intensity of the odor. After standing for several days, the pellicle seems first to give way at the centre, and fissures extend, somewhat later, from this point toward the cir- cumference. Gradually, small particles separate from the debris and fall to the bottom of the glass; the pellicle thus diminishes in thickness, but it seldom disappears altogether before the putrefaction of the liquid takes place; and the primary deposit at the bottom is thus increased by all the detached portions of pellicle, which gradually settle down. The substance forming the pellicle lias been denominated kyesteine (from xwjoii, bcos, gestation i, by M. Nauche. The globules, held in suspension when the urine is excreted, gradually aggregate, mount to the surface, and con- Btitute the pellicle above described. This pellicle rarely fails to develop itself in the urine of pregnant women ; thus, for instance, in eighty-five cases examined by Dr. Kane, it appeared in sixty-eight with all its charai teristics, in eleven it was not well marked, and in six only it failed to appear. One of the last six had a mammary abscess, and was con- valescent from typhoid fever ; another was very much enfeebled by pre- vious hemorrhages, and only four could be regarded as true exceptions to the rule. Without denying the existence of the modification which we are studying, 1 cannot accept the opinion of the American accoucheur in regard to the frequency of its occurrence. With the view of determining this point, I have examined the urine of a great number of pregnant females, and I can v, that, although it did present the characters indicated in a certain Dumber of cases, yet very frequently, and especially in the later months. nothing of the kind was discoverable, ORGANIC CHANGES DURING PREGNANCY. 163 I confess, also, that were I to depend upon the result of my latest inves- tigations, I should be inclined to regard the existence of this pellicle as altogether exceptional in the last six weeks of gestation ; for I have exam- ined (September and October, 1849) the urine of fifteen women without observing it. I do not, however, forget that I have, in former years, proved the correctness of the observations of my predecessors, and I am unable to explain this difference in the result of experiments performed in absolutely the same manner. Can it be due, as M. Regnauld supposes, to the preser- vation of its acidity much longer than usual, instead of becoming alkaline within two, three, or four days, as is customary? I acknowledge that my attention was not directed to this point. The urine of healthy women who are not pregnant, exhibits nothing similar to this, and if at any time it furnishes a pellicle, it has not the dis- tinctive characters of kyesteine. Some years ago, it was my custom to ex- amine comparatively the urine of non-pregnant females, which I placed in the same kind of vessels, and under the same conditions of temperature and atmospheric exposure ; and every time that I met with kyesteine in the urine of pregnancy, that of the other woman presented nothing similar. In certain pathological conditions, the urine is sometimes covered with a pellicle which might prove a source of error, though some authors have pretended to be able to distinguish it from that which is due to pregnancv. For instance, the pellicle which occasionally forms on the urine of persons laboring under phthisis, articular diseases, vesical catarrh, or a metastatic abscess, does not appear before the fifth or sixth day, that is, at about the period when putrefaction begins, and having once commenced, its develop- ment is completed in the course of a few hours ; whereas, the true kyesteine appears on the second day, is then developed but very slowly, and apparently quite independent of putrefaction. Again, this latter has a greater specific gravity than that produced by any pathological state whatever. According to the views of M. Regnauld, which we shall give shortly, it will be seen, that, inasmuch as it is due to the same cause, the pathological pellicle ought to present the same characters, and that writers have been deceived as to the value of the different signs just mentioned. The chemical characters of kyesteine will serve to distinguish it from all the mucous or albuminous matters found in the urine. These properties, agreeably to M. Eguisier, are nearly all negative; thus, it is neutral, in- soluble in alcohol, ether, water, and ammonia, and, unlike albumen, it is not soluble in alkaline fluids, nor, like mucus, in a mixture of soap and ammonia, neither in boiling alcohol and ether like fat. Further, the urine containing it will not coagulate by boiling, as albuminous urine does, but deposits a copious white powder on cooling ; nor will it coagulate by the addition of nitric acid. Kyesteine has, however, many of the properties of these substances; for, being evidently of an organic nature, it is precipitated by the deuto-chloride of mercury, by most strong acids, and the astringent solutions. Finally, in the present state of our knowledge, it must be regarded as a new sub- stance, which is considered by MM. Bonastre and Nauche as gelatino- albuminous. (Eguisier.) We shall find further on, that the researches of M. Regnauld tend to establish the contrary. 164 PREGNANCY. Although writers on the subject agree very nearly as to the physical and chemical properties of kyesteine, they differ widely in regard to its micro- ecopical characters. Thus, MM. Eguisier, Golding Bird, Kane, and Donn£ disagree as to the size, form, and number of the globules. M. Simon, who has very frequently subjected the pellicle to microscopic examination, gives the following as the result of his researches. It is found to contain the following elements: 1, an amorphous matter, formed of small opaque points; 2, numerous vibriones in active motion ; 3, crystals of ammoniaco-magnesian phosphate; 4, if the examination be made at a still later period, it will con- tain an abundance of monads. The most difficult point of the subject to determine is the following: To what is the presence of kyesteine in the urine of pregnant females to bo attributed ? After having endeavored to prove that it could not result from a par- ticular action in the kidney, from the functional derangement of the respi- ratory apparatus, from any modification whatever in the digestive action, or from the new functions of the mammary glands, M. Eguisier concluded that it must be owing to the passage of the amniotic liquor, or a part of its ele- ments, into the urine, and he thought that the two following propositions (which are more fully detailed in his memoir) proved the correctness of his conclusions in a satisfactory manner, namely : A. There is a continual exhalation and absorption going on upon the external face of the amnios, the products of which are removed from the organism through the urinary passages. B. The admixture of a certain quantity of the liquor amnii with the urine of a healthy person, not pregnant, confers upon it many of the properties of kyesteinic urine. The truth of this proposition being admitted, it readily explains, he says, 1, why the urine only begins to be charged with it at a period when the amniotic liquor is abundant enough for us to suppose that its passage into the urine would be appreciable ; 2, why the kyesteinic characters are not so evident at the end of gestation, a period when the liquor amnii is less abundant, or less charged with animal matters ; and 3, why they suddenly disappear after the evacuation of the waters. But Dr. Kane does not admit this explanation, plausible as it seems ; for he believes that the kyesteine is intimately associated with the lacteal secre- tion, and appears to attribute it to an admixture of milk with the urine. " In fact," he continues, " I have frequently proved the presence of kyesteine in the urine, at different periods of lactation, notwithstanding the formal proposition of M. Eguisier; for in forty-four nursing women, out of ninety- lour, the perfect kyesteinic pellicle was developed, with all the characters it exhibits during gestation ; and it was nearly always in those cases where the flow of milk is limited, or rendered difficult by some particular circum- stance, and in which the breasts were consequently more or less engorged, that kyesteine appeared in the urine; but it was found much more rarely whenever the mother nursed her infant, and her breasts were properly drawn. In a word," says Dr. Kane, "the existence of kyesteine during pregnancy, and even after the accouchement, up to the establishment of ORGANIC CHANGES DURING PREGNANCY. 165 the mammary secretion ; its rare existence during lactation, and its reappear- ance, when the latter is suspended or impeded, at the time of weaning, for instance, establish an intimate relation between the functions of the mamnue and the kyesteinic urine." Golding Bird, Simon, and Lehman entertain nearly similar views. An attentive study of the facts pertaining to this subject has led my colleague and friend, M. Reguauld, to the following opinion : Normal urine holds in solution a certain amount of azotized matter, originating, probably, in an incomplete combustion of albuminous sub- stances, which in the blood are transformed into uric acid, or, by a higher degree of oxygenation, into urea. Now we may readily assure ourselves, that during pregnancy there is a hyper-secretion by the kidney of an analogous, if not of an identical matter; and it is to the action of the air upon this azotized matter in its abnormal proportions, that the several phenomena before described appear to be due. The first cloudiness of the fluid is due to the separation of carbonate of lime, formed by the reciprocal reaction of the carbonate of ammonia, re- sulting from the decomposition of the urea, and of the phosphate of lime which already existed in the urine. In proportion as the decomposition giving rise to ammonia progresses, the fluid loses its acidity, until the bril- liant crystals of ammoniaco-magnesian phosphate, which are so readily recognized by microscopic examination, begin to appear upon its surface. It is singular, that whilst these reactions are going on, such a multitude of microscopic animalcules (vibriones) should be developed in the urine as to cause the whitish layer, when examined with a proper magnifying power, to seem composed entirely of them, in connection with crystals of ammoniaco-magnesian phosphate. In order to prove that the formation of the pellicle of which we are speaking is really due to the action of the oxygen of the air upon one of the elements of the urine, it will only be necessary to observe what takes place in two equal quantities of the same urine, one of which is exposed to the air, whilst the other is removed from its influence by being placed in an atmosphere of hydrogen, of carbonic oxide, &c. The first will present the characters described, whilst the other will exhibit no such phenomena. M. Reguauld does not regard these properties of the urine as due to a special matter contained in it, but as a consequence of the presence of an over-proportion of an element which is common to all urine; whence it seems reasonable to suppose, that this excess of azotized matter might exist under other circumstances, and then give rise to the same phenomena. The period at which the kyesteine appears in the urine of pregnant women, is stated by writers to be exceedingly variable. M. Eguisier says that the characters which we have described usually begin to show them- selves in the course of the second month, and acquire their greatest devel- opment from the third to the sixth month; after the seventh, they generally decline until the end of gestation, so that in the course of the ninth, and sometimes even of the eighth month, they are hardly more marked than in the second. M. Tanchou has observed them in women who bad missed 166 PREGNANCY. their courses but once. Dr. Kane saw them on one occasion before the fourth wetk, once before the fifth week, and often before the end of the third month. (Dr. Elisha Kane, American Journal of the Med. Sciences, July, 1842.) I think that the facts which I have observed, and the details which I have given, justify the following conclusions: 1. That the pellicle described by Nauche is not composed of a matter of new formation. 2. That it is due to an over-secretion of azotized matter which exists in email quantity in normal urine, and to the action of the atmospheric oxygen upon it. 3. That it is far from being always present at any period of the preg- nancy, and that it is very rare in the latter months. 4. That it may appear in certain pathological conditions, and then differs in no respect from that which is observed during pregnancy. \l 4. Osteophytes of the Cranial Bones. There is formed during pregnancy, and may be found after delivery, between the internal table of the bones of the skull and the external surface of the dura mater, a newly-formed product which is at first fluid, but grows gradually denser and finally ossifies, thus adding to the thickness of the cranial walls. At first it forms plates of a spongy tissue inclosed between two compact layers. At a later period the plates are no longer separate but unite so as to form a supernumerary bony arch covering the entire dura mater, but growing thinner as it approaches the occipital foramen to which it finally extends. M. Ducrest describes it as follows. I examined the surface of the cranium of 231 women who died in the puerperal state, and of these 90, or more than one- third, presented the osteophyte. The researches of M. Alexis Moreau, Interne of the Maternity Hospital, give a still larger proportion. Out of 40 crania, he found that 27 presented it to a greater or less degree. On the other hand, not one of 71 cases, 35 being male and 3G female, whose death had no connection with pregnancy, examined either by M. Cossy, hospital Interne, or by myself, afforded a single instance of the affection. To which then, of these three conditions (pregnancy, the puerperal state, or puerperal disease) can the production of the osteophyte be referred? Sixteen of the women who had it died between three and seventy-two hours after delivery, and in several of these the plates extended throughout the whole extent of the cranium, ami resisted the edge of the scalpel almost as much as the original bone. It were difficult to suppose that such extensive formations could have originated and acquired an almost bony hardness in so short a time as two or three days. As this objection applies equally to the puerperal condition and to the diseases of which the women died, pregnancy would appear to be the only cause of its development. (Ducrest. Theses de Paris, 1844, No. 12.) An anatomical alteration such as this, appearing under the influence of preg- nancy ami afterward disappearing, is certainly very curious. Though we may fail to determine its causes and importance, its existence is sufficiently proved. It had been, indeed, already described by Professor Kokitansky of Vienna, who also regarded it as peculiar to gestation and not as a pathological condition. { 5. Pigmentary Deposits We have already stated that the breasts acquire during pregnancy a much larker brown color. Other regions then also receive a deposit of coloring matter. Thus OF THE DECIDUA. 167 many -women will have on the median line of the abdomen a brown streak as dark as the areola, from the T ' s to the J of an inch in width, extending from the tnons veneris to the umbilicus, and sometimes even to the xyphoid appendage. This line, drawn as with a brush, as M. Pajot expresses it, is especially marked in brunettes, in whom, indeed, it is not uncommon to find the entire skin of the abdomen and of the upper part of the thighs of a deep bistre-like hue, and sprinkled with little white spots precisely resembling those of the dotted areola. The perineum also, and the labia majora almost always have a darker browr color during pregnancy. In connectic-n with these normal colorations, we might mention other spots which appear more especially upon the face; but as they appear to us rather of a patho- logical character, we defer their description to a later period.] CHAPTER III. OF THE DECIDUA. [The study of the decidua intervenes naturally between the history of the changes undergone by the maternal organs and that of the development of the ovum. It is now admitted that the decidua is formed of the uterine mucous membrane which undergoes changes, and becoming detached from the womb adheres so closely to the surface of the ovum as to be expelled with it during labor. Although at the outset it belongs to the mother, it is at the last a mere appendage of the ovum. Before giving the most recent description of the decidua, it will be necessary to state the old and generally accepted theory concerning it, at the same time endeavoring to indicate the cause of the erroneous views entertained by almost all who have investigated its history.] The Old Theory. — If an ovum which has been expelled intact in con- sequence of an abortion within the first two months be examined, it will be found surrounded by a sort of pouch with which it lies in contact by nearly four-fifths of its external surface, whilst the other fifth is free, and provided with the floating villi developed upon the vitelline membrane, known as the villi of the chorion. This pouch, which is pyriform in shape, like the uterine cavity upon which it seems to be moulded, generally presents but a single opening, situated at the apex of the cone, which it represents, and evidently corre- eponding to the orifice of the neck of the uterus; sometimes, however, I have found it perforated on at least one side at the point corresponding lo the opening of the Fallopian tubes. The walls of this pouch are formed by a membrane known to embryolo- gists as the decidua. It has two surfaces, one external and the other internal. The internal surface is smooth, covered with epithelium, and when examined with a Ions, presents small elevations, in form not unlike the circumvolutions of the cerebrum, and each furnished with several oval openings. The cavity limited by this Burface sometimes contains a mucn- albuminous fluid, and in certain pathological cases, fluid or coagulated blood, though ordinarily they do not exist in it. The external surface of the decidua may be divided into two portions. 163 PREGNANCY. the smaller of which is in contact with the ovum, and surrounds the greatei part of its external surface ; the other, and by far the larger portion, is entirely free, and must, when the ovum was still within the uterus, have been applied to the internal surface of the womb. This external surface is very irregular, and thickly studded with small and tender filaments. The portion of this membrane in contact with the ovum, was at first termed the ovular decldua, and afterwards, as suggestive of the way in which it was supposed to be formed, the decidua reflexa; the Fl °- 50 - other was called the uterine or parietal decidua, on account of its relation with the wall of the uterus. Now, what is the nature of this membrane? What is the mode of its formation? At what period is it developed? To furnish replies to these questions the following theory was imagined, which theoretically furnishes quite a good solution of all the difficulties of the case. a section of the womb As previously stated, the uterus, like all the other ex 11 .ltins t e era na in g eu jtal organs, becomes the seat of a more active ittu, before the arrival of & to > the ovum (ow theory), vitality immediately after a fruitful coition ; in con- b b. Orificwof ilia Ea\u> sequence of which the blood flows there in increased pian tubes, c. The de- quantity, occasioning a congestion and turgescence of m,„ u ^ i"' The ca y ity ° f tissue, not far removed from inflammation. This ab- the deciduous meiiiurane. ' normal excitement is always accompanied by the secre- tion of coagulable lymph, a sero-albumiuous fluid, which soon fills up the uterine cavity. In the course of a few days the fluid thickens, and its exterior particles, by becoming more consistent, form a soft pulpy mem- brane, which lines the whole internal surface of the womb ; thereby con- stituting a true sac, that is in contact externally with the mucous mem- brane throughout, and is filled by the uncoagulated portion of the fluid. From its position, this pouch must evidently assume the shape of the uterine cavity upon which indeed it seems to be moulded (Fig. 50). The fecundated ovule does not reach the cavity of the womb until after the lapse of eight, ten, or even twelve days, from the time of fecundation, but the membrane just spoken of begins to form much earlier. The con- sequence is, that after the ovule has traversed the tube, it finds the internal orifice closed by the decidua, and evidently can only pass between it and the uterus by pushing the membrane before it. From this time, the decidua piesents two distinct layers, the most extensive of which lines the internal surface of the uterus, except at the point occupied by the ovum ; it is called the external or uterine decidua. The other, which is pressed inward by the ovule, and is therefore in contact with a greater or less extent of its external Burface, is termed the internal or rejlexed decidua, the ovular decidua, and the epichorion of Chaussier. These two layers are at first widely separated from each other; but as the ovum increases in size, the extent of the reflected decidua is necessarily augmented and the cavity diminished, so that by the fourth month the latter has disappeared, and the parietal and ovular layers come in contact. The ovum is in immediate contact with the uterine mucous membrane OF THE DECIUUA. 169 k\ ^ I The decidua after the arrival of the ovum (old theory), c. The external, or uterine decidua. E E. The internal or reflexed layer. D. The cavity of the decidua. F The chorion. G. The amnion. The other references the same as in the preceding figure. by a small part of its surface ; all the rest of its external surface beiDg separated from it by the reflexed layer, the cavity, and the parietal layer of the decidua. All the Fl °- 51 - villi of the ovum which are covered by the ^^^^^^^^_ decidua, after a time become atrophied and dis- appear; but those which are in immediate contact with the uterus become greatly developed, and con- tract more or less intimate connections with the innermost layer of the womb, at the point where subsequently the placenta will be developed. We see that thus far this hypothesis coincides very ingeniously with the appearances presented by ova which have been expelled uninjured by abortion. It enables us to understand perfectly how that, notwithstanding the complete integrity of the decidua, the ovum is yet covered by it in but a part of its extent. Subsequently, however, at the autopsies of women who died in the third or fourth months of gestation, a membrane was discovered upon the external surface of the placenta, resembling precisely the parietal decidua, and continuous with it, without there being any discoverable line of demarca- tion between it and this inter-utero-placental membrane; so that this uterine decidua, which in aborted ova was in contact with but a portion of the surface of the ovum, was found to surround it completely, as the shell incloses the egg of a bird, when opportunity offered for examining it in situ in the uterus. 1 This apparent contradiction with the theory was accounted for by the following hypothesis. The arrival of the ovule does not at once suspend the former secretion in the uterus ; and it continues to go on, more particularly from the surface that is directly in relation with the ovum, in consequence of the greater vitality which the latter maintains ; and the secreted matter, being precisely similar to that which formed the primitive decidua, thickens in turn, thereby constituting a layer of plastic material, precisely like the first, between the ovum and the womb, which bathes both the chorial and the uterine villosi- ties; and when this deposit finally coagulates, it contributes to the forma- tion of the placental mass, the external surface of which is in this manner necessarily covered by an albuminous layer. This lamina has been called the secondary, or the inter-utero-placental decidua (decidua serotina). Al- though limited at first to the external surface of the placenta, it soon unites bo intimately with the uterine layer of the primitive decidua, that their separation becomes quite difficult at a more advanced period. 1 In 1851, I exhibited to the Academy of Medicine, and afterwards presented to M. Coste, who has bad it engraved in his great Alias, an aborted ovum, presenting a per- fect decidua, surrounding the ovum as the shell Burrounds the egg of a bird, The examination of this ovum revealed an arrangement entirely similar to what will be described hereafter from specimens observed in the uterus. This is, I believe, the first perfect aborted ovum which lias ever been studied. L70 PREGNANCY. According to this view, the decidua serotina and the primitive Je idua have a common origin and texture, and only differ a3 regards the time of their formation. In adding, finally, that the decidua was by some supposed to be destitute of vessels (anhistous membrane of Velpeau), whilst others considered it m be perforated and traversed by arteries and veins in considerable number, we shall have briefly reviewed the most generally received opinions upon this subject. With the exception of some disagreement in regard to unimportant details, all authors were unanimous as respects this capital fact, namely, that the decidua is a newly-formed membrane superadded to the uterine mucous mem- brane, from which, however, it is entirely distinct. So evident, indeed, did this fact appear, that no one, notwithstanding the old assertions of Sabatier, Mayer, Seiler, and Weber, could bring himself to admit that the decidua was only a development of the lining membrane of the uterus. And even at the present time, notwithstanding the numerous preparations of M. Coste (1842), who was the first to sustain the truth of this proposition in France, many honest minds still hold to the theory of Hunter, which I myself supported so long. In the second edition of this work, after having stated the opinions which have been successively advanced, respecting the origin, nature, and mode of development of the decidua, I said : " I have examined, with M. Coste, several of the preparations on which he relies for the support of his view, that the decidua is nothing else than the uterine mucous membrane itself, which is hypertrophied by the progress of gestation ; unfortunately the ovum in all of them had advanced to the third month at least, and it seems to me that the question can only be determined when an opportunity shall be afforded of examining an ovum of not more than five or six weeks. I am, therefore, far from having a settled conviction, though I am willing to con- fess that the last uterus examined by us together, has singularly shaken my belief on this point of ovology ; and this, conjoined with the descriptions given by Weber and Sharpey, restrains me from speaking with the same degree of confidence as formerly. I therefore think it a question requiring further examination." (Page 176, trans, of 2d edition.) My desires expressed in 1844 have been realized ; and, thanks to the kind- ness of M. Coste, I have had the opportunity of examining an admirable collection of specimens of all ages, which, I take the opportunity of acknowl- edging, have not left the remotest doubt in my mind, at least as regards the principal fact. I therefore reject the more or less ingenious hypotheses pro- posed hitherto, — hypotheses which, it is true, were rendered very probable by the examination of a large number of ova expelled by abortion, — and with the sincerest conviction of its truth adopt the opinion, that the decidua is nothing else than the hypertrophied mucous membrane. The evidence of anatomical demonstration is not, however, to be resisted, and I doubt not that all who, like myself, shall have studied the beautiful preparations at the College of France, will be convinced of the error of their views. For the benefit of those who may not have the good fortune to see these prepara- OF THE DECIDUA. 171 tions, I tliiiiK it proper to give further on the description and the figure borrowed from the magnificent atlas which he is publishing. Present Theory of the Decidua. — The history of tbe decidua is, at the present time, merely a continuation of the account of those modifications of the uterine mucous membrane, the study of which was oegun whilst treat lug of menstruation. They are, in fact, so intimately connected, that, in order to understand what remains to be said on the subject, it is necessary to recall the condition of the mucous membrane of the uterus at the menstrual period. Whilst the evolution of the ovarian vesicle is going on in the ovary, the vas- cularity of the uterine mucous membrane is, as we have stated (p. 95), greatly increased, and the highly congested vessels are discoverable beneath the epithelium. The utricular glands also become visibly enlarged. By this development of its principal elements, the mucous membrane is so thickened, that in consequence of its restriction to the small cavity of the uterus, it is thrown into folds and circumvolutions of variable depth, which are espe- cially well marked at the angles, and give forth secondary ramifications from the sides, so as to occasion some uniformity of appearance. This state of turgescence, and the violet hue which often accompanies it, is main- tained, in a greater or less degree, until the ovule is discharged ; it dimin- ishes during the last days of the menstrual period, and disappears almost entirely some time after the catamenia have ceased. But if the ovule, before leaving the ovarian vesicle, or during its passage through the tube towards the cavity of the womb, receive the vivifying influence of the spermatic fluid, the fecundation will maintain and increase the abnormal excitement of the genital organs, produced by the simple de- velopment of the Graafian vesicle. Then, instead of subsiding, the uterine mucous membrane becomes still more turgescent, and of a deeper violet color, and the folds and wrinkles increase so as to more than fill the cavity of the organ. Its vessels are engorged and distended to such a degree as to cause small effusions, which are perceptible beneath the epithelium, and also to produce ecchymosis, which give to the internal surface of the uterus a striking marbled appearance. Notwithstanding this great turgescence, the internal surface of the mucous membrane is smooth and polished, and never presents the villous projections described by Baer, neither is there any fluid secreted, nor any trace of a newly-formed false membrane. The orifices of the glandular tubes, which are much more visible than in the unimpregnated condition, are alone seen upon the surface. For a short time after it has entered the womb, the ovule is free from all adhesions, but soon becomes permanently fixed at the point where it was arrested at the outset. Before studying the means by which at a later period it becomes adherent to a circumscribed portion of the uterine parietes, let us examine the facts, and sec what can be learned respecting the youngest ovules which it has been possible to observe up to the present moment. In the beautiful Atlas of M. Coste, is figured and described the uterus of a young primiparous woman, who committed suicide about the twentieth or twenty-first day of her pregnancy, and whose body was opened at the Morgue 172 PREGNANCY. of Paris. The size of the organ was nearly double that of the normal con- dition. A longitudinal incision was made through its posterior wall, after which it was opened and spread out, so as to exhibit the whole extent of the cavity. The latter was free as in the unimpregnated condition, and con- tained no fluid. The mucous membrane was, however, much thickened and tumefied, presented numerous irregular folds, and was furnished throughout with a rich network of vessels. Notwithstanding the general hypertrophy of the mucous membrane, a sort of soft tumor was discoverable, situated on the anterior surface of the uterus between the two Fallopian tubes, as though the membrane were thicker there than elsewhere. (See Plate III, Fig. 1.) Upon incising this elevated portion, the ovum was recognized by the villi of its chorion. The internal orifices of the tubes and of the neck were free and permeable as usual. Another woman was examined at the Morgue, who had committed suicide about the fortieth day of her pregnancy. The uterus, which was much larger than in the preceding case, was incised longitudinally on its anterior surface, and so disposed as to exhibit the greatest possible extent of the internal imrface. As in the foregoing specimen, the mucous membrane, which was very vas- cular throughout and greatly hypertrophied, was in some points still more puffed up, and furrowed with folds and wrinkles. The upper two-thirds of the cavity were occupied by a soft, fluctuating tumor, situated upon the posterior surface between the two Fallopian tubes. Externally, this tumor presented altogether the appearance and organiza- tion of the mucous membrane lining the remainder of the womb. The lower third of the cavity was free, so that the cavity of the neck could be entered without any obstacle presenting. The openings of the tubes were also permeable. An incision upon the most prominent part of the tumor revealed a cavity inclosing an ovum. The most superficial examination of these two pieces convinced us : 1. That the internal surface of the uterus is lined by a thick, soft membrane, which presents numerous wrinkles and folds at several points. 2. That the ovum was situated in the upper part of the womb, and apparently lodged in a cavity perfectly distinct from that of the remainder of the organ. Now, in order to solve the problem which we are investigating, we shall have to ascertain, first, the nature of the membrane which lines the cavity of the uterus, as also of those forming the walls of the pouch which in- closes the ovule. The decidua with its three parts, (parietal, ovular, and intermediate,) is simply the mucous membrane in a state of hypertrophy. 1. When a preg- nant uterus is compared with the description given (page 95) of the changes which the organ undergoes at the menstrual period, it will be readily per- ceived that the internal layers of the uterus present in both cases the same physical properties, the former being, however, more tumefied, vascular, and folded. It will also be seen, especially after the uterus has been im- mersed in spirits and water, that the numerous small openings are merely the glandular apertures enlarged, which are observable upon the mucous membrane in the unimpregnated condition (page 80). Finally, the demon- OF THE DECIDUA I TZ stration is completed by the researches of M. Robin, showing thai this membrane, like that of the unimpregnated uterus, is composed of the same anatomical elements, that is to say: 1, of embryo-plastic elements; 2, of laminated fibres, both in the embryonic state or that of fibrd-plastic bodies, and in that of fully developed filaments ; 3, of special cells ; 4, of an amorphous matter ; 5, of glands ; 6, of vessels ; 7, that it is covered with cylinder-epithelium becoming tessellated during gestation. All these elements are, to be sure, in a hypertrophied and changed condition, but inasmuch as M. Robin has followed their changes step by step, there can be no doubt as to their identity. 2. The ovum is inclosed in a distinct cavity, separated from that of the uterus by a membranous partition, which has to be incised in order to ex- pose it. This is the membrane hitherto described as the decidxia reflexa ; now what is it? It presents, throughout, the characters of the uterine mucous membrane ; it has the same physiognomy, the same arrangement, the same vascularity, and the same glandular orifices ; only there is upon its most prominent portion a small circular space, around which the vessels disappear. This space, which is whiter, or of a lighter rose color than the remainder, is the largest in the most advanced ovum. The membrane is distinctly continuous with the uterine mucous membrane at its base, and the vessels traversing it are absolutely the same with those which ramify in the latter. Finally, microscopic investigations leave no doubt that the structure of the two membranes is identical. With the same physical qualities, continuity of tissue, and identity of structure, the membrane surrounding the ovum, the decidua reflexa of authors, can be nothing else than a portion of the mucous membrane of the uterus. 3. If the ovum be removed from the cavity which inclosed it, the bottom of the latter is found to be lined by a membrane which is thickly sown with anfractuosities or irregular lacuna? of various sizes, in which those villi of the chorion were engaged which subsequently form the placenta. It is the portion of the mucous membrane to which the fecundated ovule adhered at the outset, and is consequently continuous with that covering the parietes, and identical in regard to structure. Therefore, the ovule, which upon entering the womb lies free in the cavity, becomes, after the lapse of a period as yet unascertained, enveloped by and lodged in a sort of fold of the mucous membrane. The manner in which this inclusion of the ovule is effected is a subject of hypothesis ; for, although the ovule has been observed when free, at the outset, as also when completely enveloped after the third week of gesta- tion, observations are wanting for the intermediate period. Therefore, in the absence of direct information, we give the explanation proposed by M. Coste, and, indeed, it is difficult to conceive how the phenomenon could take place otherwise. After traversing the Fallopian tube, the ovum escapes from its internal orifice, and falls into the cavity of the uterus. On account of the swelling of the mucous membrane, this cavity is almost obliterated, and the ovule is consequently supported between two opposite points of the hypertrophied and softened membrane, Therefore, it rarely' progresses very far, and 174 PREGNANCY. usually becomes fixed upon the fundus near the middle of the interval between the orifices of the two tubes. Now, notwithstanding its minuteness, it is impossible that the ovum should not depress the softened tissue with which it is in contact, and it soon excavates, so to speak, a cell in their substance. As the ovule increases in size, the swelling of the mucous membrane also progresses, especially at the point where the former is arrested. As a con- sequence of this simultaneous development, the depression produced by tho ovule in the substance of the mucous membrane becomes deeper, and it is gradually buried, first one-quarter of it, then one-half, until at last it is almost completely hidden and inclosed. (Richard, Extract from the Les- sons of M. Coste.) In proportion as it becomes more deeply buried, the edges of the cavity excavated by it seem to grow up around it, at first to the level of the most projecting portion, and then approach each other, so as gradually to contract the opening by which a communication is main- tained with the remainder of the uterine cavity. The borders of the opening draw still nearer, and finally circumscribe a minute orifice, the trace of which remains for a short time only in the form of a central de- pression or umbilicus. The umbilicus itself at last disappears, and from this time the ovum is completely imprisoned in a sort of cyst, whose walls are composed exclusively of the mucous membrane. Whatever may be thought of this theory, we find in the uterus, five or six weeks after conception, an entirely free space, the ovum occupying but a portion of the cavity, and a greatly hypertrophied mucous membrane, which at the point where the ovum is fixed, seems to fold upon itself in order to embrace the latter. We have now to ascertain what becomes of the uterine mucous membrane during gestation, as also of the two layers produced by its folding. EXPLANATION OF PLATE IL Fio. 1. Uterus at the twentieth or twenty-fifth day of gestation. Half the natural aj*e. e, c Mucous membrane of the uterus, with its rich vascularization. c / . The portion of mucous membrane which covers the ovum. x. The small circular space around which the vessels disappear, and whose centre presents the appearance of a recently closed umbilicus. u, u Muscular structure of the uterus, exhibiting, upon the cut surface, a multitude of venous sinuses in various degrees of development. m, m. Muscular portion of the neck, distinguished from that of the body by the absence of venous sinuses. I. Vaginal portion of the neck. V. A gland of Naboth, greatly distended. q, q. The ovaries. On the one to the right is a highly developed corpus luteum. g; its surface is very vascular, and on its apex is perceived, g', the cicatrix of the opening through which the ovule escaped. t, t. Fallopian tubes. />, p. Fimbriated extremities of the tubes. , FlG. 2. Is the same specimen as the preceding, except that a circular incision has oeen made in the porticn of mucous membrane upon which the ovum is situated, and the flap turned back, so as to exhibit its deep or ovular surface. V m- ks s. V : i A : JPiglll ^ f * . OF THE DECTDUA. 175 fi. Section of the mucous membrane covering the ovum, exhibiting its thickness rela- tively to that which lines the remaining portion of the womb. c". Internal surface of the flap of the uterine mucous membrane (decidua reflexa) which covered the ovum. at. The ovum, with its surface thickly set with short but considerably branched villi, which come into direct contact with the maternal blood. Fia. 3. The uterine mucous membrane of the specimen represented by Fig. ], dinded on a level with the neck, and seen separately. The blood which distended its vessels having escaped, in consequence of its immersion in spirits and water, the vascular network which it exhibited has disappeared, and permits us to see that its entire surface is perforated with minute openings, which are the glandular apparatus, observable upon the mucous membrane of the uterus in the unimpregnated condition. The portion of mucous membrane beneath which the ovum was situated, is incised as in the preceding figure, but the ovum is here removed, so as to exhibit completely the walls of the cavity which contained it. /. The cell or cavity which contained the ovum, strewn with anfractuosities and irregular lacuna?, in which the villi of the chorion were inserted. c" '. Internal surface of the flap of mucous membrane which covered the ovum. The same lacuna? are observable in it as on the opposite surface,/, but they are smaller, less numerous, and less pronounced. «. Sections of the venous sinuses of the mucous membrane of the uterus. t f , t'. Internal orifice of the Fallopian tubes, rendered visible in the preparation by the greater unfolding of the mucous membrane. There is no indication of their ever having been obliterated. Description of the Three Portions of the Decidua. — From the foregoing account, it appears that the different portions of the decidua are the result of the successive phases of development of the uterine mucous membrane, and in order to follow with greater ease the metamorphosis of the latter, we shall describe consecutively the three portions of the decidua. A. The Intermediate or Utero-epichorial Membrane. — If, after the removal of the ovum, the cavity which it occupied be examined during the first month, or the first half of the second, a multitude of irregular grooves or lacunae, of variable size and depth, in which the villi of the chorion were engaged (see PI. III., Fig. 3), will be perceived upon the mucous membrane which forms its bottom. These lacuna?, into which smaller ones enter, and which are so numerous as to give to this portion of the membrane, the appearance of an areolar, erectile tissue, are supposed by M. Coste to be produced by the wearing away, or corrosion of the vessels, which are more hypertrophied at this point than elsewhere, by the invading growth of the chorion ; so that the lacuna?, by communicating directly in this way with the subjacent uterine sinuses, permit the maternal blood to flow into the cavity occupied by the ovum, and come into direct contact with the villi of the chorion. The presence of the ovum determines at this point a considerable hyper- trophy of all the elements of the mucous membrane. The corresponding villi of the chorion also become greatly developed, and all together con- stitute at a rather later period the mass of the placenta. (See Placenta.) B. The ovular decidua or epichorial membrane presents very different appearances according to the period at which it is examined. Shortly after its formation is completed, that is to say, after the umbilicus is obliterated, it differ? in no respect from the parietal mucous membrane: its 176 PREGNANCY. uterine surface has the same color, the same thickness, the same profile* supply of vessels, and is perforated in like manner with numerous glandular orifices. Its ovular surface presents at the same period irregular cavities or lacunae of variable depth, resembling precisely those described as belong- ing to the inter-utero-placental layer, and which are penetrated in like manner by the villi of the portion of the chorion covering the ovum. (See PI. III., Figs. 2 and 3.) But as the ovum enlarges, it elevates and extends it, until about the end of the first month, when commencing atrophy is observed at its centre, in consequence of which its vessels and glands dis- appear, and the whole of this portion of the membrane gradually loses its thickness. (See PI. III., Fig. 1.) The result is, that, either in consequence of the distention which it undergoes, or of the pressure exerted upon its most prominent portion through the growth of the ovum, a small but gradually enlarging circular space, deprived of vessels, appears in its centre, whilst the remainder of the surface presents the same vascularity as the parietal mucous membrane. This central portion becomes very thin, even at periods when the circumference of the membrane preserves a considerable thickness. The obliteration of the vessels and the atrophy of the glandules progress from the centre towards the circumference, so that by the third month the epichorial membrane differs so materially from the parietal mucous mem- brane that, except at the parts adjacent to the points where the two become continuous, the glandular orifices and vessels are no longer discoverable. - The lacuna? described as existing upon the ovular surface, are still further effaced by the atrophy, and as the villi of the chorion, which were inserted into them, can no longer derive thence the means of nutrition, they become useless and atrophied in like manner. As the development of the ovum progresses, it tends naturally to encroach upon the cavity of the womb, and consequently to bring the epichorion and the uterine mucous membrane nearer together, until, at the end of the third month, the two are in contact. At a rather later period, they become so adherent as to be separated with difficulty. It is hardly necessary to state, that when thus deprived of its vascular elements, the ovular portion of the membrane can no longer accommodate itself to the distention produced by the ovum, otherwise than by a progres- sive thinning of the membrane, and that its extreme delicacy in advanced ovums, or at maturity, is to be thus accounted for. It is found, however, even after labor, adhering either to the chorion or to the parietal mucoua membrane. c. The uterine or parietal decidua retains the characters already described until towards the end of the second month ; but from this time it begins to grow thinner, and its numerous and deep folds are gradually effaced. This first period of degeneration progresses, however, very slowly, for at the third month, the state of the membrane is very nearly the same as at the meD- etrual periods. (Richard. Thesis.) [ TuLTi-t Iii-r uiili this atrophy begins also a transformation of the epithelium, which gradually passes from the cylindric to the tessellated form. There is no proof, however, thai the prismatic cells assume directly t he pavimentous form; OF THE DECIDUA. 177 indeed Robin says that, on the contrary, some time after fecundation takes place, the epithelium of the cavity of the body of the uterus exfoliates, as it were, cell by cell, or at the most by little shreds, and is replaced by the pavimentous form. This metamorphosis of the epithelium is true for both the uterine and ovular decidua, and when the two come in contact, we have, as a result of their adher- ence, a layer of epithelial cells in the very substance of the membrane. So inti- mate, indeed, is the adhesion between the so-called uterine and reflected portions of the decidua, that at the time of delivery they seem to form but a single layer.] From the fourth month, the uterine decidua begins to lose the marks of energetic vitality which had characterized it hitherto, and its external appearance (perforation and vascularity) is altered; it becomes atrophied to such an extent as to be reduced by the seventh month to the one-twenty- fifth of an inch in thickness, and is still thinner at the termination of preg- nancy. Though inseparable at the outset from the subjacent tissue, it is now, in a measure, an independent membrane, and may be isolated and de- tached in strips of considerable size. This ready separation is due, accord- ing to M. Robin, to the commencing development, near the end of the fourth month, between it and the muscular tissue of a new membrane, which is at first soft, downy, and homogeneous, the first trace, in fact, of the mucous membrane which is to replace the decidua that falls after labor. It thickens gradually during the latter half of gestation, and lines the internal surface of the uterus, whose muscular fibres are not therefore left exposed by the •complete decollation and expulsion of the uterine decidua, which takes place after labor. [Of the Decidua at the end of Gestation. — At the end of gestation the decidua is thin, and of a grayish or rose-colored appearance ; it has an areolar texture, and an irregular surface. The outermost of its two surfaces is throughout in relation with the internal walls of the uterus, now covered by the first elements of the newly forming mucous membrane. Its internal surface adheres closely to the chorion, and at the point of insertion of the placenta becomes involved in the struc- ture of the uterine surface of that organ. (See Placenta.) When the after-birth is delivered, a rupture takes place be; veen the mucous mem- brane of the body of the uterus and that of the neck. The Matter remains, whilst that of the body, now the decidua, is expelled with the ovuji, of which it forms the exterior envelope. It is soft and easily torn ; and although the vessels which traversed it whilst it adhered to the uterus, are for the most part obliterated and atrophied, some of them may yet be found full of blood. By scraping with the nail, it may be removed in little shreds. Its softness and opacity serve to distinguish it from the other envel- opes of the ovum, which are stronger and transparent. The inter-utero-placental mucous membrane is duplicated, so to speak, by bein£ separated into two layers: the thinner is removed with the placenta, into the forma- tion of which it enters (maternal placenta, see Placenta) ; the thicker remains adherent to the uterus, and is soon blended with the newly formed mucous mem- brane of the adjacent parts. The inter-utero-placental mucous membrane does not, therefore, entirely fall away; no newly formed mucous membrane is to be found beneath it, so that it cannot be properly called a decidua. If, therefore, we consider the whole uterine mucous membrane at the time of delivery, we find that the portion lining the neck is not detached, and that the greater part of the inter-utero-placental portion remains adherent and assists iD the formation of the new membrane. (See Phenomena appertaining to the lying-ii- 12 178 PREGNANCY. state.) The parietal and ovular mucous membrane constitutes the only portion which is wholly expelled and which really deserves the name of Decidua.] From the details into which we have entered, it is evident: 1. That, excepting the membranes proper of the ovum, the amnion and c1io"ion, the uterus contains none other than its own mucous membrane. 2. That at the moment when the ovule enters the cavity of the uterus, this membrane has throughout a thickness equal to, if not greater than, that which it possesses at the menstrual period. 3. That this abnormal thickness is wholly due to the hypertrophy of its constituent elements, and especially of peculiar cells, as proved by M. Robin. 4. That immediately after the arrival of the ovule, the vitality of the uterus seems to be concentrated, in a great measure, at that point of the mucous membrane where the ovule is arrested. 5. That, as a consequence of this concentration of the vital forces, the point mentioned of the mucous membrane becomes thickened, grows up around the ovule, investing it with a circular ring, which soon incloses it completely. 6. That from this moment the ovule is separated from the uterine tissue by the intermediate mucous membrane, and from the remainder of the uterine cavity by the ovular mucous membrane. 7. That, after the first month, the ovular mucous membrane becomes atrophied from the centre towards the circumference, loses its vascularity and glandular openings. 8. That this atrophy involves that of the corresponding villi of the chorion, whilst those which are in relation with the intermediate mucous membrane become, like the latter, considerably developed, and subsequently form the placenta. 9. That, from the fourth month, the parietal mucous membrane begins to degenerate, growing gradually thinner, in consequence of the diminution of its tissue, and of the obliteration by atrophy of its vessels and glands. 10. Finally, that a new mucous membrane is formed by which the old one is removed farther and farther from the muscular tissue to which it adhered so closely at the outset, and that after labor it is completely detached and expelled with the ovum. This exfoliation of the mucous membrane of the uterus after parturition is explained, to a certain extent, by the formation of a new mucous mem- brane ; but it is much more difficult to understand how it should occur in abortions during the early months, when the adhesion between the mucous and muscular tissues is so very firm. It is true, that the exfoliated decidua i< much thinner than that which may be observed still adhering to the uterus at the same period, and that we may suppose a part only of the pari etal membrane to have been detached. DEVELOPMENT OP THE HUMAN OVUM. 179 CHAPTER IV. OP THE HUMAN OVUM AFTER FECUNDATION The human ovule, prior to fecundation and at its full matuiity, is com- posed, as previously stated (page 90): 1st. Of the vitelline membrane, or the envelope. 2d. Of a granular liquid contained in this membrane, and called the vitellus (yolk). 3d. Of a little vesicle inclosed in the first, and situated in the midst of the granular liquid. This is the germinal vesicle, originally discovered by Purkinje, in the eggs of birds, and subsequently proved by M. Coste to exist in those of mammalia. 4th, and lastly. Of the germinal or proligerous spot (macula germinativa), which is detached from the clear contents of the germinal vesicle, and is held in suspension in the fluid which the latter contains. If the ovule be examined several weeks after the fecundation has taken place, it will be found to have undergone some very remarkable transfor- mations; for it is then composed of such different parts, that if comparative anatomy had not furnished us opportunities of observing, step by step, and hour by hour, the divers modifications it passes through before the organi- zation is fully completed, we would not believe it to be one and the same product. Thus, at the end of the second or third week after fecundation, it exhibits some very different elements to the observer: for example, we encounter, in passing from without inwards : 1st. The chorion, a thick exterior membrane, studded with numerous villosities. 2d. A much thinner mem- brane, situated more internally, and designated as the amnios. 3d. A more or less considerable space between these two envelopes, that is filled by an albuminous liquid, in the midst of which a little vesicle (the umbilical vesicle) is situated. And 4th. A liquid fills the cavity of the amnios, the quantity varying with the period of pregnancy, and in this fluid is the embryo. Finally, let us add that the ovule is enveloped nearly throughout by a double membrane, which at first is entirely foreign to, but subsequently contracts intimate relations with it ; this is the deciduous membrane. But before studying the constituent parts of the ovum at an advanced period of its development, let us see what is their proper commencement, and how they can arise out of the simple elements that form the ovule prior to conception. When the ovule has attained its full maturity, the vesicle in which it is inclosed becomes the seat of an excitation which determines there a con- siderable afflux of fluid, and causes its progressive distention. This hyper- trophy may, as we have seen, be either spontaneous, or produced by coition or other venereal excitement. As a consequence of the distention, the vessels on that portion of the vesicle which projects the farthest from the surface of the ovary become atrophied, its walls grow thinner, and soon give way, thereby permitting the ovule to escape, which, in passing out, draws along with it a part of its granular cumulus. The ovum then en- gages in the tube, whose enlarged extremity had been applied to the ovary. It must not be supposed that the period for the ovule's arrival in the tube is invariable in the same species of animals, and it probably varies in the human rare also, though nothing positive is known on that point. Pending 180 PREGNANCY. its stay in the ovary, tlie ovum underwent no appreciable modification . but as soon as it enters the oviduct, the beginning of those changes it must necessarily pass through, in order to give birth to a new being, is observed ; and hence, to study these modifications in due course, we must first examine those manifested in the tube, and then such as do not appear until after its arrival in the uterine cavity. ARTICLE I. CHANGES OF THE OVUM IN THE TUBE. It has heretofore been always impossible to study these changes in the nunian ovum, and the description we are about to give is the result of observations made on the ova of mammalia, especially of the dog and rabbit ; but analogy favors the belief that similar phenomena take place in the human species ; indeed, the strongest resemblance exists between the ovum of the latter, and the unfecundated ovum of a bitch ; besides, the youngest ova that have been studied in the female, exactly resemble those which have arrived at a certain degree of development in animals. It is, therefore, extremely probable that if they are endowed with the same organization before conception, and still exhibit a perfect resemblance after the fecundation, they must have passed through similar successive transforma- tions. From analogy as well as observation, it is supposed that in the human female ten or twelve days are occupied in the passage of the ovum through the tube. [Disappearance of the Germinal Vesicle. — By the time the ovum has reached the oviduct, it has become impossible to find in it either vesicle or germinal spot; and this disappearance of the vesicle and of the collection of granules at its centre, con- stitutes the first change perceptible in the ovum subsequent to its departure from the ovary. The disappearance shows that the ovum is mature, but occurs independently of fecundation. Condensation of the Vitellns. — During the early part of its passage through tho tu^e, the vitellus becomes more dense (Bischoff) and compact, in consequence of which it no longer fills the vitelline membrane, but leaves an intervening space occupied by a clear and transparent fluid. So great is this condensation, that if its envelope be opened, the vitellus is found to be a solid body, capable of division by means of a very fine needle into two, four, and six portions. (See Bischoff* s Atlas.) Appearance of Polar Globules. — Succeeding the disappearance of the germinal vesicle and during the condensation of the vitellus, there is formed on the surface of the latter a transparent globule, 5 J ff of an inch in diameter, to which the name polar globule has been given. From the point of its formation and during the time of its appearance, there is a retrocession of the granules of the vitellus and conse- quent separation from the hyaline and transparent substance which united them. It would thus seem that the polar globule is produced by a sort of exudation or accumulation of the hyaline substance of the vitellus, and the point at which it is formed indicates where will take place the first furrow of segmentation, and where at a later period the cephalic extremity of the embryo will make its appearance. Within a few minutes after it is first perceived, the polar globule constitutes a hemispherical projection on the surface of the vitellus, and finally separates from, and remains simply contiguous to it. In some species of animals, two, three, or four polar globules are thus suc- cessively produced, all taking their origin from the same point. When the last of them is formed, all unite to form a single one, which soon exhibits distinctly an investing membrane and a cavity. DEVELOPMENT OF THE HUMAN OVUM. 181 The polar globule thus produced remains beneath the vitelline membrane and unconnected with the phenomena which are to take place in its vicinity. I» becomes useless, in fact, as soon as formed, leing intended only to prepare the way for the segmentation of the vitellus, which we are soon to study. Whethtr fecundation has occurred or not, the germinal vesicle disappears, the vitelluf condenses, and the polar globules form; but the changes which we are next to study take place only in fecundated ova. (Memoirs of Prof. Ch. Robin.) Formation of the Vitelline Nucleus and Segmentation of the Vitellus. — Both the layer of albumen which surrounds the fecundat-ed ovum, and the vitelline mem- brane become thicker during the passage through the second half and internal third of the Fallopian tube; but the most remarkable changes take place in the vitellus (Harry, Bischoff, Robin). Whilst the vitellus is undergoing its condensation, a clear spot appears in its centre and increases so rapidly in size by crowding aside the vitelline globules, that in about one hour it has attained a diameter of from ■$£, of an inch to the - x \^ of an inch (Robin). The spot is called the vitelline nucleus, and has nothing in common with either the germinal vesicle or the polar globule. It is composed of a thick fluid without a cavity or distinct walls. The vitelline nucleus has barely attained the above-mentioned diameters before it is seen to become elongated and constricted near the middle, and finally separates into two halves. This separation is the signal for the segmentation of the vitellus which itself divides into two halves, in the centres of which are found the corre- sponding halves of the vitelline nucleus. Fig. 52. Fig. 53. a. The layer of albumen, v. The vitelline membrane. .Each half of the vitellus divides in its turn into two parts and so successively, until by the process of subdivision the entire vitellus (which at first presented two regularly rounded por- Fia - 54 - tions (Fig. 52), then four (Fig. 53), and then eight, &c, the vitelline spheres becoming more numerous A T and smaller) acquires the appearance of a mul- / berry; whence is derived the name muriform body , •. : • ; S (Fig. 54) applied to the vitellus after the segmenta- , tion is completed. The segmentation of the vitellus would seem to (_';;,• be dependent upon the segmentation of the vitelline \ nucleus, a portion of which is found in the centre / of each vitelline sphere.] The time necessary for the ovum to traverse the tube is very variable in differenl animals, and oven sometimes in the same species; thus, according to M. Coste, i be ovum of* rabbits does not reach the uterus before the third or the fourth day, whilst in the bitch, it has been n , ;l „,. The Fecundated ovum at a more advanced stage. *.. The albuminous layer surrounding the vitelline membrane v, which is seen t" !»• thickened and to contain withiu its cavity the mulberry-like 182 PREGNANCY. found in the tubes as late as the tenth, twelfth, or even fifteenth day ; and we have formerly stated that, in the human species, no one case has ever proved its existence in the womb prior to the twelfth day. However, it is well to remark, that, as a general rule, the passage is very rapid through the external half of the tube, whilst its progress through the second half and especially through the last third is exceedingly slow, in consequence perhaps of the extreme narrowness of this portion of it. Finally, the ovum augments somewhat in volume during its course, being probably nourished at first at the expense of the granulations which accom- pany it, and subsequently by absorbing the albuminous liquid secreted in the oviduct itself. 1 ARTICLE II. MODIFICATIONS OF THE OVULE FROM ITS FIRST ARRIVAL IN THE WOMB UNTIL AFTER THE DEVELOPMENT OF THE ALLANTOIS. [Formation of the Blastodermic Membrane. — At the time of its entrance into the cavity of the uterus, the ovum is, therefore, composed of the muriform body, the thickened vitelline membrane, and a thin layer of albumen surrounding the latter. Each little sphere of the muriform body now undergoes an internal change by which its outer portion is transformed into a membrane, so that each segmentary sphere represents a cell with a homogeneous envelope and granular tissue. Shortly after this, fluid collects in the centre of the muriform body and presses to the cir- cumference the spheres or cells of which the body had been composed. In con- sequence of this pressure the cells become flattened and applied to the vitelline membrane so as to form a sort of lining thereto, and by their mutual adherence form a second membrane enclosed within the primary one.] This second membrane is not easily recognized ; but if the example of M. Coste be followed, and the ovule be placed in water, it will become quite apparent. In fact, a very curious endosmotic phenomenon then takes place ; the water passing through the vitelline membrane detaches the second vesicle in such a manner that the latter, being completely isolated, as also puckered and corrugated in every direction, floats or hangs suspended in the new liquid which distends the vitelline membrane ; and to this M. Coste has given the title of the blasto- dermic membrane. But while this blastodermic vesicle, or membrane, is being developed, the layer of albumen which surrounds the ovum on its first arrival in the uterus, disappears and con- Tbe ovule shortly after its arrival sequently the vitelline vesicle loses much of its in the womb, k. The diminished ? . J albuminous layer, v. The vitelline thlCkneSS. membrane, b. The blastodermic Hitherto, the ovum still remained free and without any adhesion to the uterine walls ; but Fig. 55. membrane. 1 This layer of albumen which surrounds the ovum of the rabbit and of the roebuck, whilst it remains in the tube, does not exist around the ovum of the bitch and of the sow. On account of these differences, it will remain uncertain whether it envelops the human ovum until observations which, as yet, it has been impossible to make, shi»U settle the question. DEVELOPMENT OF THE HUMAN OVUM. 183 it commences about this period to contract more intimate relations with the latter, and hence can no longer be displaced by blowing upon it. At the same period a rounded, whitish spot begins to appear on some pi int of the blastodermic vesicle, which seems to be detached, or to stand in relief; this has been called the tache embryonnaire Uhe embryonic spot) by M. Coste, and it, like the blastodermic vesicle, is composed of cellular granulations, excepting that these latter are more contracted, and are aggregated in a larger quantity at this point. (Figs. 56 and 57.) At the same time, a Fig. 57. Fig. 56. The blastoderm, with the embryonic spot seen in front, v. Tho vitelline membiane. e. Th« external layer of the blastoderm, f. The embryonic spot. Fig. 57. The same figure in profile, to show the two layers of the blastoderm. V. The vitelline membrane. E. The external; and I, the internal or intestinal layer of the blastoderm. minute examination is all that is necessary to convince us that the vesicle, as also the embryonic spot, is composed of two laniinse, lying in contact with each other, but which may be separated by a couple of fine needles. To render this doubling of the blastoderm more evident, we present two theoretical figures, exhibiting it at the same stage of development. In the first (Fig. 56), which is a front view of the ovum, the blastoderm with the rounded embryonic spot is seen. The same figure, in profile (Fig. 57), shows the two blastodermic lamina?, both presenting a swelling near the embryonic spot. One has been called the external, serous, or animal layer, and the other is denominated the internal, mucous, or the vegetative one. Shortly after this period, the embryonic spot enlarges by the further addi- tion of granules, but more in one of its diameters than in the others, so as to exchange its rounded for an elongated form. A considerable projection above the external face of the blastoderm may be simultaneously noticed, which exhibits a convexity towards the vitelline membrane and a concavity looking to the central part of the ovum (Fig. 58) ; and thenceforth the cavity of the blastodermic vesicle is divided into two distinct portions, the one embryonic, the other, which is the larger, foiming the umbilical vesicle. A line of greater obscurity may soon be recognized at the centre of this spot, being the first trace of the embryo. The margins of this spot fold inwards, as do also the extremities, thereby giving rise to an elongated body curved like a boat with the ends swollen, in consequence of their doubling up, and a cavity of some depth at its centre. The body of the embryo is then readily distinguished. The extremity that is most swollen is called the cephalic, and the other, or less voluminous one, the caudal extremity; about that time the serous 184 PREGNANCY Fio. 58. A section of a more devel- oped ovum, in which the two portions, the embryonic and the umbilical vesicle, begin to appear, o. The umbilical ves- icle. I. The internal layer of the blastoderm, e. The exter- nal layer, v. The vitelline membrane. laniime of the blastoderm can be traced as continuous with the nicst ex- ternal layers of the embryonic body, whilst the mucous one forms its internal plane. In } roportion as the embryonic spol loses its distinctive characters, numerous little eleva- tions, irregularly scattered over the external surface of the ovum, are seen to develop themselves, being, in fact, the commencement of those villosities which subsequently stud the exterior surface of the chorion. During the progress of these phenomena, the ex- ternal, or serous layer of the blastoderm (Fig. 59) forms a fold around the part which has been trans- formed into the embryo, and curved as already stated ; the fold of the serous layer being especially so at the caudal and cephalic extremities. The fold grad- ually enlarges above, below, and on the sides, in such a manner as to form a true hood over the head and caudal termination; hence named from this resem- blance the cephalic and caudal hoods. These folds elongate rapidly (Fig. 60', passing along the dorsal regions of the embryo, and ultimately coming into contact on the median line, unite so as to form a pouch surrounding the embryo, and continuous with it along the whole circumference of its large ventral opening. Although at first almost in Fl0 - 59 - direct contact with the embryo, it is soon after separated from it by a certain quantity of liquid, becoming its immediate envelope, and receiving the name of the amnion, and the in- terposed fluid, that of the amniotic liquor. As to the external layer of the fold, it is manifestly continuous with the serous lamina of the blastoderm, and although primarily ap- plied to the preceding, it is speedily separated therefrom by the interposition of a liquid which removes them farther and farther from each other, until at last its exterior face is brought into contact with the vitelline vesicle. Accord ing to some authors, these two become con- founded, and by uniting form the outer mem- brane of the ovum ; but others teach that the vitelline vesicle will be gradually absorbed (as we have endeavored to represent in the plates Figs. 61, 62, and 63), while the external lamina of the blastoderm is being developed, and the latter alone will then constitute the enveloping membrane. At the point of junction, the cephalic and caudal hoods constitute, by their union, a kind of membranous bridge, which there joins the amnios to tho chorion. This bridge is gradually absorbed, and the two membranes become completely isolated. (See Fiizs. *>1 and Uii. < Such is the view most generally received on the mode of formation of A section showing the origin and rirst traces of the amnios, o. The umbilical vesicle. I. The intestinal; and i . the external layer of the blas- toderm, v. The vitelline membrane. C c. Origin of the cephalic and cau- dal amniotic hoods. DEVELOPMENT OF THE HUMAN OVUM. 18fi Fio. 60. The amniotic hoods more developed. 0. The umbilical vesicle, i. The internal or intestinal ; and E, the external layer ol c. The limit of the am- The vitelline membrane. the amnios. We must mention, however, one other, which, without being new, has latterly acquired considerable importance by the discussions which it has created at the Academy of Sciences. We have just seen that the amnios is directly continuous at the umbilicus with the abdom- inal walls of the embryo, which is in fact so manifest, that no just ground of belief is afforded that the latter was ever independent of the amnios, as some have recently supposed. Messrs. Oken, Pockels, Serres, and Brescliet have endeavored, notwithstanding, to prove that the amnios once existed as an independent vesicle, distended by a fluid ; and that after- wards the foetus, by coming into contact with it, caused its depression, and became envel- oped by it, like a double night-cap, but having no other relation with it than that of simple apposition; or, in other words, that the amnios the blastoderm, i \ a portion of tne ex had the same connection with the embryo as E »." rhe Xibryo the serous membranes with the viscera they niotic hoods, v. cover. Messrs. Coste, Velpeau, and Bischoff have combated this view success- fully, in my estimation, by contending for the existence, at all periods, of the continuity we have just described, and they cannot possibly admit an opinion which is founded solely on pathological alterations. For my own part, after examining the preparations of M. Coste, I can have no doubt as to the little value of such asser- tions. Immediately after the amnios is formed, the margins of the embryonic spot, and especially its true extremities, become more and more turned inwards, thereby aug- menting the concavity which it previously exhibited ; and at the bottom of the groove thus constituted, the mucous lamina of the blastoderm is observed to concur in forming the intestinal canal, which is represented at this early period by an elongated gutter, communicating freely with the interior cavity of the blastoderm. But, in propor- tion as this constantly increasing inversion of the lateral walls, and of the extremities of the embryo, progresses, this communication becomes more and more contracted, «o that in a short time the intestinal cavity only connects with the blastodermic vesicle by a contracted pedicle; and thenceforth, this latter receives the name of the umbilical vesicle, and the vessels which arf Fio. 01. This figure shows the amnios ;:linot. ^viu- pleted, and likewise the origin of tl ■> all an tols. o. The umbilical vesicle, i. The in testinea. e. The amnios, k'. The externa layer of the blastoderm, or the non-vascular chorion, v. The vitelline membrane, o. The amniotic hoods ready to close up. a. The alluutois. 186 PREGNANCY. Fio. 62. distributed to its vascular layer, consisting of two veins that enter, and an artery that emerges from the embryo, are called the omphalo-mesentcric ves- sels. (Fig. 61.) As the contraction of the ventral opening in the embryo, and the circum- scription of the umbilical vesicle go on, we may observe at the inferior part of the intestinal canal, just in the region where the bladder and rectum, during the earlier days of embryonic life, are confounded under the name >f cloaca; we observe, I repeat, the intestinal parietes to form there a slight elevation. Now, this little tumor (Fig. 61) gradually elongates, so as to con- stitute a minute vesicle, which commu- nicates by its narrow pedicle with the intestinal cavity ; this is the allantois, which has been known for a long time to exist in mammalia, but which M. Coste was one of the first to detect in the human ovum. The allantois is scarcely formed before it is provided both with venous and arterial vessels, consisting of the two umbilical arteries, and one umbilical vein ; the former arising from the primitive iliacs, the latter going to the liver, as may be seen somewhat later. This little vesicle passes through the umbilicus at first alongside of the pedi- cle belonging to the umbilical vesicle, and soon undergoes a rapid develop- ment. The growth of the allantois and its vessels is so rapid that it soon comes into contact with the external membrane of the ovum. In some animals, the allantois comes into juxtaposition by its base with only one point of the chorion, and becomes attached there ; and then the terminal extremities of the umbilical vessels not only reach this membrane, but even extend for the most part to the villosities devel- oped on its external surface, and acquire there a considerable growth. In others (see Figs. 62 and 63), the allantois spreads out like an umbrella around the embryo and umbilical vesicle, and supplies itself to the whole external face of the amnios, as well as to the internal one of the chorion, then the two laminae are fused into each other in such a way as to leave no trace of the allantois. (Figs. 62 and 63.) The development of the allantois completes the essential part of the ovum, although by reference to Fig. 55, Plate IV., it will now be found to consist: 1, of the embryo; 2, of a variable quantity of liquid in which it iwims ; 3, of the amnios, already considerably distended, and forming a sheath to the parts that pass through the ventral aperture ; 4, of the umbil- ical vesicle situated between the amnios and chorion, whose delicate pedicle, This figure shows the rapid progress of the allantois, and how it spreads over the foetus, the umbilical vesicle, and the amnios. This latter begins to ensheathe the pedicle of the umbilical vesicle and that of the allantois in such a way as to form a commencement of the cord. The vitelline membrane disappears more and more. o. Tli.' nr.ibilical vesicle, e'. The amnios, e". The external layer of the blastoderm, c. The point where the two hoods come into contact. v. The vitelline membrane almost entirely atro- phied, a. The allantois. DEVELOPMENT OF THE HUMAN OVUM. 187 Fio. Co. with the oniphalo-mesenteric vessels appertaining to it, however, still com- municate with the intestinal cavity ; 5, the pedicle of the allantois vesicle still charged with the umbilical ves- sels ; 6, the space between the amnios and chorion, partly occupied by the umbilical vesicle, but principally filled with a liquid called by M. Vel- peau the reticulated or the vitriform body, according to the degree of its consistence; and 7, of the outer en- velope, or the chorion. The phenomena yet to be studied have special reference to the enlarge- ment of the ovum, and the develop- ment of the embrVO. ^ n **" 8 figure, the allantois has spread over ti s whole internal surface of the ovum, and but verj slight traces are left of the continuity between tL« amnios and that part of the external layer of th* blastoderm which formed the non-vascular chorion ■ the amnios incloses the umbilical cord more and more. o. The umbilical vesicle, e'. The amnio* c. The point where the two hoods are fused into each other, and form but a single membrane, e". The external layer of the blastoderm. a. The allantois. v. The vitelline membrane. ARTICLE III. OF THE FCETAL APPENDAGES. These comprise the allantois, the umbilical vesicle, the amnion, and the chorion. § 1. Of the Allantoid Vesicle. By the time the amnion has become a completely closed sac, a little pyriforra vesicle, which we have denominated the allantois, is observed, about the tenth day, to spring from the inferior part of the intestinal canal, and taking on a rapid growth soon becomes applied by its base to the in- ternal surface of the chorion. The terminal branches of the two umbilical arteries and vein, as previously stated, ramify on the walls of this vesicle ; and hence the urachus, which is nothing else than the pedicle of the allan- tois, is accompanied in its course by three blood-vessels (see Fig. 3, Plate IV.), two of which (i i) are arterial, coming from the iliacs, and called the umbilical arteries. They run to the chorion, where they ramify, and ulti- mately reach the villi that form the foetal placenta. The third trunk is venous, and is known as the umbilical vein. The umbilical vein j leaves the right auricle of the heart at the point /, and soon after receives the contents of the vena cava inferior k; it then traverses the under surface of the liver m, to which it sends a copious vas- cular supply, and, before passing this organ, receives the omphalo-meseuteric vein at the point o; then, after leaving the liver, it gains the left sidf of the abdomen between the walls of this cavity and the intestinal fold E 183 PREGNANCY. next, by turning abruptly towards the umbilical cord, it gets to the left side of the urachus, and accompanies the latter to the chorion, wheie it follows the umbilical arteries into the villosities. After the earliest periods of development are over, there is but a single umbilical vein left, although during the first part of the embryonic exist- ence two are met with, one upon each side of the urachus (and consequently one for each umbilical artery). That on the right side becomes efface 1, but its traces may still be found at the thirtieth or even the fortieth day ; indeed, some such existed and were perceptible on the embryo I am now describing. When the umbilical vein has actually passed the liver, it gives off no branches whatever, in its course along the urachus, nor does it divide and subdivide until it reaches the chorion. But, in the earlier periods of ges- tation, when the two exist, they are observed to spread over the walls of the chest and abdomen in the form of a large vascular plexus, extending as far as the vertebral column ; however, this new apparatus soon vanishes and leaves no vestige of its former existence. The body of the allantoid vesicle disappears very rapidly, and scarcely a trace of it can possibly be found after the lapse of a few days from its first appearance. In fact, nothing more is seen than a cord of variable length, extending from the embryo to the chorion, and having the umbilical vessels inclosed within it. This likewise becomes gradually atrophied in such a way as to disappear altogether in the substance of the umbilical cord ; nevertheless, a portion of it still persists in the abdominal cavity of the embryo, forming there the cord subsequently known as the urachus ; and just as this latter terminates in the rectum, it exhibits a small swelling which is afterwards converted into the urinary bladder. We may remark, in anticipation, that this rudimentary bladder communicates with the rectum, and constitutes there that transitory cloaca, whose existence in the human species may be positively verined by direct observation. It is this early disappearance of the allautois which has induced some ovologists to doubt its existence in the human race. It is exclusively destined to bring the embryonic vessels into contact with the external membrane of the ovum, whence they are soon placed in their proper relation with the internal surface of the womb. § 2. Of the Umbilical Vesicle. This vesicle is formed exclusively by the internal or mucous layer of the blastoderm ; at first, it is very voluminous, occupying nearly the whole cavity of the ovum, and communicating so freely with the intestinal cavity as to form with it apparently but a single vesicle. But the gradual con- traction of the ventral opening serves to separate the two, as we have already demonstrated, leaving only a pedicle of variable thickness, according to the 3ize of this aperture. Ihe umbilical vesicle contains a yellowish-wl.ite liquid often of a vitel- line yellowness, in which numerous granules and fat globules are seen floating. It seems to be formed of two laminae, between which the vessels are distributed (see Robin, Journal de Physlologie, 1861). As the amnion DEVELOPMENT OF THE HUMAN OVUM. 189 becomes developed, the vesicle is crowded by this membrane, and is then found placed between the external face of the latter and the internal sur- face of the chorion. In consequence of the development of the allantois, the umbilical vesicle loses much of its importance in the human species, as it so soon becomes an organ of little value either to the growth of the ovum or the embryo : and furthermore, it dwindles away speedily ; thus, during the first three weeks, it is as large as an ordinary pea, but after the fourt% it begins to collapse and diminish in size, and at six weeks subsequent to the concep- tion, it does not exceed a coriander-seed in bulk ; then it remains stationary for a time, not disappearing altogether until towards the fourth month. I have observed it several times of later years on ova of three to three and a half months, in which it generally still retained the volume and shape of a small lentil, being of a yellowish color, and having its surface wrinkled. However, I may remark, that its size appeared very variable in several ova of the same age. In proportion as the umbilical vesicle becomes atrophied, it is removed farther and farther from the trunk of the embryo, in consequence of the development of the amnion, and its pedicle is also elongated in a marked manner ; thus, the latter is from two to six lines in length, being continuous at one end with the intestine, and at the other with the vesicle by a kind of an infundibuliform expansion. The pedicle is apparently separated into two portions by the amnios, before the abdominal walls are completely closed up ; one part lying between the spine, or rather the intestine, and the spot afterwards occupied by the umbilicus, while the other remains exterior to the abdomen. This pedicle is traversed by a small canal for the first five or six weeks of its existence, and through it the fluid in the vesicle may be pressed back into the intestine, but it is obliterated after that period. About the same time, also, it becomes more and more delicate, and ofter ruptures from its great elongation ; and its umbilical portion being lost in the cord, can no longer be traced into the abdomen. When broken, the vesicle may be found more or less removed from the root of the cord, and lying between the chorion and amnion. The umbilical vesicle has a rich vascular apparatus, the blood of which is carried to and from the embryo by the intervention of two trunks, one venous, the other arterial ; both, however, accompany the pedicle, and form a constituent part of it. The first, n (see Fig. 3, PI. IV.), called the omphalo- mesenteric vein, enters the abdomen, winds around the duodenum, and then opens into the umbilical vein at the point o, just as the latter is emerging from the liver. As it passes the duodenum, branches are given off to the stomach and intestines, and when it discharges into the umbilical vein, it sends a voluminous trunk to the liver. That portion which furnishes the branches just described, persists in the adult under the name of the ventral or hepatic-portal vein, whilst all the rest will disappear with the umbilical vesicle and its pedicle. The arterial trunk p, accompanying the pedicle, has been designated as the omphalo-mesenteric artery. Arising from the aorta, it gains the summit of the intestinal convolution, and gives off branches to the mesentery and 190 PREGNANCY. to the intestine itself; then it reaches the pedicle, and follows the latter to the umbilical vesicle, upon which it ultimately ramifies. The part that supplies the mesentery is converted in the adult into a mesenteric artery, all the rest being effaced. From all which, it appears that the vascular system of the umbilical vesicle represents the primitive circulation in the embryo, corresponding in it to the sanguiferous apparatus of the yolk of fowls. Of course, these vessels will become atrophied with the organ to which they belong. The umbilical vesicle seems to be intended to serve as a reservoir for the fluid designed to nourish the foetus during the first weeks of intra-uterine existence. § 3. Of toe Amnion. The most internal membrane of the ovum, or the amnion, is formed by the inner lamina of the fold., or the cephalic and caudal hoods which con- stituted the external serous layer of the blastoderm surrounding the embryo. Being continuous, as we have shown, with the margins of the ventral open- ing, it seems at first to be attached by its middle part to the skin on the dorsal region. The internal amniotic surface subsequently exhales a liquid into its cavity, in which the embryo swims freely; hence the amnios constitutes a little sac around the foetus, having smooth and transparent walls. Its inner surface is bathed by the liquid inclosed in the cavity, whilst its external one in separated from the chorion by a space of variable size, which is likewise filled with a fluid and the expansion of the allantoid vesicle. Originally, this membrane was not concentric with the chorion ; but in proportion as the development advances it presses back the exterior liquid and the allantoid vesicle more and more, thereby condensing it, and finally comes in contact with the external envelope of the ovum. Now, since it adheres to the periphery of the umbilical opening, it must furnish, by such an extension, a sort of membranous sheath to the pedicles of the allantoid and the umbilical vesicles, as well as to their accompanying vessels, sur- rounding them throughout their course from the umbilicus to the chorion; and all the parts thus inclosed constitute what is called the umbilical cord; whence it follows that the abdominal cavity itself must be in connection with the canal represented by this cord, and consequently that the foetal appendages may communicate with it through the route thus opened to them. It is thus that the pedicle of the umbilical vesicle becomes united to the ileo-coecal fold of intestine, whilst the allantois connects with the rectum by the intervention of the urachus. As we have just stated, the amnios is separated from the chorion during the earlier weeks by a filled space, which space is larger in proportion a? the ivum is the more recent. This extra-amniotic liquid forms a gelatinous or albuminous mass, of a weblike arrangement, and having the umbilical vesicle in its midst. The mass becomes more and more compact by pressure of the amnion, which has a constant tendency to approach the chorion, thus acquiring the aspect of a membrane (the membrana media of BiscLoff ), which is situated between the chorion and the amnion, where, says this DEVELOPMENT OF THE HUMAN OVUM. 191 author, it may be readily distinguished towards the end of pregnancy, as a gelatinous, though continuous membrane. M. Velpeau gave it the name of the vitriform or reticulated body, but Robin has shown its structure to be identical with that of the allantoid vesicle. Velpeau was, therefore, correct in regarding the reticulated body as the analogue of the allantoid, of which it is really but the remains. The amnion undergoes no important change during the ulterior develop- ment of the ovum, nor does its texture. Of course, it would be more firm and consistent, acquiring by time a greater resemblance to the serous mem- branes, although it neither incloses nor possesses vessels at any period. Nevertheless, says Duges, it probably has some openings, which permit the waters, exhaled by the uterine capillaries, and received by the vessels of the decidua and the villi of the chorion, to be diffused around the foetus ; but this perspiration of the liquids secreted by the internal uterine surface, may very possibly be a simple phenomenon of endosmosis. § 4. Waters of the Amnion. The amniotic cavity is filled with a liquid, in which the foetus is im- mersed. At the commencement of pregnancy, this fluid is of slight density, and more or less transparent and limpid, but towards term it becomes viscid, unctuous, and more consistent than pure water : sometimes it is as clear as serum ; at others, it is of a light yellow or greenish color. It frequently be- comes lactescent, turbid, and interspersed with yellowish-gray, or even black albuminous flakes ; again, in certain cases, it is strongly tinged with yellow, when the membranes are ruptured, from the admixture of a quantity of meconium ; it exhales a disagreeable odor, analogous to that of the sper- matic fluid, and its taste is slightly saline. The quantity of the amniotic fluid varies greatly ; thus, in the early months it is, relatively to the foetus, more abundant, in proportion as the embryo is younger. Riolan found four ounces in an ovum containing a foetus of the size of an ant. The weight of the foetus and that of the fluid at the middle of gestation, are very nearly equal. Again, dating from this period, the difference is generally in favor of the foetus, and the weight of the latter at term is four or five times greater than the waters, which seldom exceed a pound or a pound and a quarter ; consequently, if the assertion is true, that the waters augment in their absolute quantity until term, it is equally so to say they increase relatively to the foetus in the first, and diminish in the second half of pregnancy. In fact, the variations in thir respect are infinite, even at the time of the accouchement. According to the analysis of Vauquelin, 100 parts of amniotic liquor consist: of water 98*8; of albumen, hydrochlorate of soda, phosphate of lime, and lime, 12. The interesting question now arises: What is the source of the amniotic fluid ? Some assert that it comes from the mother ; others, that it is produced by the foetus. Chaussier, Meckel, and Beclard, adopting an intermediate opinion, suppose that its secretion takes place simultaneously from the female and her product. Everything proves, says M. Velpeau, that the liquor amnii is the result of a transudation or of a simple exhalation, like the serum of the pleura. [92 PREGNANCY. pericardium, &c, and that this process requires no particular canals for its accomplishment, being a phenomenon of pure vital imbibition. According to Burdach, the amniotic waters cannot be secreted by the fietus, because they exist prior to its formation, 1 and therefore they must be exclusively furnished by the internal uterine surface, and reach the cavity of the amnios by traversing its walls. We also believe, that the greater part of this liquid comes from the mother's organs ; yet we must add that it also contains certain products, secreted by the foetus: for instance, it is frequently colored by some meconium, and besides, it is almost certain that the urine may be discharged into the amniotic cavity during the latter months of pregnancy. A few incontestable facts prove that such an evacua- tion is necessarv to the maintenance of foetal life: thus, Billard and T. W. King record having seen cases of ruptured bladder, resulting from imper- foration of the urethra ; ami further, Desormeaux and P. Dubois have observed an obliteration of this canal in two stillborn children, which had given rise to an enormous distention of the bladder, ureters, and both kid- neys ; indeed, the latter were found transformed into two multilocular cyst?. Similar facts have been presented before the Academy of Medicine by MM. Depaul and Moreau. According to some authors, the principal use of these waters is to contri- bute to the nutrition of the foetus, during at least a great part of gestation. (See Nutrition of the Foetus.) However this may be, the waters of the am- nios serve during pregnancy to maintain the insulation of the external foetal parts before the skin becomes covered with the sebaceous coat hereafter to be described ; to promote the active movements of the foetus and its develop- ment, both of which would have been greatly incommoded without this intervention, by the pressure of the uterine walls ; to protect the foetus from all external violence, and to afford it the means of conforming to the laws of gravity. They likewise favor a uniform expansion of the womb, and remove all pressure from the umbilical cord, thus assuring the integrity of the foeto-placental circulation both during pregnancy and labor. In the latter, they seem destined to guard the child from the violence of the uterine contractions, which, without them, would certainly compromise its existence ; to aid in forming the amniotic bag, the engagement of which renders the dilatation of the neck more uniform and easy ; to lubricate the pelvic canal, and thus facilitate the descent of the foetus ; and lastly, they render manipu- lations of every kind less difficult than they otherwise would be. § 5. Of the Chorion. The chorion is the most external envelope of the ovum. Writers are by no means unanimous in their views as to the elements of which it is com- posed. Thus, some of them, as we have had occasion to state, suppose that it is formed by the vitelline membrane, the external lamina of the blasto- derm, and the allantoid vesicle, uniting to constitute a single layer. Accord- ing to others, on the contrary, the vitelline membrane will disappear soon 1 It is only necessary to recall our remarks on the development of the amnios to refute this opinion. DEVELOPMENT OF THE HUMAN OVUM. 193 after the doubling of the blastodermic vesicle, and the external lamina of the latter, conjoined with the allantois, will then form the chorion. [M. Robin's view of the subject is as follows: According to M. Coste, three kinds of chorion appear successively, one of which, however, disappears in conse quence of the development of its successor which is substituted for it. Theirs* horion, which lasts for a few days only, is formed by the vegetations which cover the vitelline membrane at the time of the entrance of the ovule into the uterus. No vessels have yet appeared, but they carry nutritive matter from the uterus to the vitellus by endosmotic action. The second chorion is formed by the external layer of the blastoderm, which is composed of cells resulting from the segmentation of the vitellus. This layer, by gradual pres- sure against the vitelline membrane, at first lines it, and then causing its ab- sorption becomes itself the external envelope of the ovum or the second cho rion. The third chorion is formed by the allantoid, which is applied to the inter nal surface of the preceding chorion, and causing its atrophy by pressure, becomes the external membrane of the ovum which remains until the end of gestation. This membrane is at first covered entirely by vascular villi which, at a later period, remain only at the place where the placenta is developed. We thus find that these three parts are developed in the order mentioned; but the second chorion is not absorbed ; it remains, on the contrary, until the foetal evo- lution is completed, lined on its internal surface by the allantoid. the vascular loops of which enter the villi of the second chorion. Consequently the allantoid never becomes a chorion, meaning thereby the exter- nal layer of the ovum, nor is there any other chorion properly so called than the second one formed by the external layer of the blastoderm ; inasmuch as the vitel- line membrane does not deserve the name, although after the example of Bae'r and Coste, it has been applied to it by some authors. The vitelline membrane exists, indeed, only before the formation of the embryo, and disappears as soon as the lat- ter and its amniotic membrane become perceptible, leaving exposed the imperforate layer of the blastoderm, which takes the name of chorion. (Robin. Journal de 1 hysiologie, 1861.] But be that as it may, the chorion certainly does not exhibit the same aspect at the advanced stages of pregnancy: for during early embryonic existence the external membrane of the ovum is thin, transparent, and per- fectly smooth on its outer surface, whilst about the second week this surface presents some minute granular elevations, which increase in length very rapidly, and the chorion soon becomes studded with numerous villi. But at that time neither the chorion nor the villi have a proper vascular apparatus, since it is not until after the allantois, together with the umbilical vessels, has become applied to the chorion, that vessels can be detected going from this membrane to penetrate the villi. The chorion is enveloped in a great measure by the reflexed or epichorial dccidua, which separates it from the parietal decidua; and is in contact, by a restricted surface, with a portion of the mucous membrane which con- stitutes the utero-epichorial or inter-utero-placental decidna. There is at the outset a considerable space between its external surface and the internal one of the pouch containing it, which space is occupied by its villi, and may become, as we shall see, the seat of a considerable effusion of blood. Those villi which are in contact with the reflected dccidua, penetrate at first, as they increase in size, into the substance of that membrane; they 13 194 PREGNANCY. booh, however, become atrophied, and dwindle away almost completely, the interval disappears, and the two membranes come into immediate contact. As regards the villi of the chorion, not covered by the reflected decidua, bo far from being atrophied, they speedily undergo a considerable develop- ment, when they are in contact with the thickened and softened uterine mucous membrane (utero-placental decidua), and, intercrossing with the numerous vessels developed in its substance, contribute to the formation of that essentially vascular mass we are about to describe under the name of placenta. The chorion is in apposition by its internal face with the amnios at an advanced period of pregnancy ; but, as previously noticed, these two mem- branes are not concentric in the earlier months, being then separated by a considerable space that is occupied by the umbilical vesicle and an albumi- nous liquid, which is the more abundant and limpid as the gestation is less advanced. After the development of the placenta, the chorion is a thin, transparent, colorless membrane, united outwardly to the decidua by some short, delicate filaments, the remnants of the atrophied villi, and inwardly to the amnios by an albuminous layer (tunica media, reticulated body). The part corre- sponding to the placenta is no longer in immediate contact with the decidua; it is thicker, and adherent to the foetal surface of that vascular body, and the attachment is more intimate near the root of the cord. After what has already been stated, it were idle to discuss the vascularity of the chorion, f>r it evidently has no vessels until after the allantois has been developed ; but from that period it consists of two lamina?, the external or primitive of which, also called the exochorion, is wholly destitute of vessels, whilst the internal or allantoid is essentially vascular, and has been denominated the endochorion. ARTICLE IV. OF THE ORGANS OF CONNECTION. § 1. The Placenta. (After-birth, Secimdines.') The placenta is a soft, spongy mass, constituting the principal connection between the ovum and uterus, being destined to the hematosis, and perhaps also to the nourishment of the foetus. It is a flattened body, about three-quarters of an inch in thickness at the centre ; but tapering off towards the circumference, which does not often exceed two or three lines ; in some cases it is very thin, but then it is very large, and further, its figure and dimensions are exceedingly variable ; thus, the ordinary diameter of the placenta varies from six to eight and a half inches, at times one diameter is longer than the others, and the shape, there- fore, is circular, oval, &c, according to circumstances. The term battle- door-placenta has been applied to that variety in which the cord is inserted on the border. As a general rule, only one placenta exists in simple preg- nancies. However, a very curious exception was observed quite recently at the Clinique of the Berlin Hospital, namely, a double placenta for a single •mild. Dr. Ebert furnishes the following description of this anomaly ■ DEVELOPMENT OF THE HUMAN OVUM. 195 When displayed on a table, it was found to be divided into two exactly equal rounded parts, which were entirely distinct, having no connection whatever with each other, excepting through the intervention of the cord and membranes ; an interval of about three inches separated the two por- tions. The cord was twenty-one inches long, containing, as in the normal state, the three vessels spirally arranged, but this spiral form ceased nearly two inches from the bifurcation of the umbilical vein, at this point the two arteries were placed, one on each side of the vein, and only communicated by a trifling anastomosis. The vein bifurcated about four inches from the placenta ; the two result- ing branches were of unequal length, and the longest sent a branch to the opposite placenta. The arteries had a similar arrangement, one being sent to each after-birth. The one corresponding with the longest vein likewise sent a branch to the other placenta, but the interior subdivisions of the vessels offered no further anomaly. The membranes formed a single cavity for the fcetus and amniotic waters ; they invested the two portions of the cord, the fcetal face of both placentas, and passed from one organ to the oilier, thus establishing a kind of fiu.m. membranous bridge between them, which, with the cord, was the sole point of communication between these two masses. (Arch. G&n., 1842, t. xiv.) A similar case has recently oc- curred at the Clinique d' Accouche- ment de Paris, a drawing of which has been prepared by M. P. Dubois. A placenta presenting the same anomaly, was recently exhibited by me to the Biological Society. This specimen derived additional interest from the fact, that it was the pro- duct of a double pregnancy, the other ovum having a distinct and regularly formed placenta. A much more singular case has been obligingly communicated to me by Dr. Blot. In this instance, the placental mass presented nearly the usual appearance, but around it were distributed several entirely distinct cotyle- dons, which were connected with it only by the vessels proceeding from them to join the ramifications of the cord. (Fig. 64.) The after-birth presents a fcetal, or internal, and an external, or uterine surface; also a circumference, or border. The internal surface is covered both by the chorion and amnion, and exhibits numerous ramifications of the umbilical arteries and vein, which generally converge about the centre of this body to form the umbilical cord. The uterine surface is much les? smooth, polished, and uniform than the preceding, and ia slightly convex. whilst the former is a little concave. It is subdivided into a variable uuin^ Placenta, with five separate Cotyledons. Chorion, b. Amnion, c. The Cord. d. Separata cotyledons. 196 PREGNANCY. ber of lobes, or irregularly rounded cotyledons, held together by a lamel- lated, apparently albuminous tissue, which is so easily lacerated, that, a rup- ture may occur during the separation of the placenta, so that after its Fig. 68. Fig. 65. The internal, or foetal surface of the placenta. FIG. t'6. The external, or uterine surface of the placenta. expulsion, the cotyledons appear to be separated from each other by deep furrows or fissures. This surface is covered by a thin layer of adhesive matter through which the reddish and sanguinolent appearance of the coty- ledons is perceptible. The placental circumference is thin and irregular, and its extent, although very variable, is generally about twenty-five inches. The margin, accord- ing to M. Velpeau, is continuous, without a well-marked line of demarcation, with the double lamina formed by the folding of the deciduous membrane. But in the opinion of other anatomists, the periphery of this vascular mass is continuous with the chorion, and only contiguous to the double fold of the decidua, which is there thicker and more dense, and presents a kind of triangular sinus for the reception of the placental border. Our future remarks upon the structure of the placenta will serve to show that its circumference is continuous with both the chorion and the decidua; with the chorion by its foetal portion, which, after all, is formed by the h ypertrophied villi of the chorion ; and with the decidua or parietal mucous ;nombiane by its maternal portion, which is but a thickened part of this same uterine mucous membrane. [Structure. — That we may not be misled whilst studying the structure of the placenta, I think it best to state briefly the mariner in which it is formed. The history of its development shows that it formed of the villi of the chorion, the growth and ramification of which give rise to innumerable filaments which ingraft themselves upon the intermediate mucous membrane to which they soon adhere closely. The maternal vessels undergoing an inverse development form vast numbers of loops, which descend between the villi of the chorion and extend to the foetal surface of the placenta. An amorphous matter is soon deposited between the villi of the chorion uniting them together, and the placenta thus formed is at the same time a maternal and fcetal organ. The separation of the placenta after delivery takes place at the most superficial portion of the intermediate mucous membrane. (See Inter-utero-placental Decidua.) DEVELOPMENT OF THE HUMAN OVUM. 197 The foetal placenta comes entirely away, bringing with it the epithelial layer (if the inter-utero-placental decidua and the placental distribution of the maternal vessels. The thickest part of the intermediate mucous membrane remains, on the contrary, attached to the uterus. (See Decidua, and Lying-in stale.) Such, in short, are the principal phenomena which occur during the development and separation of the placenta, and they will serve to guide us amidst the different opinions which have been advanced respecting the structure of the organ.] The structure of the after-birth has been a theme of numerous discussions among embryologists ; but the researches of MM. Blandin, Jacquemier, Flourens, and Bonami, in our own times, and even yet more recently those of Reid, Weber, Coste, Eschricht, and Robin, have thrown much light on this subject. We have sought laboriously for the truth amongst these different opinions; and in believing that we have found it in the facts established by M. Robin, we are no less convinced that the task has been greatly facilitated by the researches of his predecessors. In order to render justice to all, we consider it our duty to give an analysis of the principal investigations which have been made in reference to this interesting point of ovology. If, while the placenta is still adherent to the uterine wall, a careful effort be made to detach it, we can easily see that this detachment takes place at the expense of a particular tissue, which at once separates and holds the two surfaces in contact. Now, this utero-placental substance is of an albu- minous or membranous nature, and is composed, according to Robin, of the epithelium of the intermediate decidua. This membranous layer (that has also been accurately described by M. Jacquemier) is moulded, as it were, on the irregular surface of the placenta, to which the adhesion is more per- fect than to the corresponding part of the womb ; it dips into the fissures that separate the cotyledons, unless these should happen to be very deep, in which case it merely passes from one lobe to another, thereby forming a 6pecies of membranous bridge; but a partition of the same nature much thicker than the preceding penetrates deeply between the lobes. The lamina clothing the external surface of the placenta is continuous with the decidua, without exhibiting any other difference, says the same author, than a considerable augmentation of thickness ; a disposition that is apparently mechanical, being due to the relief made by the projecting circumference of the after-birth, and which thus determines around that organ a greater accumulation of plastic material. According to that able anatomist, this membrane offers all the physical characters of the decidua ; and he seems quite disposed to consider them both as being one and the same. This inter-utero-placental tissue is traversed by a greal number of venous and arterial vessels, which pass from the internal surface of the uterus to the placenta (utero-placental vessels); but it does not appear to be th:> ultimate termination of a single blood-vessel. No trace of the injection remained, in this tissue, in the preparations just alluded to, made by M. Bonami. Let us proceed, however, to the vascular structure of the placenta, pro- perly so called; and, as 1 have witnessed the injections of M. Bonami, I cannot do better than transcribe here the following parts of his thesis : 198 PREGNAXCY. " An injection, composed of spirit-varnish, colored with red-lead, was first thrown into the venous system of the uterus through the primitive iliac and one of the ovarian veins. A second, consisting of spirits of turpentine and iudigo, was then made of the uterine arteries through the inferior extremity of the aorta, ligatures being previously placed on all the vessels capable of transmitting the injected fluids to the inferior extremities. " The uterine cavity having been opened at some distance from the placenta] insertion, and the foetus stripped of its membranes, a blackish liquid, which was nothing but the blood, was next squeezed from the vessels of the coid; then injections, having linseed-oil colored with white-lead and yellow ochre as their base, were thrown into the umbilical vein, and into one of the arteries." These injections were made with the greatest possible precaution, and the following results were afterwards obtained from a careful dissection : " At first, the red liquid injected into the uterine veins could be distinctly per- ceived on the foetal surface of the placenta. But, by what canals could the injection have penetrated so far as this? Here was a new subject of research ; but, by carefully turning the placenta aside, a considerable number of small vessels could easily be recognized, leaving the internal surface of the womb, traversing the inter-utero-placental tissue just described, and plunging into the substance of the placenta. These consisted of arteries and veins, readily cognizable as such by the different colored injections." 1st. Arteries. — The number of these is large, and they are more abundant near the centre of insertion than anywhere else; still, a few very delicate ones are found about an inch from the placental circumference. Generally, they are quite small, varying from a fourth of a line to a line in diameter. They assume very sensibly a spiral arrangement, and their course is oblique, almost always creeping along for a third of an inch, sometimes more, before their terminal extremities are directed towards the anfractuosities of the placenta ; and they evidently penetrate the proper substance of the latter, though towards the uterus they are clearly continuous with the uterine arteries. Lastly, they have but few ramifications, and these rarely anasto- mose with each other. 2d. The veins pass from the uterus, through the inter-utero-placental membrane, towards the placenta, but they have not the same disposition as the arteries. The calibre of these veins, says M. Bonami, is nearly equal to that of the arteries, sometimes even a little larger, some of them being from two to three lines in diameter. The characters by which we could distinguish these from the arteries, were conclusive in the piece under examination. Thus, these veins were penetrated by liquids thrown into the uterine venous system ; they were rectilinear, and their exceedingly numerous ramifications anastomosed freely with each other, thereby forming vast plexuses on the cell-walls, which penetrated the uterine surface of the placenta at all points; and, on the other hand, by further dissection, could be seen with the naked eye terminating in the large uterine veins. Besides these, according to Meckel and Jacquemier, there exists a vein which encircles the periphery of the placen f fl ; but this coronary vein is rarely complete, as it nearly DEVELOPMENT OF THE HUMAN OVUM. 199 always exhibits one or more interruptions of an inch or two in extent, although its continuity is sustained by a series of veins anastomosing with one another, and its course exhibits numerous varicose-like dilatations. It communicates, at short distances, with the uterine veins, and receives con tributions both internally and externally ; some of these spread over the uterine surface of the placenta, and anastomose with the veins that penetrate this body at its centre; the others, which are less numerous, ramify in the substance of the decidua, two or three inches from the circumference of the placenta. M. Robin says that it resembles a uterine sinus, and is more properly one of the latter excavated in the mucous membrane than a true vein. The presence of this coronary vein is not constant, for neither Vel- peau nor Bonami have ever met with it. There are, therefore, certain arteries and veins that penetrate the placenta, belonging to the maternal vascular system ; but before studying their dis- tribution, let us examine that of the umbilical vessels. These, consisting of the umbilical arteries and vein, having arrived at the fcetal surface of the placenta, divide into several large branches that are found between the amnion and chorion. The first of these membranes may be detached with great facility; but the second intimately adheres to the vessels, which it completely envelops, thus forming a sheath in which one artery and one vein are always found, the vein being much the larger ; shortly after, each trunk divides into two branches, each of these into two others, and thus they go on subdividing dichotomously almost ad infinitum. The two umbilical arteries communicate freely with each other in the substance of the same cotyledon, and this anastomosis may even be seen without the aid of an injection. Again, if a coarse injection be thrown into one of the arteries, it will shortly return by the other ; though, if the pressure be con- tinued, it will pass from the arteries into the umbilical vein ; but if we commence by filling the vein, the injection reaches the arteries with more difficulty. If a very penetrating mixture be used, the whole uterine surface of the placenta will be converted into a very delicate plexus, which never affords an outlet to the injected liquid ; patulous orifices do not exist, there- fore, at the extremities of the vessels. When a placenta has been thus injected, and is then macerated, it soon appears to resolve itself into a substance resembling woolly flakes covered by numerous particles of a soft pulpy tissue, that is detached from them with much difficulty. These flakes present under the microscope a large number of granulations, composed of small, convoluted, twisted vessels, like those in the chorial villi of the cow or the sheep. These small granules have been described as acini, or little grains. The vessels become longer as the maceration is continued, and finally lose flexuosity almost entirely. On the whole, therefore, the placenta is formed by vessels belonging to the mother as well as by those appertaining to the child, and each of its cotyledons is constituted in the following manner: the maternal, or utero- placental vessels penetrate at all points of its uterine surface, forming in ita hubstance a net-work of exceedingly delicate meshes, while the umbilical vessels that penetrate on the fcetal surface present those infinite ramifica- tions just described, and these twist around and em brat e the contracted 200 PREGNANCY. meshes of the maternal plexus in all directions. Further, the connection existing between these two orders of vessels appears to result from the mem- branous sheath that envelops them both, even into the substance of the placenta. This sheath is furnished to one set by the chorion, to the other by the extremely delicate prolongations of the maternal vessels. In other words, being compressed and united with each other through the intervention of a common substance, these divisions and subdivisions form a cotyledon of the placenta. Again, all the minute vascular ramuscles are so intimately connected that it is impossible to separate the vessels belonging to the mother from those peculiar to the foetus, and they can only be distinguished from each uther by the different colored injections. But, although the two series thus interlace, the maternal branches never communicate by their terminal extremities with those of the foetus ; since the finest injections, when most carefully made, have never established a direct communication between these two orders of vessels, — unless by rupture of the walls. The description of Eschricht is very analogous to that of M. Bonami ; thus, the former concludes that two orders of capillary plexuses are in con- tact in the human placenta, and that the uterine arteries are continuous with the veins of the same name through a capillary plexus, equally deli- cate with the one existing between the umbilical arteries and veins. But the researches of Weber have led to different conclusions as to the mode in which the uterine arteries run into the veins of a similar name in the placenta, and these curious results deserve some notice, inasmuch as they seem to form a natural transition to the arrangement which we shall describe hereafter. He states that the uterine arteries enter the after-birth without giving off any arborescent ramifications ; and, on the other hand, that the veins do not arise by delicate ramuscles, but present, at their very origin, large trunks, which by anastomosing with each other very frequently and at all points, seem to form in this manner a system of cells, whence the blood then passes by some venous trunks into the uterine veins. These latter are continuous with the arterial tubes from their origin ; their walls are excessively thin in the placenta, being there reduced to the internal coat, and collapse, so as to be nearly invisible when they contain but little blood. The terminal rami- fications of the umbilical vessels project into these venous sinuses; more- over, the thin tunic of the vein is pushed into the interior of the vessel bv the foetal villus resting against its outer surface, and it thus furnishes a sheath to the latter, which seems to penetrate to the interior even of the maternal vascular tube, though in reality it does not. Read, in August, 1840, easily verified, he says, the existence of the utero- placental vessels, when examining the uterus of a pregnant woman, who died at the seventh month. After having detached a portion of the placenta underwater, my atten- tion was drawn to a number of rounded bands passing between the uterus and the external surface of the placenta. When the least traction was made, their walls became thinner as their length increased, and had a eel- DEVELOPMENT OF THE HUMAN OVUM. 201 iular appearance, though they were easily lacerated ; whilst sometimes, though more rarely, they seem to separate like the tufts of the uterine sin- uses. By cutting into one of the sinuses, these tufts could be traced, and Been to ramify in its interior ; some seemed to penetrate the patulous open- ing of the sinus only, while others sank in for about an inch, and appeared to penetrate even the surrounding sinuses. I could easily satisfy myself by injection and microscopical inspection, that these tufts were the ultimate ramifications of the umbilical vessels. It is scarcely necessary to add, that these tufts only penetrate the open- ings of the sinuses situated near the internal surface of the uterus, and not those more deeply seated. Their volume varies very much, some appearing to fill the opening of the sinus entirely, whilst others only occupy it in part. Again, although the tufts appeared loose, and floating in the interior of the maternal vascular tube, yet they were evidently surrounded by the internal tunic of the latter, which was reflected on their external surface. I have assured myself that some of the utero-placental veins contained no prolongation of the foetal vessels, but in many others the villous tufts (the terminations of the umbilical vessels) could be recognized and followed into the uterine sinuses. In tracing these utero-placental veins that contain no fcetal vessels through the decidua to the surface of the placenta, the internal membrane of such veins is found prolonged on the neighboring placental tufts ; and further, by following a large utero-placental artery through the decidua, we may see that as soon as it arrives on the face of the placenta, its internal tunic is prolonged on certain tufts that are found plunged in its orifice. The numerous branches of the foetal tufts which stop at the placental sur- face of the decidua, and neither penetrate into the uterine sinuses, nor yet into the orifices of the utero-placental vessels, are fixed by their extremities to the placental surface of this membrane. Consequently, the placenta is formed interiorly by numerous trunks and branches (each containing an artery and a vein), and each of these branches, both venous and arterial, is surrounded by a prolongation of the internal tunic belonging to the maternal vascular system, or at least by a membrane continuous with that tunic. Hence, in adopting such ideas of the placental structure, it becomes evident that the internal tunic of the mother's vessels is prolonged on each placental tuft, in such a manner that the maternal blood, arriving by the utero-placental arteries, passes into a large sac formed from the internal lamina of these vessels, and the blood is thus divided into a thousand dif- ferent directions by the placental villi, which project like fringes into these vessels, pressing in their thin, soft parietes before them, and forming sheaths therefrom which completely envelop each trunk and each branch. The blood returns from this sac by the utero-placental veins without any extra- vasation or abandonment of the vascular system to which it properly belongs. Therefore, the foetal blood, and that of the mother, can have no action upon each other, excepting through the spongy parietes of the foetal vessels and the thin sac that surrounds them. It will be seen that but a single step has now to be taken in order to reach the description given by M. Coste. 202 PREGNANCY It is really impossible to obtain a correct idea of the structure and devel- opment of the placenta, without being acquainted with the nature and structure of the villi of the chorion, as also with the changes undergone by that portion of the uterine mucous membrane (utero-epichorial decidual upon which the ovule is ingrafted. a. Villi of the Chorion. — We have already stated that before the allantoic! is developed, each villus of the chorion contains a canal, which is open at its base, but terminates in a cul-de-sac at its free extremity ; after the allan- toid is developed, the terminal ramifications of the umbilical vessels, both arteries and veins, penetrate into this canal as into the finger of a glove. The villi, after having been thus rendered vascular, become atrophied, and This figure represents the manner in which the villi of the chorion ramify. — C. Trunk of the villus. E. Terminal ramification intact. O. A terminal branch broken off. V. A lateral branch. finally disappear from all that part of the chorion which is covered by the reflected or epichorial decidua. Those, on the contrary, which are in imme- diate contact with the utero-epichorial mucous membrane (inter-utero- placental decidua of authors), undergo a considerable development, and ramify ad infinitum. When viewed collectively at this period, they have the appearance of a soft, hairy mass, very tufted and flaky, and of a semi- transparent gray rose-color. If the villi which compose this hair-like mass of the chorion be separated from each other and examined, the following characters will be found Applicable to all: a common pedicle, forming the base or trunk of the villus, about one-sixteenth of an inch long, and one-half as wide, for an ovum of six week-, the dimensions varying, however, with the size cf the ovum. From this pedicle are pul forth numerous branches, forming a bulky tuft. The largest of these branches, after dividing two or three times, are again subdivided into innumerable minute branchlets. DEVELOPMENT OF THE HUMAN OVL'M. 203 Again, some of the smaller branches stand alone upon the surface of the chorion, in the interspaces of the tufted pedicles just mentioned. The extremities of the subdivisions of the third and fourth orders are here and there found to present a sort of cylindric or flattened swelling. One of the principal subdivisions of the umbilical arteries and veins is distributed to each of these pedicles, and extends into all of its branches, ramifying as it goes. Inasmuch as the branches of any one pedicle have no communication with those of a neighboring one, it follows that each tuft of the chorion has a circulation of its own. Although the terminal villi become longer, their thickness is not sensibly increased, for their diameter is nearly the same after, as before the develop- ment of the placenta. B. Utero-epichorial Mucous Membrane. — These hypertrophied villi come in contact with a very thick and much softened portion of the uterine mucous membrane. As they grow longer, they penetrate into the tissue of the mucous membrane itself, excavating therein a species of cells or lacuna?, which can be seen without difficulty upon the bottom of the receptacle represented in Plate III., Fig. 53. Since the arteries, but more especially the veins, are so developed at this point that the frequent dilatations of the latter form large cavities or sinuses, from one-eighth to one-quarter of an inch in diameter, the vascular villi of the chorion necessarily come in contact with the walls of the uterine vessels. According to M. Coste, the latter are even worn through by the villi of the chorion, which having thus ga'ned entrance into their cavities, are sus- pended freely in the blood which fills them. Soon these infinitely numerous and elongated villi become united to each other by means of an amorphous substance, which is deposited in small quantity amongst them, so as to give to each tuft of the same pedicle the compactness which each placental cotyledon presents at a more advanced period of pregnancy. The villi taken from the placenta immediately after labor, differ from those described only in the greater number of their ramifications, and the larger size of the pedicles and of the principal branches which they put forth. The foetal portion of the placental tissue is formed, in short, of interlaced filaments, which are simply the chief branches of the villi of the chorion, whose ramiiications can be followed to their termination only by the use of a lens, so inextricably entangled are they, and agglutinated by the amor- phous matter of which we have spoken. They thus form, by their agglom- eration, a tissue of a reddish-gray color, soft, elastic, giving way to pressure of the finger, and yielding a filamentous fragment by tearing. The structure of all the villi is not, however, identical at the termination of pregnancy. Although the greater number preserve until the end the double vascular canal which they presented at the beginning, the vessels of a few become atrophied, and like the non-placental villi, finally constitute a very slender filament devoid of a canal. Fig. 68, for which I am indebted to the kindness of M. Robin, exhibits these dillerences, besides showing 204 PREGNANCY. very clearly the admirable disposition of the fetal vessel within the riilua itself. 1 Thus H and T represent a terminal prolongation of the branches of a placental villus, ovoid in shape, with a contracted pedicle and obliterated cavity; at B is another terminal prolongation of the same villus, having the structure which almost all of them retain in the placenta. It is composed of an external envelope b, or wall of the villus, of a structure identical with that of the chorion. Its thickness, and consequently that of the substance separating the blood of the foetus from that of the mother, may be estimated approximative^. It is about '0004 of an inch. This villus presents internally a partition, a, dividing its cavity into two vascular tubes. The tubes are situated beside each other, like the barrels of a double-barrelled gun ; they bend toward each other at a", so as to form a single canal at the extremity of the ^ illus, which is arterial at d e, but venous at g' g. This partition a has only half the thickness of the external wall b. It has a spur-like termination at a", and adheres by its base at a' to the wall of the villus. When this disposition of the terminal ramifications is once understood, all discussion, as M. Robin remarks, respecting a direct communication between the maternal and foetal vascular systems, is ended. Each of the capillary vessels of this double canal empties into a corre- sponding one of larger size, at the point of junction or of separation of a ramification with a larger branch ; for example (Fig. 68), the arterial tube Fio. 68. The figure represents a fragment of the villi of the chorion obtained from the placenta. It exhibits prolongations of various appearance. Magnified 360 diameters. D E empties at a' into the trunk of the same nature of the principal branch C V, and the venous tube g' G discharges at the point C. 1 Tlio minute details into which I am about to enter, are the analysis of the researches of my learned colleague and friend, M. Robin. They are for the most part recorded in an excellent memoir published by him, and also in the thesis of M. Cayla, one of (lis pupils DEVELOPMENT OF THE HUMAN* OVUM. 205 The placenta is therefore composed of two parts, which are very distinct, in a physiological point of view, although they are confounded in a single mass at the end of gestation. One of these is the foetal portion, and is more especially adherent to the chorion, from which it takes its origin ; the other the maternal portion, is a greatly thickened part of the uterine mucous membrane. It is very difficult to say what is the real mode of connection between these two elements of the placenta, since such different results have followed the dissections of the most skilful anatomists. Their continuity, or direct communication, is at present, however, out of the question, for all are united in regarding their relation as one of simple contact, a greater or less extent of adhesion. [The foregoing represents what was known until within a few years past, of the structure of the placenta. More recently, Professor Robin, who at first accepted the ideas of M. Coste, has changed his opinion on the subject, and we have now to state his present views. (Various memoirs and oral communications.) A close examination of the external surface of the placenta, will soon show that the entire surface of the cotyledons is covered by a grayish, semi-transparent, and soft membrane, from the ^ 5 to the ^ of an inch in thickness in different specimens. This membrane, whose existence we have already asserted, is sometimes smooth, sometimes rough, quite elastic and adhesive, and of a peculiar appearance. It passes without interruption from one cotyledon to another, being only rather thicker in the interstices. It is formed by the epithelium of the inter-utero-placental mucous membrane in its thickened and hypertrophied condition. A few other elements, derived from the most superficial portion of the same mucous membrane, are also found in it, such as laminated fibres, amorphous matter, and molecular granules of various kinds. This layer represents the maternal placenta, and is traversed by a profusion of maternal capillary vessels which pass into the body of the placenta. If these vessels be followed into the soft, grayish, and glutinous layer, just described, we find that they become gradually flatter and more irregular; they are distributed over the convex surface of the cotyledons and in their interstices, and at all these points enter deeply in an oblique direction toward the foetal surface of the placenta. In pursuing this course, their walls become so extremely thin that they are often discerned with great difficulty. (Robin. Communications orales.) Having entered the placental tissue, they dilate and communicate so largely as to form throughout the entire mass of the placenta a pool of blood, which bathes the entire placental surface of the chorion at the point of attachment of the pedicle of each villus. This expanse of blood penetrates the fine sponge-like interstices between the reticulated ramifications of the villi, but nowhere is there any direct communication between the maternal and foetal blood. Beneath the preceding layer is found the foetal placenta, which constitutes the greater bulk of the organ and is formed by the expansion of the villi of the chorion agglutinated by amorphous matter. Amongst these villi are distributed the numerous maternal vessels. The glutinous layer, formed by the epithelium of the serotina at the surface of the placenta, is always present, unless accidentally removed: thus proving the very important fact that the placental villi are not plunged freely by means of floating extremities in the sinuses of the serotina. The cotyledons, it is true, project toward the utero-placental mucous membrane which, in its turn, penetrates somewhat into the furrows which separate the cotyledons: still, their convex surfaces are merely 206 PREGNANCY. applied against the sinnses of the serotina. which glide between the villi in ordei to open into the above-mentioned pool of blood resulting from the enormous dilata- tion and tha destruction here and there of the walls of the capillaries of the super- ficial net-work of this part of the mucous membrane. The adhesion between the cotyledons and the mucous membrane is molecular and so intimate, that, instead of merely separating from the latter, it brings away with it the superficial layer of the serotina. Notwithstanding this, it is true that, in an anatomical point of view, the cotyle- dons, in fact the placenta, are merely applied by the surface, against the inter- mediate mucous membrane. The foetal villi are not plunged in the form of arborescent or radical branches in the tissue of the serotina, as all the descriptions would seem to indicate, but it were more correct to regard the maternal blood as seeking them at a certain depth in the mass of the cotyledons.] The placenta appears to be destitute of nerves and lymphatic vessels. All the cotyledons composing the placental mass are, as we have said, united by the interlobular membrane. Occasionally, however, one or several of these lobes are separated from the others, and seem to form another placenta by their isolation ; in this way it has happened that several placentas have been attributed to a single fetus, and, perhaps, the facts mentioned at the beginning of this article are to be accounted for in the same way. The placenta may be inserted upon any part of the uterine cavity, and even upon its orifice, though most usually it is fixed near the fundus of the organ. It has been customary to account for these varieties of insertion, by eaying that the latter is determined by the most vascular portion of the organ ; overlooking the fact, that, although the point of attachment be indeed more vascular than any other part of the uterine parietes, it is simply because of the insertion, thus confounding the cause with the effect. According to some authors, the weight of the ovule determines the point of insertion of the placenta, which, if true, should most frequently take place upon the neck. Observation, however, refutes this opinion. Finally, accord- ing to MM. Moreau and Velpeau, when the ovule enters the womb, it is obliged to separate the decidua from the wall of the uterus, and therefore naturally tends towards the points of least resistance. The details which we have given respecting the mode of formation of the decidua, show that the latter opinion is without foundation. The following seems to us to be the most probable explanation : Generally, by the time the ovule enters the uterine cavity, the latter is filled to repletion by the folded and swollen mucous membrane. This state of things renders it almost impossible that it should progress very far, and the consequence is, that in the vast majority of cases it lodges in one of the numerous folds neat the fundus, and becomes attached in the vicinity of the orifice of the tube by which it entered. The placenta is, in fact, generally found in this neighborhood. Why, in some cases, it should be situated in the inferior segment of the womb, is of more difficult explanation, except upon the sup- position that fecundation was effected after the arrival of the ovule in the uterine cavity; in which case, in consequence of the less swollen condition of the mucous membrane, it may have been able to obey the laws of gravity immediately upon entering the cavity, and thus descend towards the lowest points. DEVELOPMENT OF THE HUMAN OVUM. 207 Sometimes the insertion of the placenta upon the lower segment of the aterus occurs in several successive pregnancies. Ingleby relates one case in which it happened three times, and says he knew the same thing to occur ten times in another. M. Dunal, from whom I quote the above, gives an observation of M. Menard, in which the woman had this unfavorable inser- tion twice consecutively. Whether this sort of habit can depend upon a peculiar disposition of the Fallopian tube or of the uterus, is a question which anatomical research only is competent to decide. § 2. The Umbilical Coed. The umbilical cord is the flexible trunk, which unites the abdomen of the child to the placenta; it does not exist during the early weeks of preg- nancy, and its formation only commences when the embryo is completely separated from the blastodermic vesicle, which thereby becomes the umbili- cal vesicle; when the allantois, by being confounded with the external lamina of the blastoderm, no longer constitutes a distinct vesicle, but i9 merely a simple cord upon which the two umbilical arteries and the vein ramify ; and when all these parts have received an enveloping sheath from the amnios. Now it scarcely appears thus formed until towards the end of the first month, being composed at this period, in all normal embryos of the age of the one which we shall describe (page 210), of three distinct parts : 1, of an enveloping canal, whose walls are formed by a reflection of the amnios, and which is continuous at the umbilicus with the skin of the embryo ; 2, of two pedicles proceeding from the fcetal appendages, around which this amniotic canal forms a sheath, and which communicate, the one under the name of the pedicle of the umbilical vesicle, with the ileo-ccecal fold of intestine, and the other, under the name of urachus, or the pedicle of the allantois, with the bladder. But soon after, as the development progresses, and the pedicle of the umbilical vesicle is absorbed, the cord becomes simplified, and is reduced to the amniotic sheath and the urachus, accompanied by the umbilical ves- sels, with which this sheath is confounded by the obliteration of the canal that constitutes it. The effacement of this canal, along which only the urachus and its accompanying vessels pass, progresses from the chorial extremity of the cord towards the umbilicus, or abdomen of the embryo ; and, as the progressive obliteration approaches the latter, it encounters the intestine which advances beyond the umbilicus, and forms a hernia in the cord itself; but this rupture is naturally reduced, in consequence of the pressure exercised on the bowel by the progress of effacement, which ulti- mately reaches the navel, and presses back into the abdomen everything met with outside of its cavity. However, in some instances this process is not completed in so efficacious a manner, and the intestine in such cases remaining beyond the umbilicus, produces the malformation known as con- genital hernia; a hernia that is nothing more than the persistence of an inatomical disposition, which always exists temporarily at a certain period of the embryonic life. The cord, at the end of the first month, is still thin, cylindrical, and very small; but from the fourth to the eighth, and even the ninth week, it 208 PREGNANCY. acquires a considerable proportional volume; and it exhibits either som« enhirgements, vesicles, or swellings, two, three, or four in number, whicn are separated from each other by a corresponding number of bands, or con- tractions. During the third month it diminishes in size, in consequence of a retrac- tion of these tuberosities ; but again, commencing from this latter period, it continues to grow proportionally to the other parts of the foetus until the end of gestation. The cord varies greatly in length at term : generally, it is from twenty- one to twenty-three inches ; some have been observed, however, from six inches to five feet (one metre fifty-three centimetres) ; others, still more rare, have reached five feet nine inches in length (one metre seventy-five centimetres). I delivered a woman with the forceps, June 23, 1841, in whom the head had been retained above the superior strait, and where the cord was only nine inches long. These extremes are very rare; neverthe- less, they are not the utmost varieties the cord may offer in its extreme limits, for it has been known not to exceed five inches, and has even been as short as two inches. In a case reported by Mende, it was so short that the placenta absolutely seemed fixed to the child's abdomen. Its size likewise varies in different subjects, being generally about that of the little finger, sometimes much smaller, and at others very large ; but in all these cases its volume depends much less on that of the vessels than on the quantity of fluids accumulated in the surrounding tissue. The nerves and lymphatic vessels, which certain authors have described as belonging to the cord, are still a subject of research ; admitted by some and denied by others, their existence is at least problematical. The arteries are two in number, and, following the course of the blood, they arise from the bifurcation of the abdominal aorta in the fcetus, and reach the umbilicus, whence they traverse the entire length of the cord, describing numerous flexuosities as far as the placenta, in the tissue of which we have already followed their ramifications. The vein, still following the route of the blood, arises from the numerous minuscules studied in the placenta ; the venous radicles of each lobe unite to form branches, which in their turn aggregate on the foetal surface of the after-birth, to form there the trunk of the umbilical vein ; and the latter, having arrived at the umbilical ring, abandons the two arteries, and run9 towards the Fiver. (See Circulation of the fcetus.) The vein is nearly equal in size to the two arteries united; but it is much less flexuous, and conse- quently its course is shorter. These vessels are wound upon each other in a way nearly similar to the twigs of osier forming the handle of a basket ; they give off no branches in the cord, and it has been remarked that the twisting of the vessels, which only begins after the second month, takes place, nine times in ten, from left to right. The vein usually occupies the axis of the cord, and the arteries wind uniformly around it. Of course, this enrolling must depend somewhat on the torsions of the embryo itself, and then the entire cord, together with "ts sheath, is involved, as not unfrequently happens; but when the cord ia DEVELOPMENT OF THE HUMAN OVUM. 209 straight, and the arteries are twisted at least more than it is, these contortions seem to result from a more rapid growth of the vessels within the sheath, than of the sheath itself (Haller). Now, the embryo and placenta being immovable, the turns starting from these two points will necessarily meet each other, and this indeed frequently takes place. Two, and even three umbilical veins have been met with in some cases ; in others, instead of twc arteries there is but one. Osiander once found three of the latter. It is worthy of remark, that neither the arteries nor the veins have valves at any part of their course. These vessels are surrounded by a gelatinous substance called Wharton's gelatine, which is variable in its quantity, thereby giving rise to the division made by accoucheurs into the thin and fat cords. This substance is con- tinuous on one part with the sub-peritoneal cellular tissue of the foetus, and, on the other, accompanies the vessels into the placenta. Being spongy in character, it is constituted by a clear, tenacious liquid, contained in the cellular areolae, that communicate so freely with each other. The cord frequently has one or more knots when it is very long, some of which are formed during pregnancy, and often even at an early stage; but others arc. only produced at the period of labor: they never become so tightened (in gestation) as to compromise the life of the child, to Avhose movements they are certainly due; but we can understand that the cord may become tightly drawn during labor, from being shortened by circular turns around the trunk or neck ; the knots, in such cases, may be so hardened as to intercept the circulation completely, and the death of the foetus will necessarily result if the labor be prolonged. In one case, figured in the work of M. Baude- locque, the cord was knotted three times at the same place, and was inter- laced like a mat. 1 M. Soete, an accoucheur at Gheluwe, has described a very singular case of double pregnancy, in which the two foetuses were inclosed in the same bag, and the two cords formed a perfect knot with each other. Besides these knots, true nodosities likewise exist at times in the cord, pro- duced either by the duplicature or the varicose state of one of its vessels. We have already stated that the cord is attached by one extremity to the umbilicus of the child, and by the other to some point of the foetal surface of the placenta ; but this, however, is not always the case, for the facts are too numerous which go to prove that the cord may An anomaly, described by Benckteer. indeed be inserted on the head, neck, shoulders, and other parte of the Fig. 69. 1 The ancients thought they could determine the fecundity of the female by these knots: thus, according to Avicenna. the more knots the more will be the future con ceptions; and if they occur at some distance apart, the pregnancies will also he more distant from each other. — (fsrselis Spachii gynieeeorum lihri.) 14 210 PREGNANCY. foetal trunk, not to admit some of them, at least ; such, for example, as the one observed by M. Jules Cloquet, at Brussels. The placental extremity of the cord also presents some anomalies ; it is usually fixed very near the centre, but sometimes is found attached to a part of the periphery, bearing then the title of the battledoor-placenta. Nor is it always attached to a point of the foetal surface of the placenta. For instance, Benckiser has collected in his thesis numerous cases in which the cord was inserted at some point on the periphery of the membranes; and having arrived there, the vessels of the cord then divide into five or six large trunks, the branches of which, by ramifying between the membranes, reach the placental circumference, and plunge into the parenchyma of this body. (See Fig. 69.) All such modifications, however, merely depend on the way in which the allantois contracts its adhesions with the point of the ovum in contact with the womb. In fact, the placenta is always developed there, and if the allantois happens to strike the chorion at a point somewhat removed from that which is in apposition with the internal uterine surface, the umbilical vessels must evidently have a tendency towards the latter, just as the roots of a plant always stretch towards the spot which will afford them the most nourishment. CHAPTER Y. OF THE FCETUS. We shall not attempt to study the foetus by describing the different organs, and the various tissues successively, that enter into its structure at the moment of birth, nor by tracing each of them through the modifications it undergoes at the divers periods of the intra-uterine life; for such a course would evidently compel us to overstep the limits imposed by the nature and character of this work. Therefore, laying aside all embryological researches, we shall content ourselves with mentioning a few interesting particulars of organogeny; and while considering the foetus in a general manner, we shall point out succinctly the successive development of its form and its external parts. But before entering upon this subject, we believe it will prove profitable to present, in a figure, the various details already furnished, as such an exposition will complete the description previously made, and facilitate a knowledge of the facts we have yet to speak of. EXPLANATION OF THE FIGURES IN PLATE III. lie. 1. The human ovum, of its natural size, at about the thirtieth or thirty-sixth day. Fig. 2. The Bame ovum (of its natural size) laid open to show its constituent parts. a a. The chorion. n. The amnion. c. The foetus. i). The umbilical vessel. Pig, 3. The same ovum highly magnified, and opened in such a way as to exhibit the principal relations existing between the embryo and its appendages. The walls >?W- I Fig. JC ■-W •a&ftl r/ "I'?^%, 4 K O M. OF THE FCETUS. 211 of the abdomen an J chest have been cut away so as to bring the viscera into view, and the umbilical cord has also been split up, for the purpose of showing how the appen- dages of the foetus are brought into relation with this latter. a a. The chorion, consisting of two layers, placed back to back, and confounded with each other, but which have been dissected apart for a limited extent at a / a'. b b. The amnion, laid open, so as to show how it is continuous with the umbilical cord, along which it is reflected, thereby forming a sheath, which, under the form of • the canal b' b', is directly continuous with the umbilicus or the abdominal walls c of the embryo. d. The umbilical vesicle, and d' its pedicle. d // . The point where this pedicle communicates with the intestine e. e. The loop of intestine prolonged into the cord. f. The urachus, continuous by one extremity, g, with the chorion, and by the other with the rectum at the point h. ii. The umbilical arteries. j. The umbilical vein. y. The part of the right auricle from which the umbilical vein comes off. k. The vena cava inferior. m. The inferior surface of the liver. n. The omphalo-mesenteric vein. 0. The point where this vein empties into the umbilical vein, p. The omphalo-mesenteric artery. 1. The heart. 2. The arch of the aorta. 3. The pulmonary artery. 4. The lung of the right side. 5 The Wolffian body. 6. The branchial fissure, which is converted into the external ear. 7. The lower jaw. 8. The upper jaw. 9. The nostril of the right side. 10. The nasal canal still forming a kind of fissure, which extends from the eye to he nostril. 11. The caudal extremity, or coccyx, projecting like a tail. 12. The upper extremity. 13. The lower extremity. ARTICLE I. DIMENSIONS AND WEIGHT OF THE FffiTUS AT THE DIFFERENT PERIODS OF INTRA-UTERINE LIFE. At the time when the embryo first begins to be distinct, that is, about the third week, it is oblong, swollen in the middle, obtuse at one extremity, though drawn to a blunt point at the other, and straight, or nearly so, being somewhat curved forwards. It is therefore vermiform in shape, of a grayish- white color, semi-opaque, almost without consistence, and gelatinous, vary- ing from two to four lines in length, and weighing one or two grains. At this period, the only trace of the head is a small tubercle separated from the rest of the body by a notch, but no rudiments of the extremities are observed, nor is there a cord at first. The embryo is clearly surrounded by the amnion, which lies quite near it, in the form of a delicate membrane, leaving it, however, always free. The abdominal cavity is opened for a very considerable extent in front. The embryo becomes more consistent towards the fifth week: its head then 212 PREGNANCY. increases greatly, in proportion to the remainder of the body, and the rudimentary eyes are indicated by two black'spots turned towards the sides; the development of the thoracic extremities is announced by two small, obtuse nipples, situated on the sides of the trunk ; it is nearly two-thirds of an inch long, and weighs about fifteen grains ; the cord exists in a rudi- mentary condition, and the abdominal members are likewise present, in the form of two rounded pimples. The vertebral divisions are quite apparent, all along the back, although the caudal vertebra; closely approach the front part of the head, in consequence of the anterior curvature of the embryo. Already does the heart exhibit, in its external form, a tolerably close resemblance to that in the adult ; for we may even now observe the fissure that will afterwards separate the auricles, as also one corresponding to the inter-ventricular partition ; but there is, in reality, only one ventricle, from which both the aorta and the pulmonary artery arise. And, further, there is but one auricle ; or, rather, the two communicate so freely that the inter- mediary contraction which should divide them is still very imperfect ; for the partition is formed by the progressive contraction of the orifice of com- munication, and this incomplete opening, which sometimes persists in the septum until birth, is known under the name of the foramen of Botal. But, after birth, the opening becomes obliterated, and the two auricles are thence- forth isolated by a complete partition. The single ventricle will be converted into two cavities, by the interven- tion of a septum, which will be gradually developed from the summit towards the base, being placed between- the two arteries (the pulmonary and aorta), and so disposed that one of them shall open into the right and the other into the left cavity. The lungs at this period are constituted of five or six lobules, in which we can readily distinguish the bronchial extremities, terminating in slightly swollen cul-de-sacs. Moreover, two large glandular structures lie along the vertebral column at this period, extending longitudinally on each side, from the lung to the bottom of the pelvis. These are the Wolffian bodies. They are constituted by an excretory canal, which runs throughout their whole length, being placed on their external margin, and terminating below in the transitory cloaca. The canal puts forth, on one of its sides only, a series of more or less elongated coeca, which roll or curl up, so as to form a considerable mass by their agglomeration. These coeca secrete a liquid, which is subsequently emptied into the cloaca by means of the canal. The Wolffian bodies anticipate the function of the kidneys until the latter are developed, and hence they have been denominated the false kidneys; but they disappear as soon as the true organs can replace them, leaving no trace of their past existence. Just alongside of the excretory canal, in the Wolffian body, a second one is seen to accompany it through- out, and even in like, manner to empty into the cloaca. But this second canal is perfectly distinct from the other, and will become, in the adult, either the oviduct or the vas deferens, according as the new being shall be of the male or female sex. In the early stages of embryonic life, there likewise exists on each side of the neck in the human fetus, as also in the mammalia, four transverse OF THE FCETUS. 213 fissures which open into the pharynx. These are separated from one another by certain bands, or fleshy partitions, that correspond with the branchial arcs of fishes ; for the vascular apparatus distributed there affects, to a cer- tain extent, the same form temporarily, that it has permanently in the inferior vertebrate. We, therefore, see that the bulb of the aorta, instead of curv- ing immediately in a single arch, divides, on the contrary, into three or four branches, on each side of the neck ; and after these branches have each accompanied a branchial arch, they reunite, at a common point, to form the descending aorta; however, they are soon effaced,, along with the corre- sponding fissures, and but two remain on the left side, one of which is con- verted into the arcus aortse, while the other, after having existed as an arterial canal, will form the common trunk of the pulmonary arteries. The branchial fissures just under consideration also disappear, with the exception of a single one (the first on each side), which is converted into the external ear, as may be seen in the figure. (See Plate IV.) At this period, the upper jaw is still composed of two papula? one for each side. These pimples, or isolated mandibles, gradually approach the median line, and there unite in a single body, which forms the jaw such as we find it in the adult. The nostrils are separated by the incisive papulse, which keep them apart for some time ; then, as the latter diminish in size, they approach each other and assume their definitive form ; but, in the meanwhile, they are separately split down to the mouth, and it is the permanence of this transitory state that constitutes the double hare-lip. All of the branchial fissures have disappeared by the sixth week, leaving only a slight cicatrix behind. The first centres of ossification appear during the seventh week, first on the clavicle and then on the lower jaw. The intestine still extends for a considerable distance along the interior of the umbilical cord, but the omphalo-mesenteric canal is nearly obliterated, although it may yet be traced as far as the umbilical vesicle, where it is reduced to a very delicate thread. The anus remains closed ; and the bodies of Wolff alone exist near the vertebral column. It is only then that the kidneys and capsular renales begin to appear, and soon after them the sexual organs. The urinary bladder is first manifested under the form of a tumor that is continuous with the urachus. At this time, the embryo is nearly an inch in length. At two months, the tubercles of the extremities become more prominent. The fore-arm and hand can be distinguished, but not the arm ; the hand is larger than the forearm, but it is not supplied with fingers. The cord has not as yet assumed a spiral arrangement, but it is infundibuliform in shape, the base corresponding to the abdomen, being continuous with it, and con- taining a large quantity of intestine; it is four to five lines in length, and is inserted near the lowest point of the abdomen. A small tubercle, fur- nished with one or more very contracted openings, may be distinguished between it and the termination of the spine, which are the rudimentary external organs of generation ; but the extreme length of the clitoris renders the distinction of the sexes difficult at this period. The embryo is from one and a half to two inches long, and weighs fiom three to five drachms, the head forming more than one-third of the whole. 214 PREGNANCY. The eyes are prominent, but the lids, from being ttill rudimentary, do i»o« cover the eyeball ; the nose forms an obtuse eminence ; the nostrils are rounded and separated ; the mouth is gaping, and the epidermis can be distinguished from the true skin. At ten weeks, the embryo is from one and a half to two and a half inches in length, and weighs an ounce or an ounce and a half. The palpebral, having become more apparent, descend in front of the eye, and the puncta lachrymalia are now visible ; the buccal fissure, which has increased in size begins to be obliterated by the commencing development of the lips. The thoracic parietes are apparent ; hence the heart's movements cease to be visible. The fingers are distinct, and the toes look like little tubercles held together by a soft substance. The cord is longer than the embryo, and begins to assume the spiral arrangement ; it is less infundibuliform than previously, and is not inserted so low down on the abdomen, but its base always contains a portion of intestine. At the end of the third month, the embryo weighs three to four ounces, and measures from five to six inches ; the eyeball is seen through the lids ; the membrana pupillaris is more manifest ; the forehead and nose are clearly traceable, and the lips well marked and not turned outwards. The neck now establishes a visible separation between the head and thorax ; the latter cavity is closed at all points, but is still very slightly developed relatively to the other cavities. The cord contains no intestine, and its spiral turns are more numerous and evident. The nails begin to appear as thin mem- branous plates ; the sex is distinct, and the integuments, which heretofore were only a soft, viscous covering, acquire more consistence, but are still very thin, transparent, of a roseate hue, and without an apparent fibrous texture. At the fourth month, the embryo takes the name of foetus; its growth is not so rapid in the commencement as at the end of this month. The body is six to eight inches in length, and weighs from seven to eight ounces. The fontanelles are very large, as are also the sutures; and some short, whitish, silvery hairs may be observed on the head. The face still remains but little developed, although more elongated than it has previously been. The eyes, nostrils, and mouth are closed, and when the occlusion of the lids happens to be incomplete, it is generally at the internal part. The tongue may be distinguished behind the buccal fissure, and the projection of the chin is observable. The cord is inserted higher up on the abdomen, whence the centre of the body is an inch or two above the umbilicus. The skin has a rosy color, and begins to be covered by down ; and some fat, tinged with red, is deposited in the areolae of the subcutaneous cellular tissue, and the muscles now produce a sensible motion. A foetus born at this period might live for several hours. Whilst I was Interne at the Hotel Dieu, I received one that had scarcely reached the fourth month. It lived, however, from half-past seven to half-past eleven o'clock. At five month.*, the length of the body is eight to ten inches, and it weighs from eight to eleven ounces. The skin is more consistent, and many patches of sebaceous matter may already be seen, but the pupils cannot be dis- tinguished. OF THE FGETUS. 215 At six months, Uie length is eleven to twelve and a half indies, an* ■ >*" jfHBifti s& Pulmonary Art. ;g^S I'll \ ^Pulmonary Art, Foramen Ovale. / Left Auricle. —Left Auric. - Vent, Opening. Eustachian Valve. (t \ * \ Right Auric. - Vent. Opening. \\ 5*1 \~3* \ \\ <** \ ^* » V \\ % Hepatic Vein. y Branches of the Umbilical I T ein > to the Liver, '"••-. Liver. \f '^Ductus Venosut. Madder. V Internal Iliac Arteries, DIAGRAM OFTH1. FCETAL CIRCULATION. ..; Tnm&r'i Obstetric*. OF THE FOETUS. 23$ b. Now, having acquired these anatomical views, let us see what is the course of the blood in the foetus. A part of this fluid, circulating in the umbilical vein, is, therefore, discharged by the venous canal directly into the vena cava ; another part is distributed to the liver, where it probably undergoes, as before stated, some purification, and thence is brought back by the hepatic veins to the vena cava. Consequently, all the blood from the umbilical vein reaches the vena cava inferior either directly or indirectly. The blood contained in the latter is therefore a mixture of that which returns from the inferior extremities of the foetus and of that poured into the liver by the vena portse, with the addition of the portion contributed by the umbilical vein. This compound reaches the right auricle through the ascending vena cava, where it only mixes partially with the blood of the upper extremities, which has been brought back by the descending vena cava ; because, in passing into the auricle, the ascending or inferior vena cava is directed towards the foramen of Botal, and hence its blood passes in a great measure through this opening into the left auricle, and thence into he left ventricle. By the contractions of this latter the fluid is then forced into the aorta, its impetus being broken against the great curvature of this artery ; and the blood then passes into the vessels which arise from the arch, and is distributed through them to the head and superior extremi- ties, a very small portion of it only reaching the descending aorta and the lower parts of the body. The blood, after having thus supplied the upper half of the body, is col- lected by the veins, which, by their successive union, form the superior or the descending vena cava ; the latter empties into the right auricle, where a email quantity of its blood mixes with that brought by the ascending cava ; but much the largest part passes directly into the right ventricle, which forces it into the pulmonary artery. This vessel sends but a trifling portion to the lungs ; the rest being thrust into the ductus arteriosus, which discharges its contents into the aorta : that is to say, the blood that has contributed to the nutrition of the superior parts of the body, and has traversed the descending vena cava, the right auricle, the right ventricle, and pulmonary artery, and then has passed through the ductus arteriosus, finally mingles with the remnant of blood still existing in the descending aorta. The whole now descends to the inferior part of the latter vessel, where a small portion of it is sent through the arterial trunk to supply the inferior extremities, whilst much the largest quantity is driven into the umbilical arteries, and is carried by them back to the placenta : where, after having undergone the modifications produced bj the placer, la 1 respiration, it is again taken up by the radicles of the umbilical vein to once more traverse the same circuit. c. Of the Changes in the Circulation after Birth. — It is difficult to explain the cause of the first inspiration ; by some, it has been attributed to an instinctive movement of the foetus, from the " besoin de respirer" (necessity uf respiring) experienced by it, after a separation from the placenta ; but these reasons are not satisfactory to me, for the air is only introduced into the lung as a consequence of the enlargement of the cavity of the chest, and not, as some imagine, to fill a vacuum which never existed. Now this 234 PREGNANCY. expansion of the chest has for its sole cause the violent, jerking, spasmodic contraction of the diaphragm, which is always the result of a suffering con- dition of the foetus, caused by the suspension of the utero-placental circula- tion, the sudden impression of cold, or the different characters of the media to which the child is successively and rapidly subjected. Finally, also, by the artificial excitations (friction on the surface, irritation of the mucous membranes, &c.) resorted to when the infant is feeble. As soon as the respiration becomes established, the sanguineous current- takes another direction ; because, on the one hand, the fluid flows towards the lungs in greater quantity ; and, on the other, the placental circulation is forcibly interrupted. Below, I subjoin the results of the labors of Billard, who has devoted particular attention to the modifications then observed in the organs of circulation, as they are interesting alike to the accoucheur and the medical jurist. The fcetal openings are generally obliterated in the course of a week after birth, still, they may remain patulous at that age; and, I may add, that either the foramen of Botal or the arterial canal may continue pervious at two or even three weeks, without the child's experiencing any particular disadvantage therefrom during after-life. The umbilical arteries are usually closed on the second day ; even at twenty four hours they have already become smaller in the vicinity of the ring, and they are obliterated by the third or fourth day as far as their junction with the hypogastrics, by gradually changing into a fibrous cord; the whole process being completed in three weeks. The umbilical vein is never obliterated until after the arteries have become impervious, and the same is true of the ductus venosus ; however, both are quite empty, and considerably contracted on the fourth day, and they are generally closed up by the sixth or seventh. The arterial canal and the foramen of Botal are the last to undergo this process ; but they rarely persist beyond the eighth or ninth day, although the foramen sometimes remains open much longer, being only effaced com- pletely towards the end of the first year. If the ductus arteriosus and the umbilical arteries be examined during the progress of obliteration, their parietes will be found to grow gradually thicker; this hypertrophy is particularly observable in the arteries near the navel, as may be easily verified by making sections of them at this point ; but the thickness gradually diminishes towards their origin from the iliacs, and their canal is likewise obliterated precisely in the same order of pro- gression. Of course, the contractility of its walls will also contribute towards effecting the occlusion. The arterial canal undergoes a similar hypertrophy and parietal retrac- tion, which takes place in such a manner that, whilst the absolute size of the vessel does not appear diminished, its orifice is greatly contracted, resembling a pipe whose fracture is quite thick, and opening at its centre of very moderate calibre. The obliteration is therefore the immediate result of the retraction and concentric hypertrophy of the walls ; neverthe- less, it should not be regarded as the primitive cause, for if the same quantity ( f blood flowed into those vessels, such a retraction evidently could OF THE FOETUS. 235 not take place; but from the very first inspiration, this fluid is driTen by the contraction of the right ventricle (see hereafter) almost entirely into the pulmonary arteries, scarcely any of it passing by the ductus arteriosus; and, on the other hand, the very oblique angle at which the umbilical arteries pass off, satisfactorily explains why the blood, that flows into them in such great abundance when it has no other outlet, no longer enters them at all, or at least only very feebly, when the establishment of respiration has completed the vascular circle of the new-born child. But the umbilical vein and the ductus venosus are not obliterated in this way, and their walls exhibit no remarkable increase of thickness ; for, after the cord has been cut, these vessels receive no more blood, excepting in those cases where it regurgitates from the vena cava, and then the walls •fall in and become contiguous, just like any other canal, when the liquids that habitually traverse it are cut off; nevertheless, the umbilical vein and the ductus venosus retain their cavities free for a long time, for a large probe may easily be introduced into them ; but this cannot be done in the arteries nor in the ductus arteriosus. 1 The foramen of Botal is the last to disappear, although an effort at obliteration may be observed there sooner than in any other of the foetal openings : thus, the two auricles are nearly confounded in one in the early stages of intra-uterine life, and the diminution of the foramen ovale only begins to take place about the third month by the development of a semi- lunar valve on its inferior border. This valve, composed of a double mem- branous layer, containing fleshy fibres in its substance, gradually rises along the margins of the opening towards the left auricle, by contracting adhesions with the circumference of the foramen, and it ultimately forms the fundus of the fossa ovalis, as also, the little semilunar fold seen in the auricle. In this way the partition is completed, being merely perforated by an oblique canal occasionally found in young subjects, which also dis- appears after a time. 2 The following summary Avill enable the reader to appreciate the influence of these vascular changes upon the circulation. Immediately after the first inspiration, and from the sole fact of the dis- tention of the pulmonary cells, the branches of the pulmonary artery, ramifying in the mucous membrane, and contributing to the formation of their walls, are suddenly rendered permeable throughout their whole extent, and a vacuum is therefore produced, into which the blood is sent from the right ventricle; consequently, from that period, the route travelled by this 1 A case of persistence of the umbilical vein in the adult, which communicated at one extremity with the vena portse, and at the other with the crural vein through the superficial abdominal veins, is reported by M. Cruveilhier, in the 16th number of his Pathological Anatomy. 2 According to Dr. Tyler Smith, the expansion of the lungs produces a compression of the ductus arteriosus by the left bronchus, and thus assists in its obliteration. The change effected in the position of the heart also aids mechanically the occlusion of the foramen ovale; and finally, the depression of the liver by the respiratory act. closes the umbilical vein by flattening its walls. [The Lancet, Sept., l s ls.| Nunc of these assertions appear to us sufficiently well proved, and therefore demand further investi- gation. 236 PREGNANCY. fluid, from the right ventricle to the aorta, is much longer than heretofore, and the ductus arteriosus, being thus emptied, -will retract at once, and have its calibre very much diminished. The right auricle, "which could scarcely force all the blood that it received from the venae cavse, through the foramen of Botal, now sends the most of it into the right ventricle. Prior to birth, the left auricle only received the blood by the foramen ovale, but it is henceforth filled with that brought through the four pul- monary veins. Moreover, the relation that existed, in the quantity of the blood deposited in each auricle, is changed from that time ; for the right, which was distended beyond measure, now relieves itself with facility, while I he left, that scarcely received any before, is filled with the blood brought by the pulmonary veins ; so that it would flow from the left to the right auricle, through the foramen ovale, if the semilunar partition, which acts as a valve, did not prevent such a movement. [$ 4. Innervation. Most of the encephalic functions remain, according to M. Jacquemier, entirely dormant during intra-uterine life. Sensibility, however, becomes highly developed in the foetus at quite an early period ; in proof of which it is only necessary to press upon the womb through the walls of the abdomen, when the foetus will be found to move for the purpose of avoiding compression. A more direct experiment may be made as follows. If the abdomen of a pregnant rabbit be opened, the foetus will be visible through the transparent walls of the womb, and a foot may be readily caught and compressed by a pair of forceps. When this is done, the foetus moves in such a manner as to leave no doubt that it feels a certain degree of pain; for its action could not be regarded a merely reflex phenomenon. Spontaneous motions are caused by instinct or a vague and obscure exercise of volition. During intra-uterine life, therefore, and especially near the end of gestation, innervation is almost as perfect as in the new-born child. The functions of the foetal nervous system present, like those of the adult, an intermittent action or periodicity, resembling the waking and sleeping states. When a new-born child is asleep, if it be awakened and excited briskly several times with the tip of the finger, it will, at the moment of awakening, almost always make some abrupt motions. The same thing takes place, no doubt, during intra- uterine life, so that when we try to produce active movements by compressing the uterus, it is probably aroused from the sleeping to the waking state, and just then the hand on the abdomen becomes conscious of the actions elicited.] § 5. Secretion. As it is not our intention to treat of all the various secretions which occur in the foetus, we shall confine our remarks to those of the bile, meconium, and urine. 1. Secretion of Bile. — The liver is the most voluminous of all the foetal organs. At three months its texture Is 3oft and pulpy, not yet having the granular character visible at term ; the gall-bladder at that period resembles a white thread, its inferior extremity being the largest, and its cavity exceedingly contracted. At five months the volume of the liver is much greater, the texture more condensed, and the gall-bladder more apparent; the secretion of bile then begins, and continues to augment thereafter DIAGNOSIS OF PREGNANCY. 28'/ throughout pregnancy. We have just stated what appear to us to bt the principal elements of the bile. At the seventh month, the gall-bladder is tilled with a yellow secretion, and a considerable quantity of this is also found in the intestinal canal. 2. Meconium. — During the early periods of the intra-uterine life, the digestive canal is merely moistened by a little fluid, but a more abundant secretion begins to take place towards the third month. According to Lee, the stomach then contains a clear, acid, and non-albuminous fluid ; whilst at the upper part of the small intestine a substance similar to chyme is found, consisting of pure albumen, and there is an analogous albuminous liquid in the biliary duct. The meconium exists in the small intestine only, prior to the fifth month, and is of a greenish-brown color, but after that period it reaches the large intestine, becomes of a darker hue, and finally accumulates in the rectum. This fluid is a mixture of bile with the pro- ducts secreted by the intestinal mucous membrane. 3. Urine. — The urine never fills the bladder entirely in the human embryo ; now, as the kidneys are developed early, and their secretion com- mences at once, the urine must certainly be evacuated by some outlet. On this account, certain embryologists have supposed that the bladder com- municated originally with the allantois by means of the urachus, and that the cavity of this membrane was the ultimate reservoir of the urine. However, this is not the generally received opinion, for, as we have else- where proved, the allantois ceases to exist in the human species as a distinct vesicle long before the development of the kidneys ; and the urine must therefore be expelled through the urethra into the amniotic cavity. That its evacuation is necessary is proved by the facts already cited, in which the existence of an imperforate urethra led to extreme distention and even rupture of the bladder. CHAPTER VI. DIAGNOSIS OF PREGNANCY. The signs of pregnancy are divided into the rational and the sensible. The first comprise all those characters pointed out by authors as existing in the earliest periods, by which they assert a conception may be justly suspected; then in the subsequent stages, — the suppression of the menses, the enlargement of the abdomen, the pouting of the navel, the phenomena just studied in the breasts, the symptoms, or rather the functional disturb- ances in the digestive organs, the condition of the pulse, the modifications in the urine, and lastly, certain changes that occur in the woman's habits, as well as in her moral and intellectual faculties. § 1. Rational Signs. According to Aristotle, there is some ground for believing the woman has conceived, if no fluid oozes out from the vagina after coition, and if the ZOO PREGNANCY. penis is unusually dry when withdrawn ; and the opinion seems to be uni versally received by shepherds, that the retention of the semen is an evi- dence of impregnation. Agreeably to Hippocrates, the eyes become more sunken, more languishing, and are surrounded by a bluish circle, and spots of different sizes appear on the face. Again, since the days of Democritus, a swelling of the neck is also enumerated as a sign of conception. How- ever, all these symptoms have but little, if any value, and I accord far greater importance to the more voluptuous sensation, the more general erethism experienced by some females during a prolific coition, by which a few of them can recognize with a degree of certainty that they have become pregnant. 1. Suppression of the Menses. — Females cease to be regular during preg- nancy; and this is a law of such general truth, that whenever it occurs in a healthy woman, without a known cause, and not attended with, or followed by any moi'bid symptom, it is justly regarded as a probable sign of gesta- tion ; but as this suppression might be produced by a number of other causes, whenever a physician is consulted about it, he ought carefully to inquire into all the circumstances, past or present, which may have pro- duced such an effect. It would be out of place now to enter into this diag- nosis but we may reiterate an observation, already made by several authors, and which our experience has frequently verified, namely, that in some young married women, who had hitherto been quite regular, the menses be- come at once suppressed, and continue so for several months, without any known cause; and this suppression, resulting probably from the irritation or derangement produced in the genital organs by the first conjugal approaches, is frequently accompanied by an augmented volume of the ab- domen, and a more exalted sensibility of the mammary glands ; and, as the mind so readily believes what it most ardently desires, nothing more than this is wanted to found a hope of a commencing pregnancy. Hence the physician must exercise great discretion in his diagnosis, when consulted on so delicate a subject. The menses may continue during pregnancy ; thus they frequently appear in the earlier months, more rarely during the first five or six months, and what is still more unusual by far, they may exist during the whole period of gestation. Numberless observations of this kind, recorded by authors, prove the truth of these assertions, and we also can bear testimony to the same point ; thus, we saw some females in 1837-38, who were evidently pregnant, and in whom the menses flowed at the usual periods, and lasted for the same num- ber of days; one of them assured us that she menstruated during the first 'ive months, and that her courses appeared on the second of each month, and lasted for two days, just as she had them previously. Again, two females came under my observation at the Hotel Dieu, whose cases have been already published in my thesis, who were regular throughout the whole term of pregnancy. DunaKof Montpellier), Haller, and Mauriceau likewise cite similar cases; but notwithstanding all this, some accoucheur? still deny that women can be regular whilst pregnant. M. Moreau, who professes this belief, has, however, often known females DIAGNOSIS OF PREGNANCY. 23tJ to have sanguineous discharges at variable periods during gelation, but the irregularity of their appearance, the qualities of the blood itself, and the greatness or smallness of its amount, serve to distinguish these, in his estimation, from a true menstrual discharge. The remark of M. Moreau is certainty applicable to many cases, but the instances above cited, and num- bers of others that might be quoted from various writers, do not permit iiir to entertain a doubt that a woman may menstruate during pregnancy. On the other hand, females may become pregnant without ever having had their menses; 1 and the same is true of some others in whom they are suppressed either by accident, from the progress of age, or in consequence of nursing. 2 All those anomalies will be understood without difficulty, if we do but recollect that, although the appearance of the menses is always connected with the ovarian evolution, the latter may take place without being accom- panied by the menstrual flow. (See Menstruation.*) Deventer, Baudelocque, and Chambon furnish accounts of women who were regular only during gestation ; the case cited by Deventer is particu- larly curious, from the opportunity he had of observing this fact in four successive pregnancies of the same woman. Finally, Desormeaux believes from his observations, that in certain years, and often without any apparent cause, a greater number of women have their menses during gestation, even where they were completely suppressed during former pregnancies. Does this result, as he appears to think, from atmospheric influence, or is it pure chance? For my part, I am unable to decide the question. Though it is important to be aware of these exceptional cases, it is equally necessary to guard against the general tendency to a belief of the marvel- lous. It should not be forgotten, that the continuance of the menses during 1 A young woman presented all the signs of pregnancy, and although she had never menstruated previous to that period, her courses then appeared and continued during the whole of gestation. (Perfect, Cases of Midwifery, vol. ii. p. 71.) A lady, aged twenty-four years, during eight of which she had been married, waa never regular except during pregnancy, and each appearance of her menses proved to be a certain sign of that condition. A woman, who married at twenty-one, had never been regular; two years after- wards she experienced some gastric distress, and the flow appeared. Nine months subsequently, she was delivered of a healthy child, notwithstanding the menses did not fail to appear every month. (Churchill, Observ. on the Diseases of Pregnancy, p. 36.) 2 Dr. Flecliner, of Vienna, relates that a young woman of twenty-two, had always been regular, but the menses never reappeared after the first accouchement, being replaced each month by an intense headache, accompanied with a feeling of oppres- sion and heat in the forehead and parietal regions. During the succeeding thirteen years, she gave birth to six healthy children. (Gaz. Med., p. 91, 1811.) Dewees states, that a woman who had been married for several months, Buffered some gastric distress. She had never been regular but three times, and for a number of years there was a complete suppression. He directed rhubarb pills, which purged her slightly, but did not relieve, her; six months afterwards, the abdomen being some- what enlarged, he was enabled to ascertain that she was six months advanced in preg- nancy ; and soon after the menses returned, and continued regularly until term. Dur- ing lactation, which lasted a year, the courses did not appear; she then weaned the child, and in a short period again became regular, and this, like the former, was the announcement of a new pregnancy. 240 PREGNANCY. pregnancy is of rare occurrence, and that, although then suppression is of gieat value as a point of diagnosis, it may nevertheless be the result of a variety of causes. 2. Enlargement of the Abdomen. — An increase in the size of the abdo- men may be produced by so many different causes that its slight value as a sign -will be readily foreseen. There is, however, something peculiar in its shape and mode of development in gestation. Thus the abdomen swells somewhat in the first month, but this is owing to a collection of gas in the intestinal cavity, which, after remaining a few weeks, diminishes and dis- appears, whence the woman often seems smaller at the end of the second month than during the first ; but whenever this slight tympanitis is not manifested, the abdomen is flatter the first month than before, probably be- cause the uterus settles down in the excavation. At the beginning of the third mouth, or at three months and a half, the hypogastric region evidently becomes more salient, and the enlargement is thenceforth regular and always increasing until term. Consequently, the tumefaction begins to show itself just above the symphysis pubis, being more considerable at first on the median line than elsewhere, while the sides appear flattened ; after the fourth month, the upper extremity of the uterine tumor may be clearly perceived through the abdominal wall, especially in thin subjects, by placing the woman on her back and the abdominal muscles in a state of relaxation ; but if the parietes be thick and tense, palpation, practised in the manner hereafter described, will become necessary to ascertain this point. The modifications in the size of the abdomen, at different periods of ges- tation, have already been described ; but its development is not always regular, being, for instance, much more rapid in twin pregnancies, and in dropsies of the amnios than in other cases. Besides, the relation between the volume of the abdomen and the stage of pregnancy, is not always main- tained; thus, some women are no larger at seven or eight months than others are at five, owing either to their high stature, their breadth of pelvis, or the small degree of projection in the vertebral column and upper part of the sacrum. On the contrary, in small women, more especially in those having a contracted pelvis, and in whom the womb is therefore necessarily raised, during the early months, above the superior strait, the abdominal protuberance is premature, if I may so express it, and is much better marked at quite an early period than ordinary. The umbilical depression at first appears deeper, its bottom seeming to be drawn downward and backward in consequence of a tension of the urach us, occasioned by the fundus of the bladder following the descent of the uterus in the excavation. The circumference of the ring becomes at the same time the seat of a distressing dragging sensation, and is more sensitive to pres- sure; and this sensibility is sometimes extended over a considerable portion of the abdominal wall. But about the end of the third month, that is, as soon as the uterus gets above the superior strait, the umbilicus resumes its normal condition ; at the fourth month, it is less hollow than before concep- tion — then its bottom becomes more and more superficial during the fifth and the sixth, and the whole depression is effaced, and is found on the same level as the skin by the seventh month, and in some cases, the umbilical DIAGNOSIS OF PREGNANCY. 241 ring is sufficiently dilated to receive the end of a finger; finally, in tl e last two months, the navel forms a protuberance. Not unfrequently, small por- tions of the epiploon become engaged in the ring during the exertions of the female and project externally. These changes in the umbilicus afford a rational sign of great valve-., because they are almost constant. I say almost, for in a case observed by M. Blot, there existed a depression three-eighths of an inch in depth, the woman being at term and of ordinary embonpoint. Though these altera- tions of the umbilical depression may be produced by a pathological tumor of considerable size, or by an accumulation of fluid in the peritoneum, it is equally true, that they almost always exist in advanced pregnancy, and that their absence is, in a majority of cases, conclusive against the existence of a foetus of seven or eight months. 3. The presence of the streaks, and especially of the brown line, which extends, as we have stated, between the pubis and umbilicus, is very impor- tant to the diagnosis, especially in a primiparous female. The streaks, how- ever, may be present whenever the abdomen has suffered great distention from any cause whatever. 4. The phenomena presented by the mamma? afford, in the opinion of Mr. Montgomery, a certain sign of pregnancy. Smellie and Hunter also con- sidered the changes in the areola as a positive evidence of this condition. The latter surgeon, indeed, did not hesitate on one occasion, when examin- ing a dead body, to declare from this sole indication, the uterus to be enlarged by the product of conception ; as the examination proceeded the hymen was found intact, but even this did not change his opinion, and when the womb was opened its correctness was fully confirmed. This fact, with many others which might be cited, prove the value of these signs when they exist, which unfortunately is not always the case ; any one of them, indeed, may be wanting, and sometimes they are totally absent. Thus, in 1837, I saw a strong and vigorous young brunette at La Clinique, who had advanced to the end of gestation, without any of the indicated marks appear- ing around the nipple; and I have since made the same observation on several different occasions. Their absence is not therefore an absolute proof of the non-existence of pregnancy, so that their importance in this respect has been exaggerated by some English surgeons. These cases, however, are rare, and I should diagnosticate as almost certain the existence of preg- nancy in a young woman who had never borne children, and whose breasts presented both a brownish-colored areola, the tubercles, and the freckled characters before described. But in those who have had children, it is very difficult to determine whether these signs result from the modifications of the breast in former pregnancies, or from a new conception. In such cases we have only the testimony of the women themselves to rely on, and this more especially, if but a short time has elapsed between the hist and the present gestation. [We have examined a young woman in whom both vagina and uterus were absent, although the external genital parts were well formed. Pregnancy in such a case is evidently impossible, yet here the true areola was of a very dark color. and the dotted one very decided. Still, the deepened color of the breasts, when 16 2-A2 PREGNANCY. well marked, is a good rational sign, though its absence is far from disproving the existence of pregnancy. In brunettes, the true areola almost always darkens as the dotted one forms. Such, however, is not the ease with blondes, in whom the color of the breasts is far less decided, and in women of a ruddy complexion it is generally absent even at the end of gestation.] 5. I have never been able to appreciate the reputed value of the signs founded on the state of the pulse of pregnant women, for although it has always seemed more developed, fuller, and harder, I could discover nothing further concerning it. 6. The disorders of digestion, as well as of the moral and intellectual faculties, are of but secondary diagnostic importance ; they can do little more than direct the attention of the possibility of a doubtful pregnancy, but as they belong more properly to the pathology of gestation, they will be Btudied hereafter. 7. Alterations of the Urine. — Having treated at length of the production of Kyesteine in the urine of pregnant women, we merely state here that its presence is not as certainly diagnostic as some authors have supposed. Yet its existence in the urine of an otherwise healthy woman is an important rational sign. Finally, it will be perceived that no one of the rational signs whose diag- nostic value has just been discussed is conclusive, when taken singly; excepting, however, the changes undergone by the breasts, which, if well marked in a primiparous female, may of themselves remove all doubts as to pregnancy. But although, singly, these various signs may only give rise to doubts, their union furnishes a sum of probabilities nearly equivalent to certainty, a certainty which, however, could never be complete until after a determina- tion of the sensible signs, which we shall next proceed to examine. § 2. Sensible Signs. All the sensible signs of pregnancy are derived either from auscultation or the touch. Hence, we must carefully study these two means of explora- tion, as well as the results which they furnish. A. Of the Touch. — The touch, considered in an obstetrical sense, is the art of ascertaining the condition of the various hard and soft parts in the female, which contribute to the great act of reproduction ; and it consists in the exploration of those parts by aid of the finger and hand applied to the vulva, vagina, and rectum, or upon the abdomen. The touch is practised under various circumstances, for the purpose of ascertaining the existence and stage of the gestation ; the imminence of an approaching accouchement; the progress of the travail; the presentation and position of the foetus; the nature and energy, or the feebleness of the contractions ; and the character, volume, and situation of obstacles pre- sented by the hard or soft parts, which might prevent the spontaneous termination of labor, and demand the resources of art. The fact that any moment in the life of the accoucheur may call for its exercise, is of itself an evidence of its great importance, and of the necessity for practising it. With some experience, any one, whatever be the shape or size of his finger, DIAGNOSIS OF PREGNANCY. 2W n,ay acquire such a degree of skill in the .ouch as will bear bin, through "^."rtWeCtTisheartened by the difficulties met at the Let no student , f ghort a nuger , for thu ZZZ;X^n 9 Z a U and those pedants are unworthy of credence who seize a hand, and after examining it gravely, reject t 1 dUdam exclaiming, » Vou wiU never be an accoucheur with such a hand a tat' 'Woln! generally, have shorter fingers than ourselves, yet they "come very perfecHn the touch ; and I repeat, that, unless there is a mad- formation of the hand or fingers, anybody may learn by practice to touch, "I *Cw Si -The index-finger is usually employed for this purpose; after bin" ex ended, it is entered horizontally in the fissure between the „ ,es until arrested by the soft parts, and the index is then drawn .awards, as fr as he opening of the vulva. I prefer this method to the one m !4cl the fin™ is carried from before backwards, in such a manner as to uass o -er the" clitoris and the meatus urinarius, because fnction against nm e oarts should always be avoided with the greatest care. In brmging eL'^f on behind forwards, it would not be possible, except through „=s ntlfoen ce, to confound the anal orifice with the vaginal opening, and ffiZS. found, the index is first pressed almost directly backwards uoti o e4hirdof it has penetrated into the vagina, and then by strongly denies n' the wrist, the operator gives his finger a nearly vertical direction o hat the thumb may be applied against the anterior face ot the symphysis, Lalial bonier of the index be directed in front, and its cubital border be nhced against the anterior perineal commissure, which it serves to push CI The other three fingers vary in position, «^£*£* „„,1 m nre esneciallv to the object in view ; for example, if deniable to "I" the m ■ uatcd on the posterior plane of the excavation with .he explo.e t ,e p m (he penneum> pressing i: tt. r up b .'., rlal'bordc'r cf the medics ; but if, on the other hand, ewh to perform the ballottement, or to explore the parts on the anterior 1, twill be more convenient to flex the thumb and the other three fi i ; into the palm, the index alone being extended, with is palmar X Erected il, front. Stein directs the medius to be joined with the in-er, but this is generally useless, and often inconvenient, for although the tw? fingers may possibly penetrate a little deeper, the sensafon is not so clear as that obtained by one. P hvsicians should accustom themselves to touching with both hands for .her are some diseases of women, and some posit.ons of the cetus, w Inch ■ , , "be accoucheur to use the left hand. Or, it may also happen that a wound upon the right will necessarily require the left to be substituted, 'ihoimh for all ordinary purposes the right is sufficient. Tim woman should be placed either in the erect, or the recumbent posi- Honouring the examination, according to circumstance*. In the commence- ment ""pregnancy, it is better, as a general rule, to have her lying down Tcaise "in this position, the head being propped up, and the in.erio extr mi ies flexed and separated, the abdominal muscles are thrmvn mto a 211 PREGNANCY. Btate of relaxation, and thus the development of the uterus cai. more easily be determined. Again, such diseases as prevent the female from standing erect, may also require the same posture. But at a more advanced period, either position may be used indifferently, though most frequently the bal- lottement can be accomplished better while the woman is standing. In this latter case, her loins should lean against a wall or some piece of furni- ture ; a chair must he placed at each side for her hands to rest upon, and the upper part of her body is to be slightly flexed forward. Where any difficulties are encountered in the exploration, it is advisable to touch in both positions. Before operating, the accoucheur should anoint his finger with some unctuous substance, fat, butter, oil, mucilage, &c, for the double object of rendering the introduction easier and less painful to the woman, and to protect himself from the contagion of any disease she may be affected with. When the patient is recumbent, the accoucheur places himself at her side, the right one, if he intends using the right hand, and on the left, if the other is to be employed. One hand is then placed upon the abdomen, while the other is engaged in the vaginal exploration ; and this precaution is especially advisable, when the ballottement is practised, in order to fix the fundus uteri, and keep it steady. In passing the finger over the perineum, and before entering the vagina, we ascertain the presence or absence of the fourchette, or the inequalities that supply its place after a labor; and as the index enters the vagina, it should examine the condition of the external labia, the length and width of the vagina, its mucous membrane, whether smooth or rugous, the various diseases, tumors, or degenerations that may exist on the surface or in the substance of its walls, and the condition of the rectum, whether full or otherwise. Hereafter, we shall have occasion to speak of this process as a mea'ns of diagnosis in the various vices of con- formation. All these explorations being made, the next step is to examine the neok of the uterus, and learn its modifications in form, consistence, situation, direction, and in the dimensions of its cavity; all which have been carefully described. (See page 130, et seq.) The finger may detect the development of the body of the uterus, by ascertaining the spreading out of its inferior part. During the first six or eight weeks of pregnancy, the changes in the uterus are practically limited to the body of the organ, which loses its nulli- parous pear shape and bellies out over the cervix in all the transverse diameters, particularly antero-posteriorly, BO that it resembles very much an old fashioned fat-bellied jug; at the same time the muscular substance be- comes less firm, giving to the palpating finger a peculiar feeling of resiliency and compressibility. These changes, first noted by Hegar, are considered by him to be an unfailing sign of pregnancy, and his researches have been cor- roborated by Grandin (A 7 ". Y. Med. Bee, 1886), Compes and others. The recognition of this sign requires a certain degree of expertness in bimanual palpation and familiarity with the sensation communicated to the finger by the multiparous uterus, and by the uterus pathologically altered. Owing to the normal slight ante-curvature of the uterus, it is best noted, in most cases, in the anterior cul-de-sac, where the finger, instead of following the line of the cervix in a gentle curve up on to the body, is at once conscious of a DIAGNOSIS OF PREGNANCY. 245 swelling out of the body over the cervix, and on bimanual pressure the body is felt to be resilient and compressible. Until toward the third month, the organ is almost wholly within the excavation, and its mobility is very slight, in consequence of its restrained position, whilst in the ordinary unimpregnated state, it may be carried to the right or left, forward or back- ward, by simply pressing with the finger on the side of the neck. 2. The Aiml -Examination. — The accoucheur is very seldom obliged to lulroduce his finger into the rectum, but still a partial obliteration of the vagina may render such an exploration necessary; it might also be useful where there were reasons for supposing a young girl to be pregnant, who insisted upon her virginity. For the necessity of sparing the hymen, which may possibly be intact, renders the vaginal touch very difficult. In cases where a tumor exists at the posterior part of the vagina, it is sometimes difficult to decide whether the enlargement is located in the recto-vaginal septum, or is attached to the bony structure. Here the diagnosis is verv important, for the course to be pursued in the two cases would be widely different, and all doubt may be removed at once by introducing the index into the rectum, and the thumb into the vagina. B. The Passive Movements, or Ballottement. — This, according to most authors, is a sensation analogous to that produced by placing a ball of marble in a bladder full of water, and then striking the bladder with the finger just under the spot where the ball rests, when the latter is thrown up, and falls back from its own weight upon the finger which displaced it. This comparison, however, only holds good at a certain period of gestation, and we shall again take occasion to refer more particularly to this point. To perform the ballottement, M. Velpeau directs the index finger of one hand to be placed under the cervix, and the palmar face of the other hand over the fundus uteri ; then, by a sudden movement of the finger in the vagina, the uterus is to be pushed upwards; being movable, free, and the only solid body in the amniotic liquid, the foetus ascends, strikes the point diametrically opposite, and falls back upon the finger which gave it the impulse. But as this mode will not, I believe, afford any satisfactory results in the majority of cases, I recommend students to pursue the following plan in performing the operation : the vaginal finger should not be placed under the cervix, because it will then be separated from the fcetus by the whole length of the neck, and of course the finger cannot recognize so clearly the descent of the displaced body ; but rather in front of, or behind the neck (according to the woman's position ), upon the walls of the body itself, for then the index is only removed from the substance to be examined by the very thin walls at the inferior region of the uterus, and it detects very readily the least motion of the inclosed foetus. If the woman is standing, the index should be introduced in a vertical position, with its palmar face turned forward, and the other three fingers flexed into the palm, and as the symphysis pubis scarcely exceeds an inch and a half in length, the digital extremity of the forefinger easily passes its superior part, and reaches the body of the organ, where it almosl always encounters a hard globular tumor formed by the head of the foetus; then a light, (| lick Mow is to be given by it, after which the finger must remaili 246- PREGNANCY. immovable on the part struck. This shock should be made in a direction from below upwards and from behind forwards, by suddenly flexing the first phalanx. This last recommendation I deem very important ; for in the great majority of cases, the uterus is inclined forwards, its long diameter, like that of the foetus, corresponding very nearly to the axis of the superior strait. Now if, under these circumstances, the shock be communicated to the presenting part of the child from below upwards, and from before back- wards, as generally done, it is evident that the motion given to it will, at furthest, be but a slight movement, of displacement or jolting, but never one of ascension, which in fact would be impossible, because by the direction of the blow the foetus is pushed against the posterior uterine wall, and not along the axis of its cavity. The ballottement may also be effected when the woman is recumbent, by acting in the manner I have just indicated, but it is then generally necessary to place the finger upon a point somewhat nearer to the neck, sometimes before, but at others behind it. The erect position, however, is usually the more favorable for the perception of the ballottement, and therefore pre- ferable. It sometimes happens, about the fifth month of gestation, that if the woman be standing, the vaginal touch does not afford the sensation of ballottement ; but if she be directed to lie down, and the vaginal finger be applied upon the uterine wall, whilst the body of the womb is forcibly depressed by the other hand placed near the umbilicus, the vaginal finger is struck by some part or other of the foetus, which is displaced by the ex- ternal pressure. At an early period of pregnancy, it is sometimes possible to perceive the ballottement by simply feeling the abdomen. If the woman be placed on her side, in a horizontal position, the foetus, in obedience to gravity, descends to the lowest points. If the hand be then glided beneath the side of the abdomen which touches the bed, some part of the foetus will be distinguished and may be readily displaced, but soon returns to its original situation. This sign usually becomes valuable about the fourth month, for before that period the foetus is generally too small, and, possibly, the uterine walls are too thick. Again, it varies much after that time: for instance, our search is not always successful in the fifth month, the small size of the child permitting it to change position very easily; on one day it is found without difficulty, and on the following it defies all efforts at detection. Towards the seventh month, the ballottement is in general the most clearly recognized, since it is at this period, especially, that the finger per- ceives the solid mass, inclosed and swimming in a liquid, to rise up and shortly afterwards to fall back upon it; but the sensation is no longer perceptible at the end of the eighth or the beginning of the ninth month, unless there happens to be an unusual amount of water, for then the foetus has become too large. The finger can indeed raise it, but the friction againsl tlif walls of the uterus almost destroys the tendency to ascend. The mobility of the tumor is readily detected, but it now leaves the finger which impels it; it is a displacement in mass rather than ballottement. Finally, in the latter periods of gestation, flic head pushing the uterine DIAGNOSIS OF PREGNANCY. 247 wall before it, engages in the superior strait, sometimes even gets low down in the excavation, thus becoming jammed in, as it were, and of course the hallottemcnt is then altogether impossible. Writers declare this sign to be a certain indication of pregnancy ; but the proposition is, perhaps, somewhat too absolute : for example, it is possible for a stone resting in the bas-fond of the bladder to lead to an enor, and 1 once met with a case which might readily cause a mistake of this kind. During the time I acted at the obstetrical clinic, as chef de clinique, a woman was subjected to the touch, who declared herself pregnant, and advanced three or four months; at first, I examined her in the recumbent position, and found all the negative signs of gestation, but one of my advanced pupils then performed the same manipulation in the standing posture, and declared that he perceived the ballottement, when I re-exam- ined her, and found the following condition of things : The neck was strongly pushed backwards and a little to the left ; it was slightly softened, and sufficiently patulous to admit the extremity of the finger. (This woman afterwards acknowledged she was delivered only four months previously.) As the finger left the cervix, and advanced just behind the symphysis pubis, it encountered a large resisting surface, which was evidently the body of the organ, and then, by giving a slight blow, a movable body was felt there. which immediately fell back upon the finger, exactly as the foetus wduld in the fourth month. I confess that at first I believed her pregnant, and re- touching her in the recumbent state, I once more remarked the negative signs, but my finger could not now detect the substance that had been sc easily moved when she was standing. At the third examination, I dis- covered an anteversion of the womb, so complete that its anterior face had become inferior or horizontal, and it was over nearly the whole extent of this face the finger had passed in examining : and further, I found that the fundus uteri, situated behind the symphysis pubis, was the light movablo body which had produced the sensation of ballottement. If a similar case should occur again, it might give rise to uncertainty in diagnosis, and on that account I concluded to make it public through this work. There are also some particular positions of the foetus in which the ballotte- ment would be of little service: for instance, in those of the breech it is generally very difficult, and nearly impossible in those of the trunk. In two cases, however, I succeeded in detecting a small part, which, from its diminished size, must have been an elbow, wrist, or heel; and this, together with the other signs, satisfied me that it was a position of the trunk. U. 1 latin, who attended one of these women in her accouchement, found a presentation of the left shoulder ; the other was delivered at the Clinique, and like the first, verified my diagnosis. 2. Palpation of the Abdomen. — An exploration of the abdomen, says Schmitt, is of great importance in diagnosis, and should always be resorted to when it is desirable to ascertain whether pregnancy exists. It is often, indeed, more instructive, and furnishes surer results, than the internal examination. Some obstacles are, however, met with in this mode of research. Thus 248 PREGNANCY. 1, the walls of the abdomen may be too thick ; 2, its muscles may be very tense; 3, the bladder may be greatly distended with urine, and the intes- tines with gas or fecal matter; 4, lastly, a fixed pain in the hypogastric region, rendering any pressure there often insupportable to the patient. The too great thickness of the walls of the abdomen is the only one of these difficulties which is permanent, but which, nevertheless, frequently renders the palpation of the abdomen entirely fruitless ; for as the tension and sensibility of the walls are but temporary, the exploration may be deferred to a more favorable opportunity, and the bladder and rectum may always be evacuated beforehand. These obstacles are of rare occurrence, the examination being generally quite easy, owing to the flexibility of the walls of the abdomen. In order to practise it, the female must lie down in such a way that her hips shall be elevated, the head flexed on the chest, and the thighs on the abdomen ; in a word, so as to relax the abdominal muscles completely. Whilst in this position, the abdomen should be first examined with both hands, so as to ascertain its form, size, tension, resistance, and hardness, especially in the sub-umbilical region. In the earlier months of gestation, if the parietes are not too thick, a round tumor, of fleshy consistence, can be detected rising out of the pelvis, sometimes in the middle, and at others a little towards the right or the left side ; during the first two months it seems to rise higher above the pubis than in the course of the third, which fact is readily accounted for by the sinking down of the organ, occasioned by its increasing weight and volume. This tumor, which is the womb, rises gradually toward the epigastrium as gestation progresses, and it often becomes necessary, in order to form some idea of the time at which labor win probably occur, to ascertain the exact amount of its elevation. The following is, I think, the best mode of accomplishing this object: Place the ends of the eight fingers immediately above the symphysis, and then continue to ascend gradually so long as they feel any resistance, for when the fundus uteri is gained, the resistance suddenly ceases, and the fingers sink deeper as they glide over the convexity, which is thus recognized with- out difficulty. The uterine tumor, which is at first quite resisting, becomes less so as -^station advances; sometimes, however, it is so soft as to be barely dis- tinguishable. An attentive examination will enable us to detect the following characters: 1. It always remains circumscribed and retains its oval form ; 2. It presents a certain amount of elasticity, similar to that of a cyst filled with serum ; 3. If this manual exploration be continued in the Miine direction, the examiner will detect greater or lesser parts of a single irregular mass, which are movable and easily displaced like bodies sus- pended in water. Often, indeed, these movable parts may be recognized as belonging to the foetus. As a part of the abdominal exploration should also be reckoned the sign furnished by percussion, namely, a dull sound over every part of the abdomen occupied by the developed uterus, instead of the resonance per- ceived at other points. Some care is necessary in percussing, during the first four or five months DIAGNOSIS OF PREGNANCY. 24.9 not. to be misled by the dulness which a distended bladder, or a patho- logical tumor of considerable size might produce. It should also be borne in mind, that although the uterus may have risen to near the umbilicus, a clear sound will be yielded on percussion throughout the greater part of the sub-umbilical region, provided a few folds of intestine be interposed between the walls of the abdomen and the womb. Sometimes the uterus is above the superior strait in the earliest months. I had an opportunity of observing a case of the kind at the Clinic, with Professor Dubois, in a woman who was advanced six weeks or two months ; the uterus was so elevated, being found in the right iliac fossa," that at first we doubted the existence of pregnancy, which however was real, as was proved more positively several weeks after, and fully justified by the event of the case. The palpation of the abdomen and the vaginal touch are in most cases practised simultaneously ; we shall, therefore, point out the signs which this joint investigation furnishes at the different periods of pregnancy. In the first three or four months the uterus either remains wholly within the lesser pelvis, or else its fundus projects somewhat above the superior strait. In the first case, it will he easily discovered by the vaginal touch that the entire excavation is occupied by a slightly movable tumor, with a smooth and regular external surface. In the second case, the lower half of the lesser pelvis is empty, but the examination of the abdomen, con- ducted according to the rules above mentioned, discovers the tumor formed by the womb in the hypogastrium. The first point to be ascertained is the exact size of the uterus, and this can only be determined by the double exploration spoken of: the finger having been introduced into the vagina, is applied directly on the neck, or, still better, against the anterior or pos- terior portion of the inferior segment of the uterus, while the other hand placed above the pubis, presses down the muscular walls, and searches for the tumor formed by the fundus uteri ; the womb is thus included between the finger in the vagina and the hand on the hypogastrium, and, of course, the volume of the organ may be thus ascertained, and a comparison made between it and the unimpregnated uterus. Moreover, its displacement in mass can be very easily recognized in this position. To accomplish this, the finger should remain applied as above stated, and when the hand slightly depresses the fundus, the finger in the vagina recognizes the de- pression ; and the counter-proof may be made by endeavoring to raise the uterus from below, by pressing strongly on the inferior part, which is found deep in the excavation. But the tumor which is felt in the lesser pelvis, or in the hypogastric region, may be either formed by the uterus, or developed in the adjacent parts. In the latter case, the womb will generally found to be displaced, and pressed by the tumor against one of the sides of the pelvis ; and if the neck be traced from below upwards, the finger will detect a line of demarcation between the wall of the uterus and the pathological tumor; sometimes, it can even be insinuated between them. The motions to winch the neck is subjected are not usually communicated to the tumor, and vice versti. Finally, the neck will exhibit none of the changes peculiar to pregnancy. 250 PREGNANCY. Hitherto y> e have only demonstrated that the uterus is developed, bui the question arises, what is the cause of that development? The solution is nearly always difficult ; we may state, however, that when the womb ig enlarged by a product of conception, its walls are generally more flexible than if the enlargement were dependent upon some chronic disease; and that, after a little practice, this suppleness can be detected by carrying the finger to the posterior surface of the body, which may be done in conse- quence of the depression and retroversion of the fundus. The uterine wall then offers about the same resistance as an oedematous limb, or perhaps still nearer, that of caoutchouc when slightly softened in hot water. The tumor detected either by the vaginal touch, or by depressing the ven- tral parietes, is rounded and smooth throughout, and does not present any of those irregularities observed in cancerous or fibrous degenerations of its walls ; and this fact, together with the preceding observation, will serve to distinguish a morbid state from a true gestation. It certainly will not prove quite so easy to determine whether the enlarge- ment is caused by a foetus, or the presence of a mole in the cavity ; in fact, I do not believe this diagnosis is possible, except at a very advanced stage, and then the absence of the foetal inequalities, the non-appearance of its movements, auscultation, &c., might suffice to remove the doubts on the subject. In some women, the womb becomes congested and considerably tumefied at the menstrual periods. Now this state may readily be confounded with a commencing pregnancy, the more particularly, because at those epochs the neck usually becomes softer and dilates a little; and I know no way of escaping this error, if the woman insists that she is pregnant, and experiences the various rational signs of that condition. In two cases of the kind I have met with, I only succeeded in detecting the falsity of my diagnosis by examining the woman a second time, two or three weeks after; for these females, who were used as subjects for practising the touch at the Clinique, wished to be considered pregnant ; but, unhappily for them, the fortune which aided in the first examination, deserted them at the second ; for, being ignorant of the cause of my mistake, they returned at a time still more dis- tant from their menstrual period. On the whole, then, there is no certain sign of pregnancy during the first three or four months; yet it becomes almost certain, when the sensible signs above indicated coincide with the presence of the rational ones, in a healthy woman who can have no intention of deceiving us as to her condition ; still, in a medico-legal case, the physician should express his doubts, and demand a new examination at a more advanced period. But if it is not always pos- sible at the beginning of a gestation to prove that it does exist, we can, at least in the great majority of cases, satisfy ourselves positively that it does not ; for most frequently the unimpregnated state of the organ can be readily made out. 3. Active Movement* of the Foetus. — The existence of pregnancy is an- nounced during the last five months by certain signs that are far more reliable than any of those hitherto mentioned ; these arc the fcetal move- ments, which have improperly been called the active and passive, but bettei DIAGNOSIS OF PREGNANCY. 251 designated by M. Stoltz as the movements proper and the communicated ones. We have already studied the communicated ones in treating of bal- lottement and palpation of the abdomen; so that it only remains to describe the active movements. The woman generally perceives the foetal movements at about four months and a half, although the muscles of the infant had contracted long ere this, unconsciously to her ; for every accoucheur must have detected the3f motions by placing his hand upon the abdomen, at a time when the mother herself still doubted her own pregnancy. Now these movements are exces- sively feeble at first, and produce a kind of tickling, or rather a sensation analogous to that of the crawling of a spider; they gradually become more characteristic, and may then be classified in two species. One of these is produced by the movements of the whole trunk, or some of its parts, the first of which are recognized by a quivering that is perceptible to the female, while the partial motions give rise to quite large projections, which are even visible through the abdominal walls ; the other, on the contrary, are blows, certain small, short strokes, which at times are violent enough to elicit cries from the sufferer, and these shocks are evidently produced by the action of the thoracic or inferior extremities of the child. Such movements, so dis- tinct and clear to the mother, would seem to be an infallible sign of gesta- tion, and yet such is by no means the case, since it is not at all uncommon to find women, whose veracity is beyond question, asserting that they have felt them for a long period, and sometimes the motions have even been per- ceived by the husband or other persons, yet without their being pregnant. The history of one of the English queens is well known, who, believing she had felt the motions of a child, dispatched couriers with the happy news to all the foreign courts, but proved to be only the commencement of a dropsy ! Such errors are frequent, and there are but few accoucheurs who have not met with many of them in practice. Consequently, the physician should not rely in this matter upon the statement of the woman, but should perceive them for himself before hazarding an opinion. It would seem, indeed, that in some cases, the intestinal movements, the rapid passage of gas in the intestines, certain partial and irregular contractions of the ab- dominal muscles, and the pulsation of a large artery, especially when situated behind any tumor which it raises at every beat, have often deceived not only the patient, but even her medical attendant. Some females, from the desire of simulating pregnancy, have acquired the power of contracting their abdominal muscles in so singular a manner, that many able accoucheurs have been deceived, and believing that they felt the foetal movements, have consequently pronounced them pregnant. (Montgomery, p. 84.) These motions may be detected by the vaginal touch in certain positions of the breech, or even of the trunk, but we must rely chiefly on the abdo- minal palpation for their detection. In general, it is only necessary to place the hand flat on the abdomen, or to make use of slight pressure, to perceive them ; though if they are feeble and infrequent, it is hetter to dip the hand in some very cold liquid, and then place it suddenly upon the skin. This rapid change in the temperature of the abdomen probably reacts upon the 252 PREGNANCY. infant, for it generally moves convulsively. I believe, with Dr. Tyler Smith, that the sudden impression of cold is more likely to produce a rapid contraction of the abdominal muscles or uterus, than to act directly upon the foetus, and that its use might readily deceive as to the nature of the motions which it occasions. I prefer placing a hand upon one of the sides of the abdomen, and strik- ing with the other on a point opposite ; for the foetus then rarely fails to move briskly as though to resist the impulse. As before stated, the movements begin to be felt about the end of the fourth month. To this law, however, there are numerous exceptions; thus, fome women perceive them as early as the latter half of the third month, others not before the fifth, sixth, seventh, or eighth months of gestation. One woman, who had advanced to the latter period, was brought to the Clinique, in consequence of a fall in the street, and she assured us that she had never felt the movement prior to the accident. We have already alluded to the person, seen by us at La Charite, under the care of Professor Fouquier, who was delivered at term of a very healthy child, but the motions of which were neither perceptible to the mother nor ourselves. Mauriceau, Delamotte, and many others, bring forward similar cases. Bat the most remarkable of all is the one reported by Campbell. I knew a lady, he says, the mother of nine children, who, excepting in her first pregnancy, never perceived any motious of the foetus; but she was herself very inanimate and passive, and what was still more singular, the children were equally nonchalant with herself. Whenever ascites complicates the pregnancy, these motions are very indistinct, thus affording an evidence that it is the abdominal walls, and not the uterus, which perceive the impulse. After the movements have been distinctly felt, they sometimes diminish without any appreciable cause, both in frequency and intensity, and then altogether disappear, which circumstances demand the most serious atten- tion of the accoucheur, as it is in general an unfortunate symptom. I believe this spontaneous cessation of the active movements may usually be referred to a congested state of the uterus, which reacts on the child's health. But whatever may be the value of this opinion, it is quite certain that bleeding, under such circumstances, has always produced a favorable result; for when not delayed too long, the movements reappear soon after, and hence I cannot recommend the measure too highly. 4. Of Auscultation as applied to Pregnancy. — M. Mayor, of Geneva, first detected the pulsations of the foetal heart by auscultation ; but this dis- covery, originally published by him in 1818, had been entirely forgotten, when M. de Kergaradec announced, in 1823, that if the abdomen of a woman who has passed the first half of her pregnancy be carefully auscul- tated, two sounds, which are perfectly distinct in character, will be recog- nized: one of them, consisting of double pulsations, or rather of redoubled ones, according to the expression of M. Stoltz, is evidently produced by the movements of the foetal heart, and has been compared, with some reason, to the ti king of a watch enveloped in a napkin ; the other is a kind of rustling, unattended l>v shocks, and consequently without beating, being DIAGNOSIS OF PREGNANCY. 253 characterize*] by simple pulsations, accompanied by the souffle, which have been successively compared to the sibilant murmur, or to the sound of an erectile tumor, or varicose aneurism ; this is called the bellows sound (bruit dc souffle). Another bellows murmur, of more frequent occurrence than the former, is termed the murmur of the cord, and will be studied after the preceding. 1 [At the end of the third month the pulsations of the foetal heart may, therefore, be heard, though not as a general rule. Careful and long continued auscultation at this period, however, often enables us to detect with the stethoscope sudden and repeated blows, which would seem to be produced by rapid motions of the foetus. The sensation is sometimes so clear, and leaves so little doubt as to its cause, that the sound occasioned by the displacement of the foetus in the amniotic fluid may be accepted as a useful sign in the diagnosis of pregnancy, and one which, in a diffi- cult case, ought not to be neglected. It cannot, however, be always detected, inas- much as it is necessary that the foetus should move briskly at the moment of observation.] 1. Sound of the Heart. — The pulsations of the heart generally become perceptible in the course of the fourth or fifth month, though more fre- quently during the latter, and often then at an elevated part of the abdo- men near the umbilical region ; in one case, however, I thought I heard them a little before the fourth month, but, unfortunately, I could not re-examine the female until six weeks afterwards. M. Depaul declares that he has heard them at the end of the third month and in the eleventh week. These pulsations are far more frequent than those of the mother's heart ; ranging, as they do, from one hundred and thirty to one hundred and sixty per minute ; and, moreover, they are very often accelerated or diminished, without our being able to detect the cause of the changes. Like most observers, I have several times remarked that, if the foetus exhibited any violent movements during the examination, the pulsation increased and became very difficult to county but they are not influenced by any variations in the mother's pulse, whatever may be their cause. The dorsal region of the child seems to transmit the double pulsations most easily, and consequently they are more clearly perceived at that part of the abdomen which corresponds to it. This circumstance likewise explains why the pulsations change position so easily prior to the seventh month ; in fact, it is only during the last three months, that extensive movements on the part of the child become difficult, and its position nearly fixed. They may be heard most frequently on the anterior inferior portion of the abdominal wall, just above the iliac fossa, or still more rarely on the median line, and not merely at a very limited spot, but over a radius of two or three inches. In some cases they may even be heard over more than half of the abdomen ; but it is always easy to perceive that bhey are stronger 1 The character of this work prevents our giving a detailed account? of the history of this important subject. I cannot, however, too strongly recommend all who wish to be fully informed upon the matter, to consult the excellent Monograph recently published by M. Depaul. (Truitt de I' Auscultation Qbstetricale, 1847.) 254: PREGNANCY. and clearer at one point than elsewhere, and from this point as a centre, thev become weaker and weaker as the distance increases. The intensity of pulsation is of course less marked as the child is younger, although, in some instances, they exhibit as much force in the sixth month as at term, but this is very unusual. As regards the number of pulsations, the statement made by many observers that it is much more considerable at an earlier period than at term, is not absolutely true, for the fetal heart always beats with the same quickness, saving some accidental variations, at whatever period it may be examined. Labor produces no modification of the foetal pulsations up to the moment of rupturing the membranes; but this rule fails after the amniotic liquid has escaped, because they are then generally louder and clearer, and may be heard over a more considerable extent of surface, which can readily be explained by the fact that the ear or instrument is then nearer the foetus. When the contractions become more energetic, the pulsations are not so regular, and they are more feeble and slower while the contraction lasts. In those cases where the labor is of moderate duration, the indistinctness of the sound of the heart may be referred, I believe, to the difficulty of ausculting during the pain ; but if the foetus has been too long subjected to uterine pressure — as where the labor has been unusually prolonged — the number, force, and regularity of the pulsations sensibly decrease .Most observers have asserted that the sounds are not always perceptible, and M. Stoltz even declares that they cannot be heard whenever the dorsal region is directed backwards, unless some part of the thorax be in contact with a portion of the uterine walls which may be explored. For my own part, I have not failed, for several years past, to hear them in examinations made after the sixth month, in all cases where the children were living ; and as my researches have now extended to at least seven or eight hundred women, I feel convinced that we can always distinguish them after that period, in any position of the foetus whatever. M. Dubois was the first to point out the fact, that the sound of the foetal heart has sometimes a peculiar resonance, resembling the metallic tinkling, a singularity which I have twice had the opportunity of observing at the Clinique. This remarkable sonoriety is most frequently met with in women in whom the uterus is distended by a great quantity of fluid. There are also some circumstances which render the pulsation a little obscure and somewhat difficult to hear; thus, for instance, a lumbo-posterior position of the foetus, a large quantity of water, by which the uterine walls are greatly distended, and a sufficient depression of them by the stethoscope to approach the child prevented ; the interposition of several folds of intestines between the abdominal walls and the uterus, and the existence of borborygmi, are nil so many circumstances calculated to render the perception of the pulsa- tions more difficult, although not absolutely impossible. The beatings of the foetal heart are composed of two distinct sounds, the second being stronger and more sonorous than the first ; but, u. a great in ijority of cases, both of them may be heard quite distinctly. M. Nsegele, however, appears to think that enly a single 3ound is heard DIAGNOSIS OF PREGNANCY. 255 under certain circumstances, and I have sometimes made the same observa- tion ; but it has always seemed to me that the perception of only one sound might either be referred to bad manipulation on my part, or else to some one of those circumstances just described having prevented the application of the stethoscope over a point near enough to the back of the foetus. Thus, though I have frequently heard but a single sound at first, after changing the instrument, others became clearly perceptible. I am happy to extract the following paragraph from the thesis of M. Carriere, a pupil of M. Stoltz, which fully confirms my opinion. He says: "I have remarked that the single character of the fcetal pulsations here described, is most likely to be observed when the point examined approaches the fundus of the uterus." Like all useful discoveries, obstetrical auscultation has had its opponents as well as its partisans; and though the former are daily diminishing in number, the latter certainly have injured their cause by exaggerating its importance ; we shall, however, carefully endeavor to ascertain its practical utility. a. It has been stated that a perception of the pulsations of the foetal heart was a certain sign of pregnancy, as also that the absence of this sound, positively determined by several examinations made after intervals of some hours, subsequent to the sixth month, announces with certainty the death of the foetus; supposing, of course, we have a satisfactory assurance of the previous existence of gestation. [It is a very rare circumstance, says M. Depaul, for the pulsations of the fcetal heart to be inaudible during the three last months of gestation, unless the child be dead. They failed to be detected in but eight cases out of nine hundred and six, examined at this period.] There is, notwithstanding, one circumstance which might lead to a sus- picion of pregnancy even when the uterus was really empty; it is this: in certain females the pulsation of the heart is felt and heard as low down as the sub-umbilical region, and we can imagine that if, in such persons, under the emotions naturally produced by an unjust suspicion of gestation, or, from the influence of any febrile movement, the circulation be accelerated, the pulsations, from their number and rapidity, might be mistaken for those of a foetus; but in such cases, all errors of diagnosis may be easily avoided by observing: 1st. The perfect isochronism between the pulse at the wrist and the abdominal beatings; and 2d. That the intensity of pulsation con- stantly increases as the precordial region is approached ; which two pecu- liarities are never presented by the sound of the foetal heart. b. Can a twin pregnancy always be recognized by auscultation? It is said that, in most cases, the existence of two children in the uterine cavity may be known by the following sounds: 1st. The sound of the heart will be heard at two distant parts of the abdomen ; and 2d. The want of isochronism, and of frequency, which may sometimes be detected between these two series of pulsations. These characters are advanced by some writers as indicating a double pregnancy with cerlainty, but we shall point out several sources of error on this point: thus, it frequently happens that the pulsations of a single heart resound in very distant parts. Now, can this be referred, as M Dubois 256 PREGNANCY. thinks, to deficient thoracic development, to the unusual com} arative siz« of the heart's cavities, to the density of the lungs, or, lastly, to the position of the foetus itself, the head and extremities of which, being applied against the thorax, and there receiving the impulses from the heart's contractions, serve to transmit them to a greater distance? I should be inclined to adopt this view; for, whatever be the explanation, the fact is certain, and the following appears to me the best method of resolving the difficulty: When- ever the pulsations are heard at two distant points, the line between these should be carefully followed with the instrument; for if they are produced by the presence of two foetuses, the pulsations will become feeble, or almost disappear, towards the centre of this line; but if, on the contrary, they are due to a single child, they will be just as strong at its middle part as at either extremity. Again, the absence of isoehronism in the pulsation does not positively prove the existence of two children; for one series may be owing to the foetal heart, and the other belong to the same organ in the mother, the resonance being transmitted to the abdominal cavity. Hence, it is evident that the unusual distinctness of the mother's pulsations coinciding with the presence of a single foetus may lead to the belief of a double pregnancy which does not exist, and a comparative examination of the pulse then becomes necessary. [After all, it must be acknowledged that the pulsations of the fcetal heart may vary from one instant to another, without our being able to comprehend why such should be the case. It may lead, also, to a wrong inference when the auscultation is practised at two different points successively, inasmuch as a want of isoehronism might in this case give rise to the impression that there were two children, whilst, in fact, there was heard the sound of but a single heart beating with variable rapidity. To avoid all chance of error, two practised observers should place their stethoscopes over the two points where the sounds are most clearly heard, and then count them together during the same time. Should there be a notable difference between the two numbers thus obtained, a twin pregnancy may be regarded as certain.] A double gestation may be easily recognized, if the precautions just indicated are observed, because, the twins being habitually placed one on the right the other at the left part of the abdomen, distinct beatings will be clearly heard, if the stethoscope be successively applied to each side. But this happy state of affairs does not always exist, for sometimes one foetus is situated directly before the other ; and then it is nearly impossible, even with the greatest attention, to hear the heart of the posterior child ; and, consequently, when the other signs of a twin pregnancy are present, the results derived from auscultation would not prove its non-existence. Is it necessary to add, that equal care should be taken to abstain from hasty deci- sions in those cases in which there is reason to believe that one of the children is dead ''. c. Can we appreciate the state of the child's health or disease, of its debility or vigor, during labor, by means of auscultation? This question, which was brought before the Academy by a memoir of M. Bodson, and which gave rise to a remarkable report by M. P. Dubois, DIAGNOSIS OF PREGNANCY. 257 is certainly one of 1he most curious and interesting suojecls of &iudy ; for if we could possibly judge from the signs furnished by auscultation, of the integrity of the fetal life, no uncertaiutv could arise with regard to the course to be pursued when the labor is 100 long delayed, after the rupture of the membranes ; for the feebleness and relaxation, or the excessive fre- quency of the foetal pulsations ; the interniission and irregularity of their rhythm ; the absence of the second stroke ; or the complete cessation of this phenomenon during the uterine contraction, and the slowness of its return after the pain has ceased, would sufficiently authorize a prompt termination ; whilst the opposite phenomena would justify delay. These signs, and more especially the irregularity of the pulsations, which appears the most important of all, indicate in the clearest manner that the fcetus is in a state of suffering; and hence they should serve as a formal indication to the accoucheur to remove the infant promptly from the danger which threatens it, by an artificial termination of the labor. But, as M. Dubois has very judiciously remarked, there is not then a sufficient integrity of circulation to establish the extra uterine life; for, although the foetal pulsations may be still regular and sonorous at the moment of birth, yet the child has suffered so much from the long pressure of labor, that the respiration cannot be established ; and hence, in this respect, the accoucheur should not rely upon auscultation alone for judging of the opportune moment for the intervention of art, because other considerations quite as important should influence his decision ; still, however, this is a method of diagnosis that is never to be neglected. 2. Souffle of the Cord. — M. Nsegele, junior, has recently described a bel- lows murmur, which he attributes to the pulsations of the umbilical cord, and compares it with the sound produced by the beating of the carotids in chlorosis, and the murmur consists, he states, of a simple pulsation which is caused, as he thinks, by the winding of the cord around the neck of the fcetus, or by its compression between the child's back and the uterine walls; the sound increases after the escape of the liquor amnii, and its force is greater in proportion as the arteries of the cord are the more developed, and subjected to greater tension. In the positions of the head, it is situated below the umbilicus, but higher up in those of the breech, and it seems to descend during the expulsion of the foetus. Sometimes a bellows murmur is heard accompanying the cardiac pulsations, especially at the first sound, but it appears difficult to reconcile this circumstance with the interruption in the circulation caused by any pressure on the cord. Since M. Najgele, junior, pointed out this peculiarity, several others have noticed it, and I also have met with it at different times, where nothing would indicate even a slight compression of the cord, or any winding around the neck. Does this belong to the fcetal heart, as M. Dubois and M. Depaul believe? Indeed, the latter states that he has detected this sound, which he had pre- viously heard during the intra-uterine life, by ausculting the infant imme- diately after birth. But nine other cases, he says, turned out differently, and oblige me to state the facts as they occurred. The foetal murmur occupied a part of the uterus entirely removed from that where the beating 17 25S PREGNANCY. of the heart was detected ; the latter being pure, and unmixed with any murmur. Five of these children were boru with one or several turns of the cord about the neck, whilst in the sixth, it surrounded the lower part of the thorax. The remaining three were free from anything of the kind. All were born living, and on none of them was it possible to detect a souffle in the cardiac region immediately after birth. The question must therefore be decided by new observations ; for, although the sound may be produced by the compression of the cord, the compression often exists without the abnormal murmur. 3. Uterine Souffle. — Numerous denominations, each of which is founded on its supposed nature, have been applied to this sound ; for instance, M. Kergaradec thought it was produced in the utero-placental circulation, and hence gave it the name of the placental murmur; on the other hand, M. Bouillaud, and many others, have subsequently assigned its seat (which, to say the least, is very probable) to the large arterial trunks placed on the posterior abdominal plane, where they are subjected to considerable pressure from the developed uterus, and they have denominated it on this account the abdominal souffle ; and still more recently, M. Paul Dubois has endeavored to prove that it originates in the vessels which ramify in the substance of the uterine wall itself, whence he has called it the uterine souffle. But as we shall take occasion hereafter to discuss these three opinions, which em- brace all our present knowledge on the subject, we will pass them over here. In general, the bellows murmur may be heard as soon as the uterus, by rising above the superior strait, becomes accessible to the stethoscope — that is, a little earlier than the sound of the fcetal heart; in fact, M. Delens asserts he has detected it at the third month, and Dr. Kennedy towards the tenth, eleventh, or the twelfth week. M. Depaul has also made the same observation ; but as there is a very great difficulty in approaching the uterus at so early a period, these facts are certainly exceptional. The murmur undergoes some very singular modifications during the course of pregnancy : thus, we do not hear it in every instance ; again, it is not at all unusual for it to escape detection for a long time after having once been heard, and then to reappear somewhat later; sometimes even we may auscult for several minutes in vain, when it suddenly appears directly under the ear, augments, becomes quite loud and distinct, lasts for a few moments, then diminishes, and finally ceases altogether. In other cases, two or three pulsations, attended by blowing, are heard during profound silence, but nothing more after that ; and on the other hand, very frequent opportunities are afforded us of observing the prompti- tude with which the sound changes its locality; for it seems to pass suddenly from one point to an opposite one, being sometimes immediately beneath the ear, at others very distant: only covering a single spot in the majority of cases, but occasionally extending to two remote regions, and, what is very remarkable, with equal force and clearness at both these points ; further, the extent over which the sound is heard is usually quite limited, but in Bome instances it becomes perceptible over a very large surface, trespassing upon neaily the whole anterior abdominal region. On several occasions my pupils have had opportunities of studying all DIAGNOSIS OF PREGNANCY. 259 these varieties, which indeed are almost inexplicable, whatever opinion may be adopted as to the cause of the sound. The murmur is modified during labor ; for at the very instant when the pains begin, and even before the patient herself is aware of them, it becomes at once louder, more sonorous, and more distinct, and at times exhibits some strange modifications: thus, at one time the sound heard resembles, par- tially at least, the tone of a reed, or a tense cord thrown into vibration, though as soon as the contraction becomes stronger and more general, it seems to grow weaker, appearing at longer intervals, and finally becoming imperceptible ; but when the pain ceases, the sound returns, at first with the intensity it manifested at the beginning of the contraction, and gradually regains the same sonorousness it had during the gestation. Such is the order presented when the contractions are regular and energetic ; but if they are false or irregular, the souffle is not modified, or at least is not any stronger, except it be for a few instants only. It may likewise be perceived after the expulsion of the foetus, and even of the after-birth : for example, M. Carriere says he heard it twenty-four hours subsequent to the delivery of the placenta. Generally, it extends towards the inferior lateral part of the abdomen ; more rarely, it is heard near the fundus uteri. The following is the result of 295 observations, made by M. Depaul, of women who had passed the fifth month of gestation ; it will be seen that it accords with my own experience. It was heard very distinctly 182 times on each side of the uterus, at a short distance from the crural arch ; in 27 cases, it appeared on one side only ; in 43, towards the fundus of the organ ; and in 18, it was spread over the entire surface of the uterus. Finally, M. Depaul states, that in 12 cases, it was present in three distinct situations, namely, the fundus of the womb and the parts above the crural arches. During the first half of the pregnancy, it was oftenest observed when the stethoscope was placed upon the median line a little above the pubis. The character of the sound heard varies greatly ; sometimes it is short, abrupt, and separated from the succeeding one by a longer or shorter inter- val of complete silence, which is dependent upon the frequency of the pulse; sometimes it is a prolonged roaring, a true ** bruit de diable," which has its period of beginning, of increase, and termination, the latter blending with the next succession. In short, it presents all the variations of rhythm which have been attri- buted to the chlorotic murmurs. Though generally simple and intermit- tent, it is sometimes continuous and double (bruit de diable) ; finally, it may be both continuous and simple. I have not yet met with the typical, double intermittent sound. Like the murmur in the carotids, the rhythm may change in a few moments so as to present in a very short time several of the varieties just mentioned. The quality of the sound also varies greatly ; and this not only in dif- ferent women, but even in the same woman, and sometimes whilst the exploration is going on. Occasionally it is whistling, and resembles much the sound of the wind blowing through a badly closed doorway ; again it becomes roaring, so as to imitate the vibrations of a base cord ; at other times it is plaintive, suggesting the cpoings of a turtle-dove. 260 PREGNANCY.. The seat and mode of production of this sound is a question that has given rise to much controversy, though, as the sound is synchronous with the mother's pulse, it must be evidently connected with the maternal vascu- lar system. Thus far all agree, but diversities of opinion immediately spring up when a more precise location of it is attempted ; for the murmur is pro- duced outside of the uterus, exclaims one party; not so, it is seated in the uterine or the placental vessels, say the others. 1. The Murmur is produced in Parts distinct from the Uterus. — When- ever a tumor is developed over the course of a large arterial trunk, the compression exercised by it on the vessel produces a souffle, and it is not at all unusual, whenever a pathological tumor is developed in the abdomen, to hear a murmur in such cases, very nearly resembling that of pregnancy ; now, the uterus developed by a product of conception constitutes a consider- able tumor, one which must necessarily compress the vessels and produce the effect described. This view is advocated by numerous partisans, who contend that the murmur does not begin to appear until the uterus really compresses the iliac vessels by being elevated above the superior strait ; that it is usually heard at the inferior lateral part of the abdomen, and more frequently on the right side, because the uterus is habitually inclined to the right; and lastly, that if, according to the plan of my friend, Dr. Jacquemier (which I have since often practised myself), the female, after having been ausculted in the supine position, be made to kneel down, with the body bent forward nearly horizontally, and the elbows resting on the ground, in a word, in such a position as to throw the whole weight of the uterus upon the anterior abdominal wall, the murmur will no longer be heard, although distinctly audible before. In support of this opinion the following considerations may be adduced : The abdominal souffle is, like that of chlorosis, partly due to the altera- tions which the blood undergoes during pregnancy. Whatever theory be embiaced respecting the mechanism of these abnormal vascular sounds in chlorosis, whether they be attributed to the diminution of the corpuscles, as M. Andral supposes, or to hydremia, according to M. Beau, and, we may add in passing, this latter theory seems to me to be the only admissible one, the great analogy between the blood of chlorosis and that of pregnancy can- not be ignored. It is equally difficult not to recognize the entire resemblance between the souffle of pregnant women and that of chlorotic patients. They exhibit the same varieties of rhythm, as also of tone and sonorousness ; both are some- times mixed or composed simply of buzzing, rasping, or whistling sounds, which seem to be alike peculiar to the early stages of the affection. Both present, if I may so express it, the same mobility of duration, rhythm, and intensity, and appear to be similarly affected by the greater or less pressure of the instrument, as also by changes in the circulation of the female as a con- sequence of disturbances of temper, violent movements, &c. Is it not, therefore, natural to conclude, that since pregnancy and chlo- rosis produce the same changes in the blood, the souffle, which is exactly alike in both cases, is also due to the same cause ? But, it will be replied, in chlorosis the murmur is heard more especially DIAGNOSIS OF PREGNANCY. 261 in (he cervical region ; why, therefore, during pregnancy should it, if due to the same cause, fix itself particularly in the abdomen ? I would reply, in the first place, that in some cases the cardiac and carotid murmurs have been observed in pregnant women ; still I admit that, most generally, they are not heard even when the abdominal souffle is present. The latter cir- cumstance can be readily explained, for it is in fact rarely that the altera- tion of the blood is carried to the same extent as in ordinary chlorosis ; the proportion of globules rarely descends below one hundred, and the* amount of water is far from equalling the enormous proportion which it reaches in chlorosis. Now, if it be true, as M. Andral supposes, that the production of abnormal sounds is an indication of a more advanced alteration, we can comprehend why they should not be perceptible in the carotids, where only poverty of the blood could produce them. The conditions are not the same in the abdominal vessels, for there, to a commencing hydrsemia, is superadded a considerable diminution of the calibre of the vessels, which diminution is a result of the compression of the uterine tumor ; and these two circumstances united are capable of produc- ing a souffle which they would be unable to determine singly. The com- pression of the arteries thus gives rise to a sort of insufficiency, which ren- ders still more sensible the slight increase which the total amount of the blood has undergone. It has been stated that we have several times known the sound to dis- appear when the woman was placed on all fours, but that in other in- stances it still remained. M. Depaul recollects having repeated this ex- periment, with the effect of continuing to hear the uterine murmur, without the slightest variation. This last remark, made by such observers as MM. Depaul and Carriere, deserves further attention on our part. As M. Beau has pointed out, it is much more difficult than would be supposed, and sometimes even impossible, to cause the woman to assume such a position that the large arteries shall escape all compression by the uterus. The abdominal walls of young primiparous women are too resisting to yield under the momentary weight of the uterus, and whatever position be assumed, they retain the organ strongly applied against the posterior plane of the abdomen. M. Beau has also proved that this persistence of the abdominal souffle is not peculiar to pregnancy, but that in the case of a woman affected with a cyst of the ovary, shown to be such at the autopsy, it was impossible to give the tumor any position in which it ceased to compress the arteries of the pelvis, and consequently to put an end to the murmur. I would add, that, whilst admitting that compression is not the sole oause of the murmur, but that the serous plethora of pregnancy also con- tributes to its production, it might be readily supposed that if the latter reach a certain degree, it might of itself give rise to the abnormal sound, even should the position of the female entirely relieve the abdominal ves« sels from pressure. The same remarks will apply to the variable results which are some- times obtained, when, after having heard the sounds on one side of the abdomen, the woman is made to reverse her position. Sometimes, we have 262 PREGNANCY. said, it ceases to be heard ; at others it persists, although the inclination of the uterus had removed the pressure from the vessels on the point opposite the side upon which the woman lies. In the first case, the ple- thora was too slight to maintain a sound, the production of which was partly due to the compression of the vascular tube; in the second, either the inclination of the uterus had not removed the pressure, or else the alteration of the blood was alone sufficient to produce the abnormal sound. Although MM. Barth and Roger are disposed to attribute the abdominal murmur to pressure, they nevertheless find some objections which prevent their adopting the opinion in its full extent. Why, say they, is not the sound increased when the uterus is pressed upon with the stethoscope, and why does it sometimes disappear when the pressure is made rather stronger? It is, replies M. Beau, because the murmurs are the result of a certain degree of pressure, which if increased or diminished, the sounds are altered or lessened. The effect is the same as that which is frequently observed in the carotid murmurs, which do not increase, and which even disappear, when too much pressure is made upon the artery ; and as these latter sounds are sometimes found to have their intensity somewhat increased by a slight pressure, so the abdominal murmurs are occasionally notably in- creased when the uterus is a little pressed upon. Finally, how happens it, say MM. Barth and Roger, that in certain cases in which no souffle was heard upon auscultation of the abdomen, it could, through the assistance of the metroscope of M. Nauche, be perceived upon the neck of the uterus, which is situated in the centre of the pelvic cavity, and therefore removed from the vessels ? We may suppose, again replies M. Beau, that in the cases in question the murmur had its origin in the hypogastric arteries. Now the neck of the uterus is nearer these arteries, than that part of the body of the organ which is in relation with the abdominal parietes. Besides, it is not pos- sible that certain organs which are poor conductors of sound, such as a mass of intestine or of omentum, might have been interposed between the surface of the uterus and the walls of the abdomen, and thus have pre- vented the transmission of the vibrations to the ear? 2. The Murmur is produced in the Uterus. — Those who locate the sound in the uterine circulation, differ essentially as to its precise seat and the mode of its production. Thus, M. de Kergaradec attributes it to the pla- cental circulation ; whilst M. Hohl, who also believes it is perceived at the point where the placenta is inserted, locates the murmur at a point corre- sponding to the insertion of the placenta, and bases his opinion upon the following reasons : 1. In 21 cases in which he removed the placenta with his hand, he found it adhering where the souffle was first heard; 2. In 15 cases where it was inserted upon the orifice, the murmur was heard very low down ; 3. In 10 others the autopsy revealed the after-birth where the souffle had been distinguished ; 4. In 8 cases of version the same fact was discovered directly ; 5. In 12 cases of twin pregnancy, one murmur uflly was heard when but a single placenta was present, and two distinct ones when the after-births were separate; 6. Lastly, in a great number of cases the intensity of the sound appeared to be in direct relation with the bulk and extent of the placenta. DIAGNOSIS OF PREGNANCY. 263 M. Hohl differs from M. Kergaradec by supposing that the sound results from the passage of the arterial blood into the venous sinuses of the placenta ; but, to refute this latter opinion, it is only necessary to bear in mind the great variety in the seat of the murmur during pregnancy, and that in some cases it is still perceptible after the delivery of the after-birth. I am therefore, like M. Depaul, convinced, that there is no relation between the point where the souffle is heard and that of the insertion of the placenta The views of M. Dubois still claim a notice ; for whenever, says this Pro- fessor, the disposition of the uterine apparatus is carefully studied, the freest communication will be found to exist between the arteries and veins, the uterine walls appearing to be transformed into an erectile tissue, or one of varicose aneurisms ; and the column of blood brought by the arteries, and divided through their branches, mingles, whilst passing directly into the veins, with the slower and less compressed columns contained in the canals of the latter. This circumstance is incontestably the cause of the murmur and souffle that is so remarkable in varicose aneurisms and the accidental erectile tissues, and it is very likely that the same cause pro- duces it in the uterine walls. Hence we can comprehend why it is only heard at that period when the vascular modifications of the organ are the most marked ; why it is most frequently audible over the spot correspond- ing to the placental insertion, because the development of the uterine vascular system is the most considerable there ; and finally, why this sound may still be heard in some women after delivery, when the retreat of the uterus is not yet complete, and the circulation in its walls has not been reduced to its condition in the non-gravid state. No one, since the researches of M. Dubois, has been able to rediscover the large and free communications between the uterine arteries and veins; it is in fact certain, that they communicate directly in no other way than through their terminal and capillary ramifications. It is plain, that when a sup- posed anatomical fact is proved to have no existence, the theory which is founded upon it can no longer be maintained. There are still some other points concerning the uterine circulation, which have recently been advanced: thus, Dr. Corrigan thought the passage of the blood from the uterine arteries into the sinuses, was the cause of the souffle; and M. Carriere, who admitted this opinion, added, that the circula- tion being much more active at the point corresponding to the placental insertion, the sound should be most audible on a level with that insertion. M. Depaul has quite recently repromulgated the views of Corrigan, adding thereto the compressions produced both within and without by some port ion of the foetal ovoid, and he attributes an important influence to these com- pressions, which, however, had previously been brought forward by M. de Kergaradec, in explanation of the frequent variations of the souffle in its seat and intensity. The cause of the sound, says M. de la Harpe de Lausanne, neither rests on a particular condition of the blood, nor on a modification of its course, nor yet in any peculiar state of the vessels, but simply on the multiplicity of the vesiels concentrating at the same point; which multiplicity, b) 264 PREGNANCY. increasing the currents a hundredfold, increases the sounds in the same ratio ; thus rendering those audible by multiplication, which, taken singly, were imperceptible to the human ear. Perhaps a comparison will serve to illustrate this idea : if a person place himself, on a mild day, under a tree that has been closely pruned, deprived of its leaves, and only having some large branches left, he will hear no sound or rustling of the air ; now let him pass from this tree to another one better furnished with branches, though still deprived of leaves, and he will perceive, if the same air be stirring, a commencing sound, produced by the branches that are agitated in the wind ; again, the intensity of sound will become much greater, if he once more changes to a fir-tree ; for notwithstanding the leaves of this latter are rigid and immovable, yet they are innumerable ; and just such is the case with the placental murmur. In fact, a liquid cannot circulate in a tube without producing a certain amount of sound by the friction of its molecules against the walls of the tube; only the sound is not detected by the ear when the vascular canal is isolated, but the contrary results, when thousands of little canals are found at the same point. [Amidst so many contradictory theories we shall not undertake to decide upon the mechanical production of the bellows murmur, but will endeavor to determine the seat of the sound, premising, however, that we do not believe that it is pro- duced in the great blood-vessels which are situated behind the uterus. The sound is sometimes really so superficial that it cannot be produced in the aorta or the iliac vessels; how, besides, will this explanation enable us to understand the facility with which it changes place, a circumstance to which all observers can testify? Finally, we would add that, in some very rare cases, the sound is accompanied by a thrill, which is easily perceived by the finger, and felt, so to speak, to be pro- duced behind the anterior wall of the abdomen. We regard it, therefore, as certain that it is produced in the uterus, and as we have already shown that it cannot have its origin in the placenta, we agree with MM. Dubois and Depaul, that it is located in the walls of the uterus. It is evident, therefore, that the term uterine souffle is the only one which can be properly applied to it.] The abdominal souffle is not of great practical importance ; its value, as a sign, is limited to rendering the existence of pregnancy probable. It may exist independently of pregnancy, and does not always accompany it; it is not influenced by the life or death of the foetus, nor is it modified in any degree by a state of suffering of the child ; it cannot, in any case, enable us to determine certainly either the place of insertion of the placenta, nor its form, size, or the changes which it may undergo. The observations of MM. Depaul and Na3gele, Jr., prove, in opposition to the conclusions of Hohl, that the diagnosis of double or triple pregnancies, is incapable of assistance from the souffle, presenting as it does in these cases no modifica- tions which are not also observed in simple pregnancies. Summary. — It is now well understood that, in ausculting the abdomen of a pregnant woman, we may hear both the pulsations of the foetal heart and the bruit de souflle. The first is a certain sign of pregnancy; but the gecond, being also produced by other causes, only becomes of importance when we have previously ascertained that the female has no other disease. The sound of the heart may aid in ascertaining the position of the foetus; the souffle can communicate no information as to the place of insertion of DIAGNOSIS OF PREGNANCY. 265 the placenta, and indicates nothing as regards the child's position ; while any feebleness, and more especially any irregularity or intermittence of the heart's pulsations, furnish strong presumptive reasons for believing that the foetus is suffering, and that its life is compromised. When desirable to auscult a female who is supposed to be pregnant, we must request her to lie down on her back ; at the commencement of gesta- tion this precaution is indispensable ; but towards the last it becomes less so, and she may then be examined standing. In fact, whatever be her position in the latter months, this exploration is quite easy, on account of the dimensions of the uterus and the volume of the foetus, but at first it is nearly always necessary to flex the thighs upon the belly, so as to com- pletely relax the abdominal muscles, and of course this could only be done in the horizontal position. The dorsal or lateral decubitus is requisite to explore thoroughly the fundus or sides of the womb, and also to cause thp foetus to fall from either side; the thighs should also be flexed, or extended, according to the region examined. The unaided ear will answer, but the stethoscope should generally be employed ; for, by using it, the sounds detected can be more readily limited, and the abdominal parietes more easily depressed so as to approach nearer to the foetus; besides, many females object to the accoucheur thus applying his head flat on the abdomen. Experience has likewise convinced me that, when the unassisted ear is used, the clearness of the sensations is singularly diminished by the frictions which the respiratory movements of the abdomen make against the ear. When used, the enlarged extremity of the instrument should be deprived of its mouth-piece, and its whole circumference be exactly placed over the region to be ausculted. It is also advisable that the woman lie on a bed of sufficient height, other- wise the accoucheur is obliged to stoop too much, and this inconvenient position is attended by such a degree of congestion as to render it impos- sible to hear anything. And further, to avoid all unnecessary searching, it is best to place the stethoscope at first directly over the part where the pulsations of the heart are most commonly heard, that is, in front, below, and a little to the left side. « It is equally desirable to ascertain from the female where she generally perceives the foetal movements, for most frequently the pulsations of the heart will be found on the opposite side, because the superior and inferior extremities being always folded on the abdominal plane, the back, in other words, the part of the foetus which most easily transmits the sounds, will evidently be turned towards the left, if the right side is the habitual seat of the active motions. Before the fifth month, the pulsations are usually perceived in the lower part of the abdomen on the median line, about half-way between the pubis and umbilicus ; consequently the instrument should be first applied tnere. The instrument proposed by Nauche, under the name of metroscope, the extremity of which is intended to be introduced into the vagina and applied to the neck or inferior part of the woiab, ought not to be used. 266 PREGNANCY. A Table exhibiting the Signs of Pregnancy at various Periods. RATIONAL SIGNS. SENSIBLE SIGNS. First and Second Months. 1. Suppression of the menses (numerous 1. Augmentation in the size and weight of the uterus. 2. Descent of the organ. 3. The womb is less movable. 4. Its walls have the consistence of caout- chouc. 5. The neck is directed downwards, for- wards, and to the left. C. The body becomes more globular and feels elastic to bimanual palpation. 7. The oritice of the os tiucoe is rounded in primiparae, but more patulous in others who have had children. 8. A slight softening of the mucous mem- brane covering the lips, and this mem- brane appears cedematous. Third and Fourth Months. exceptions 2. Nausea — vomiting. 3. Slight flatness of the hypogastric region. 4. Depression of the umbilical ring. 6. Tumefaction of the breasts, accom- panied with sensations of pricking and tenderness. Suppression of the menses (a few excep- tions). 1. The fundus uteri rises to the level of the superior strait towards the end of the third month, and is perceived at the close of the fourth about the middle of the space between the umbilicus and pubis. 2. A perceptible flatness on percussion in the hypogastric region. 3. A rounded tumor, as large as a child's head of a year old, may be detected by the abdominal palpation. 4. By resorting to this process and the vaginal touch jointly, the displacement en masse, and the volume of the uterus may easily be ascertained. 5. The neck has the same situation and direction during the third month as in the preceding ones; at the (uirth it is elevated and directed backwards and to the left. side. G. The softening of the periphery of the orifice is much better marked. The lat- ter is more open in multipara, even ad- mitting the extremity of the finger ; but is closed and always rounded in primiparae. Fifth and Sixth Months. 1. Suppression of the menses (some rare 1. The fundus uteri is one finger's breadth 2. Frequently, the appearance or the con- tinuance of the vomitings. 3. A small protuberance in the hypogas- tric region. 4. Less depression of the umbilical cica- trix. A ugmented swelling of the breasts, pro- minence of the nipple, and slight dis- coloration in the areola. 6. Xyesteine in the urine. exceptions). 2. The disturbances in the digestive organs generally disappear. 3. Considerable development of the whole sub-umbilical region. below the umbilicus at the end of the fifth month; and the same distance above it at the expiration of the sixth. Foetal irregularities, and active move- ments, which are very perceptible. The sound of the heart and abdominal sMiillle are now perceptible. DIAGNOSIS OF PREGNANCY. 267 RATIONAL SIGNS A convex, fluctuating, rounded abdomi- nal tumor, salient, particularly on the middle line, and sometimes exhibiting the foetal inequalities. The umbilical depression is almost com- pletely effaced. 6. The discoloration in the areola is deeper; glandiform tubercles; areola spotted. 7. Kvesteine in the urine. SENSIBLE SIGNS. 4. Ballottement. A tumor is felt at the anterior superior part of the vagina, which is sometimes soft and fluctuating, at others rounded, hard, and resisting. The inferior half of the intra-vagina 1 portion of the cervix uteri is softened The whole ungual part of the first pha- langeal bone can penetrate the cavity of the neck in multiparse. The latter is softened to the same extent in prinii- parse, but the orifice is closed. Seventh and Eighth Months. 1. Suppression of the menses (the excep- tions are very rare). 2. Disorders of the stomach (rather rare). 3. The abdominal tumor has the same characters, except that it is more volu- minous. 4. A complete effacement of the umbilical depression, the dilatation of the ring, and sometimes a pouting of the navel. 5. Numerous discolorations on the skin of the abdomen. C. Sometimes a varicose and ©edematous condition of the vulva and inferior ex- tremities. 1. Increased size of the abdomen. 2. The fundus uteri is four fingers' breadth above the umbilicus at the seventh month, and five or six at the eighth. 3. The organ is nearly always inclined tc the right. 4. More violent active movements of the foetus. 5. Sounds of the heart and abdominal souffle. 6. Ballottement is very evident during the seventh month, but more obscure in the eighth. 7. Deeper discoloration of the central 7. The softening extends along the neck. areola, and an extension of the spotted areola. Sometimes there are numerous stains on the breasts; flow of milk ; com- plete development of the glandiform tubercles. 8. Persistence of kyesteine in the urine. above the vaginal insertion. In primi- parae, the cervix is ovoid, and seems to have diminished in length; in others it is conoidal, the base being below, and sufficiently patulous to admit all the first phalanx. The neck at its superior fourth is still hard and shut up. First Fortnight of the Ninth Month. 1. The vomitings frequently reappear. 1. The fundus uteri reaches the epigastrio region and gains the border of the false ribs on the right side. 2. Active movements. Sounds of the heart and abdominal souffle. 3. Often there is no proper ballottement, but merely a kind of rising of the tumor formed by the head. 4. All the other symptoms persist, ana are 4. The neck is softened throughout its increased in intensity. whole length, excepting the circumfer- ence of the internal orifice, which still 2. The abdominal tumor has increased ; the skin is much stretched, and very tense. 3. Difficulty of respiration. 26S PREGNANCY. KATIOKAL SIGNS. Last Fortnight of 1. Tbe vomitings often cease. 2. The abdomen is fallen. 3. The respiration less oppressed. 4. More difficulty in walking. 5. Frequent and ineffectual desires to uri- nate. 8ENSIBLE SIGNS. remains closed and resisting. In won.cn who have previously borne children, th* finger may be introduced into the cervix to the extent of a phalanx and a half, and in fact is only arrested by the internal orifice, which is closed and wrinkled, though, in some cases, already beginning to open. In primiparae, the softening is equally extensive, and tbe neck is swollen in the middle in an ovoidal form ; but the external orifice, although partially opened, does not per- mit the introduction of a finger. the Ninth Month. 1. The fundus uteri has sunk lower than in the first fortnight. 2. Active movements ; sounds of the heart and bellows murmur. 3. Ballottement often imperceptible. 4. The head more or less engaged in the excavation. 5. In multipara, the internal orifice softens and dilates; the finger can then pene- trate through a cylinder, as it were, an inch and a half in length, and come into contact with the naked membranes. In primiparse, the internal orifice experi- ences the same modification, but the external remains closed. During the last week, in consequence of the spread- ing out at the internal orifice, the whole cavity of the neck becomes confounded with that of the body, and the finger, in reaching the membranes, only traverses a thin orifice in primipara). but a round- ed collar in the others of a variable thickness. 6. Hemorrhoids ; augmentation of the oedema and varicose state of tbe lower extremities. 7. Pains in the loins, and colics. OF TWIN PREGNANCY. 2G9 CHAPTER VII. OF TWIN PREGNANCY. The term compound or multiple pregnancy has been applied to that in which two or more foetuses are inclosed in the uterine cavity. Certain females seem to be greatly disposed to these anomalies ; thus, cases are recorded where six, seven, and even eleven children have been born at three successive confinements. Double pregnancies are quite frequent: that is, one case is met with in about seventy or eighty labors. Triplets, on the contrary, are very rare, since there were but five in the records of 37,441 accouchements that occurred at La Maternite in Paris. Further, we cannot call in question those instances in which there were said to be four at a birth ; for such men as Viardel, Mauriceau, Hamilton, and many others, furnish examples of it. 1 Both Peu and Lauverjat declare that they have witnessed cases of five at a birth. 2 And lastly, must we consider those cases of six, seven, eight, and 1 The following statistical account is extracted from Churchill's work. In 161,042 pregnancies, there were 2477 cases of twins, or 1 in 69, and 36 triplets do., or 1 in 4473 (English accoucheurs). In 36.570 pregnancies, there were 582 cases of twins, or 1 in 110, and 6 triplets, or 1 in 6095 (French accoucheurs). In 251, 386 pregnancies, there were 2967 cases of twins, or 1 in 84, and 35 triplets, or 1 in 7186 (German accoucheurs). Total, in 448,998 cases, there were 5776 instances of twins, being 1 in 77f, and 77 triplets, or 1 in 5831. The same author furnishes the accompanying information as to the sex of the twins: Dr. Joseph Clarke states, that in 184 twin cases, both children were boys 47 times, girls 68 times, and one boy and one girl 71 times. Dr. Collins reports 240 cases, in which there were two males 73 times, two females 67 times, and male and female 97 times ; and Dr. Lever 33 cases, two males 11, two females 11, and male and female 11. 8 M. Pigne" informed me that he saw a single placenta at Strasbourg, from which five separate cords arose, although only a single sac existed, which was composed of three membranes, decidua, chorion, and amnion, in which the five embryos were in- closed. Dr. Kennedy [London Med. Gazette) presented to the Royal Society the history of a woman who aborted at three months of five embryos. There were three ovums, on" being double, and each ovum had a placenta and its own proper membrane. M. Bourdois (Oaz. Mid., p. 569, 1850) describes a quadruple pregnancy, in which the delivery occurred at the seventh month. The second child was born twelve hours after the first, and the other two a few minutes subsequently. The second accouche inent was attended by a new discharge of waters; there were two placentas, one of which had three cords and was adherent, and some portions of it remained behind in the uterus. Dr. Hull, of Manchester, deposited five little twin foetuses in the Museum of the London College of Surgeons, that he had obtained from a woman who aborted at the fifth month of gestation. Chambon records an instance of quintuple pregnancy, where the children survived their baptism. A woman of Naples was delivered of five infants at seven months. (British ana Foreign Med. Review, 1839.) Dr. Kennedy (Every) states (in the Dublin Med. Journal, Jan. 18401, that a woman 27u I'KEGN'ANCY. nine cmldren, or even more, at once, so many examples of which are found in the authors, as true statements or as fabulous tales? It is a very difficult matter to point out the causes of this anomaly in the present state of our science; true, numerous explanations have been offered, but all are nothing more than pure hypotheses: for example, it is said that a single fecundation may affect both ovaries, or two of the Graafian ve=i- cles in the same ovary ; and again, that several impregnations may occiil successively in a short period, that is, before the first fecundated ovu'^e has arrived in the uterus. Both take it for granted that two ovules are de- tached, either at the same time or successively, from the ovary, and, conse- quently, that two corpora lutea are developed. Several well-attested facts prove, however, that a different state of things may take place ; thus, for instance, two ovules have sometimes been found in the same Graafian vesicle, and it is evident that the rupture of this vesicle alone, in such a case, might produce a double fecundation ; at other times, two yolks have been seen in the same ovule, and in such a condition a twin pregnancy might certainly occur, although but one ovule be fecundated. Hereafter we shall see, that these peculiarities serve to explain the varied disposition exhibited by the membranes be compound gestations. It is frequently possible to recognize the presence of twins during preg- nancy ; indeed, the abdomen is ordinarily more voluminous then than at other times, and the belly is generally flattened on the median line, instead of presenting there a well-marked protuberance ; the middle is depressed, in consequence of the two children lying one upon each side ; nevertheless, this sign may fail when one child happens to be placed before the other. The form of the uterus varies also with the position of the foetuses, their number, and the amount of amniotic fluid. Thus, when the head of one is above, and that of the other below, there may result therefrom two corre- sponding depressions and projections, as M. Hergott has represented. Should both pre- sent by the head, the fundus of the womb will be very much dilated, and the contrary is the case when they present by the pelvis. In a case which occurred at the Clinic of Strasbourg, the shape of the womb was irregular and oblique; the two heads occu- pied the angles of the uterus, and formed two tumors separated by a depression ; the one at the right being much the higher. The twins were born by the feet. The slight blows perceived by the mother are sometimes felt at one and the same time in two distant parts of the abdomen ; and the importance of auscultation as an ele- ment in this diagnosis has already been pointed out. (See p. 256.) aborted of five embryos between the second and third months of gestation ; and finally, Dr. Francis Humsbotham has collected three cases of quintuple pregnancy from the public- journals. Fio. 73. OF TWIN PREGNANCY. 271 The bellows murmur can, I think, rarely furnish useful iuformation. Still, it is asserted by Hohl, that in sixteen twin pregnancies, the murmur was heard seven times on both the right and left sides simultaneously, and nine times on one side only ; and he affirms, that when the latter was the case, there was a common placenta, whilst in the other instances {hero were two. He is also of the opinion, that a double souffle is diagnostic of a double pregnancy, even though the sound of the heart be heard at a single point only. We cannot admit the last conclusion, since we have already denied the very relation which Hohl would establish between the 6eat of the murmur and the insertion of the placenta; besides which we have often heard a souffle on both the right and left sides in single pregnancies. Again, as the two foetuses mutually interfere with each other, neither of them presents itself to the vaginal touch ; and of course the ballottement is then exceedingly difficult, if not wholly impossible ; for, even if the finger should easily reach the presenting part, the presence of another child would interfere with the ascending movement of the first. Desor- meaux, however, cites a case where the ballottement was manifest in a twin gestation, but even here a large quantity of water was present at the same time. Whilst in charge of the Clinic of the Faculty, in 1845, I observed on two occasions the same fact noticed by Desormeaux ; for the existence of dropsy of the amnion rendered the ballottement very perceptible, although two children were present. The course of twin pregnancies is sometimes accompanied by peculiar- ities which it is important to be acquainted with. Thus, the two foetuses do not always attain to the development which we have indicated. One of them may die, and yet the other continue to grow. In such cases, which, however, are rare, the dead body may remain in the womb, where it hardens, withers, and is expelled during labor. In my course of 1853, I exhibited a placenta obtained from a woman who was delivered at term of a living and well-developed child. It was provided with two amniotic bags, one of which belonged to the living child, and presented no unusual appearance. The other, which was much smaller, contained barely a trace of fluid, but inclosed a small mummy- like foetus, about the size of one of four months' development. On the other hand, the dead foetus may irritate the uterus, bring on contractions, and be expelled, whilst the other remains and is developed as usual. Lastly, the twin that perished during pregnancy may still remain in the womb, in consequence of the adherences which its placenta has contracted with that organ, for a long period after the expulsion of its living brother, that occurs at the ordinary term of gestation. Guillemot furnishes one of the most curious observations of this kind (Heureux Ace, livre ii. p. 225) on record, in which the artificial extraction of the dead body did not take place until two years after the accouche- ment. But what is the cause which thus determines the death of one foetus ? Mauriceau and Peu thought it might be attributed to the fact that one child, by receiving all the nourishment, becomes strong and vigorous at the expense of the other, thereby rendering it feeble and languishing, and causing its early death. 272 PREGXAXCY. M. Guillemot believes that one child, in its growth, gradually compresses f he second against the uterine wall, and the latter, not having sufficient Pliace for its development, soon after dies. Lastly, M. Cruveilhier explains (he atrophy of the foetus by a gradual separation of the placenta, founding his opinion on a single case, in which the hemorrhage was great enough to account for the early death of one of the twins ; but in the greater number of cases that have been recorded, no mention whatever is made of any hemorrhage during the pregnancy ; whence, of course, the opinion of M. Cruveilhier would not be applicable to them. For my own part, I believe these cases, in which the death and atrophy of one foetus takes place, should rather be attributed to some disease of the infant or placenta, or of some parts of its envelopes. It may be urged, indeed, that these alterations are not observed at the time of accouchement, which is not to be wondered at, considering the state of degeneration exhibited by all parts of the ovum ; and, although no positive fact sustains this opinion, it seems to me more admissible and more rational than the others. It not unfrequently happens that twin pregnancies terminate before full term, owing, doubtless, to the great distention of the uterus, which is often as large at seven or eight months as in a simple pregnancy at nine months. The same labor generally suffices for the expulsion of both, though such is not always the case ; for, after the first child is born, the uterus may re- traci, upon the remaining twin, and leave it unexpelled for eighteen or twenty-four hours. A still longer interval, several months even, may separate the two parturitions ; and it is upon such facts as these that some persons have improperly admitted the doctrine of superfoetation. A refer- ence to the latter is, however, unnecessary to explain these observations, for the cause of premature delivery is dependent solely on the enormous dis- tention of the uterus, because as soon as one infant is expelled the womb retracts, the cause of irritation no longer exists, and we can readily con- ceive that the gestation may continue on until term. A child born at seven months may live equally well with one delivered at the end of preg- nancy. The peculiarities just studied in twin pregnancies may also present themselves in cases of triplets, &c. Thus, in a case cited by Port?'., after the delivery of the first child and its placenta, which were healthy, he was obliged to extract two others that had apparently been dead for a long time, and were thoroughly dried. Again, the membranes are not always disposed in the same manner in these pregnancies ; and on this head we may admit, with M. Guillemot, who has particularly studied the subject, four distinct varieties: thus, in the first, two ovules are fecundated, and each embryo becomes developed, and is surrounded by its own proper membranes; in the second, the ovule con- tains two germs, though each foetus has but a single envelope, the chorion being a common membrane; in the third, both embryos are inclosed in a single cavity, which appears never to have been divided by any membranous diaphragm ; and, finally, the last variety is met with when the ovule con- tains a second germ, and both become developed together, which gives rise to what are called monstrosities by inclusion. Adopting this classification OF TWIN PREGNANCY. 273 as the basis, let us now proceed to the different modes of termination presented by these pregnancies, according to the species to which they belong. 1. In the first variety, both ovules are developed, retaining their proper membranes, the chorion and amnion ; at first, each ovum has its own re- flexed decidua, but generally that portion of the latter which forms the partition is very thin, and becomes absorbed as the gestation advances, and a single decidua then appears to envelop both. The two chorions repose against each other, being only separated by some very fine areolar tissue, so that the children are divided by one very thick partition composed of four layers. The placentas are sometimes separate, though usually confounded with each other, or else are united by a kind of membranous bridge; but, notwithstanding the continuity of tissue, there rarely exists any vascular communication between them, and this fact is so uniform that the exceptions to the law are very rare indeed. From all which it must therefore be evident that two distinct ovules have been fecundated, whether they are deposited separately, or are contained in the same vesicle. The first variety is the most frequent. 2. In the second variety of compound pregnancy, the chorion is common to both twins, and each foetus has but a single envelope formed of the am- nion — the two lamina? of which, resting against each other, constitute the median partition. MM. Dance and Mancel have furnished an example of this variety in which there were but two children. Brendelius reports that a woman was delivered of two girls after three days' travail, but she died before the extraction of the third infant, which was found dead on opening her body ; the placenta was single and very large, and the chorion had been common to all three, although each foetus had a distinct amnion. There is therefore only a single placenta, and a communication nearly always exists between the ramuscules of the two cords, as I have verified myself, on a placenta, which was presented by one of my former pupils, an Interne of the Ursuline Hospital, where he obtained it. In this, as in the preceding variety, one foetus may die, the other continuing to live; but it is easily foreseen that an expulsion of the two children cannot take place separately. 3. Further, it may happen that the foetuses are not separated by any partition, and are all shut up in the same amniotic cavity; and to the ex- amples of this kind, already cited, I may add a case observed by my friend and colleague, Dr. Founder. The two cords arise, most frequently at least, from a distinct point of the placenta ; but sometimes they are observed to come from a common trunk, which bifurcates at a variable distance from the placental surface. In this variety, the expulsion of one foetus must evidently be followed by that of the other; but I do not know to what ex- tent we can justly say that the death of one necessarily endangers the other's life, if not speedily delivered by nature. (Baudelocque.) This inclusion of two foetuses in the same amniotic cavity is often met with in those cases where one of them is destitute of an important part of its body: thus, the monstrosity that I presented to the Royal Academy of Medicine was in- 'dofeed in the same sac with its twin brother. 18 274 PREGNANCY. But it is nearly or wholly impossible, in the present state of ovological knowledge, to explain this strange anomaly, the existence of which, how- ever, has several times been clearly verified. In accordance with what we have said respecting the formation of the amnion (see Art. Otology), this membrane emanates from the embryo itself, and consequently the amniotic membranes should equal the foetuses in num- ber; but, without admitting the theory of Pockels and Serres on the devel- opment of the amnion, a theory which, notwithstanding its want of proba- bility, derives, from the facts alluded to, a certain degree of support, we cannot explain them but by supposing that two amniotic membranes existed primitively, and that the partition produced by their contact has been some- how destroyed. Most generally, there are numerous communications exist- ing between the umbilical ramifications, as we have stated, when the cho- rion, and especially the amnion, are common to both, which is not always the case. Thus, Dodd reports a case of triplets, where the placentas wen' consolidated into one, two of the children being inclosed in a common cho- rion, whilst the third had a special one; the umbilical vessels did not com- municate with each other. In another instance, recorded by Davis, the three foetuses had a common decidua ; two of them were surrounded by the same chorion and amnion, but the third had its chorion and amnion distinct from the others ; the placenta formed a single mass, bui the vessels had no communication with each other. {London Med. Gazette, 1841.) 4. Finally, the fourth variety of compound pregnancy that we have admitted, along with M. Guillemot, constitutes what has been called a mon- strosity by inclusion. It consists of the complete inclusion of the elements, whether more or less numerous, of one foetus in the body of another foetus, which is otherwise well formed. Table for Calculating; the Period of Utero-Gestation. (Smith.) NINE CALENDAB MONTHS TEN LUNAR MONTHS FROM TO DWS. TO DATS. January 1 . . . . February 1 . . . . July 1 \ li g MSt 1 September 1 October 1 . . . . November 1 . . . December 1 . . . September 30 . . . October 31 ... . November 30 . . . December 31 February 28 March 31 ... . April 30 May 31 June 30 August 31 ... . 273 273 275 275 276 273 274 273 273 273 274 October 7 . . . . November 7 . . . 1 December 5 ... ' February 4 . . . . May 7 August 7 . . . . September 6 280 280 280 280 280 280 280 ■j SI) •j so 280 280 280 Explanation. — The above obstetric "Ready Reckoner" consists of two columns, one of calendar, the other of lunar months, and may be read as follows: A patient has ceased to menstruate on July 1 ; her confinement may be expected at soonest about March 31 {the end of nine calendar months) ; or at latest on April 6 [at the end of ten lunar months). Another has ceased to menstruate on January 20 : her confinement mny be expected on September 30, plus 20 days (the end of nine calendar months) at soonest ; or on October 7, plus 20 days (the end often lunar month*) at latest. (Playfair.) PAET III. OF LABOR. LABOR is that function which consists in the spontaneous or artificial expulsion of a viable foetus through the natural parts of generation. The term labor is used more especially to designate the expulsion of the child ; the expulsion of the placenta being treated of under the head of Delivery, of that organ. This definition of labor, differing as it does somewhat from those given by most modern writers, has the advantage of furnishing me a basis whereon to found a practical division ; for when the expulsion of the foetus takes place from the efforts of nature alone, it is called a spontaneous, or a natural labor ; but when nature is inadequate to the accomplishment of this effect, and art is obliged to intervene, the delivery is said to be artificial, laborious, and also (though improperly) unnatural. This function has also received different denominations, according to the period of pregnancy at which it is manifested : thus, it has been named legitimate, timely, or at term, when occurring within a week before or after the expiration of the ninth month. On the contrary, it is called premature or precocious, if it takes place during the seventh, the eighth, or the begin- ning of the ninth month. Again, the latter may be spontaneous or artifi- cial, according to whether it is simply the work of nature or has been brought on by the intervention of art. This last case should be carefully distinguished from what the ancients called forced labor, in which they not only provoked the manifestation of the uterine contractions by a more or less direct irritation, but effected the delivery at once. Lastlv, it is called tardy, or retarded, when the delivery is not accom- plished before nine months and a half or ten months. At whatever period delivery may occur, it is always effected under the influence of the same forces ; though there is an important distinction to be established in the phenomena, constituting what practitioners are agreed to call the labor. Whenever we examine carefully the whole of those phe- nomena, we can readily make out two very distinct orders of facts. The one is nothing more than an expression of the vital action brought into pl.iy for the expulsion of the foetus, while the other is constituted of the suc- cessive movements which the child itself executes during such expulsion ; the first is purely physiological, the second embraces the mechanical phe- nomena of the labor. Though often confounded in practice, these two orders should be carefully distinguished in theory. We shall therefore have to examine, in as many separate chapters, I he causes and physiological phenomena, as also the mechanical phenomena both of labor p; rperly so called, and of the delivery of the placenta. 275 27() LABOR. Again, although in the vast majority of cases the woman is really able to deliver herself, yet there are many precautions which the accoucheur should bear in mind, and a series of little attentions he must give to the patient it! the course of the parturition ; besides, the child will likewise require his intelligent aid, either during the travail or immediately after its birth, and therefore we shall devote a chapter to the exposition of those attentions and precautions. "We shall, in the first place, enter upon the study of natural labor at term, spontaneous premature delivery, retarded labor, and natural delivery of the after-birth ; leaving the subjects of difficult labor and preternatural delivery of the placenta, to be treated of hereafter under the head of Dystocic. Premature artificial delivery will be described in connection with the other obstetrical operations. CHAPTER I. OF THE CAUSES OF NATURAL LABOR AT TERM. These have been divided into the efficient and the determining causes. § 1. Efficient Causes. For a long time the foetus was regarded as the principal agent of its own delivery, and as the chick breaks the shell of the egg, so it was supposed to effect the rupture of the membranes which contained it. The advocates of this opinion, which is no longer admitted, except by some persons out of the profession, relied chiefly on the fact of dead children being expelled more slowly from the womb, and with more difficulty than others; and further also because, in certain instances, the child has been known to escape from the uterus some time after the mother's death. But, in reality, these two facts have no value whatever in the question before us ; for the death of the foetus, when recent, does not materially retard the parturition, and writers were altogether in error as to the influence attributable thereto. The living infant is expelled more rapidly, not in consequence of being the agent of its own discharge, but because its movements irritate the uterus and solicit its more frequent contractions ; after its death the organ is, on the contrary, deprived of that natural irritant. Besides, whenever the foetus has been defunct for a long time, another cause of retardation is added to the former; for where the product of conception has undergone a partial decomposition, the contractility of the uterine walls is unfavorably influ- enced thereby. In fact, the vitality of the organ seems to be in relation, to a certain extent, with that of the inclosed body ; the blood being no longer attracted thither by the ordinary stimulus, does not reach there in such large quantities as before, and consequently the greater vital activity usually manifested in gestation is lost; hence arise atony of its walls, an excessive feebleness of its contraction, and slowness of the labor. Again, the fcetal trunk, being softened by the changes before described, collapses, as it were, and ceases to offer that resistance to the uterine wall which is necessary to the CAUSES OF NATURAL LABOR AT TERM. 277 energy and the maintenance of its contraction. Therefore, if it be true that the death of the infant renders its delivery more difficult, it is solely from the unfavorable influence that this occurrence may have over the exercise of the organic contractility. Instances of children having been delivered spontaneously after the mother's death are quite numerous, and this is the strongest argument adduced by those who believe that the foetus is the principal agent in the expulsion. But numerous observations, among others those related by Dr. Planque (in La BibliotUque tie Medecine Choisie), prove that those infants were dead even before the mother. Now these facts, extraordinary as they appear, can be very naturally explained as follows : Supposing the delivery took place shortly after the parent's death, the motor faculty of the uterus is not so dependent on the nervous system as to be entirely lost immediately upon the cessation of vitality in the latter, and is evidently retained for some time after the mother has succumbed. Thus, Leroux has observed the uterus contract a quarter of an hour after the last breath ; and Osiander, after having performed the Cesarean section on a corpse, found the uterus as much contracted the next day as it usually is in a woman just after her confinement. It is, therefore, very natural to suppose that such deliveries are owing to the contractile action of the womb, which, says Desormeaux, it, like other hollow muscles, still preserves for some time after death ; l and finally, let us add, that the real death in many cases may have been preceded by an apparent one, and possibly that the former may not have occurred until just at the instant of, or immediately after the delivery took place. But when the expulsion of the foetus did not occur before the lapse of two or three days, we must suppose, with M. Velpeau, that the labor was well advanced at the time of the mother's death, and gas being rapidly produced in large quantities in the intestinal canal, the uterus was thereby mechani- cally compressed on its exterior, and the ovum consequently forced out entire. Perhaps the subjoined case, reported by Hermann, might be ex- plained in that way. (Edin. Med. and Surg. Journal, New Series, N^ vi p. 431.) A young woman died in her tenth month, and the third day after, the ' Dr. Tyler Smith states that the reflex action may continue for some time after the complete cessation of the respiratory movements, and in some cases be powerful enough to effect the delivery when the patient has died during labor ; but that, in most instances, \hz post-mortem expulsion of the foetus is due to a peristaltic contraction of the uterine fibres. We find it difficult to admit the existence of a vermicular contraction powerful enough to produce such a restdt. M. Brown-Sequard has recently advanced what he regards as an explanation of this posthumous contractility. According to this learned physiologist, the contact of venous blood with the muscular fibre is sufficient to stimulate it to contraction. I have observed, he says, movements in the uteri of recently killed animal-, whose spinal marrow had been destroyed throughout its length. I have seen these same movements in the uterus extracted from a living animal. These, which could nol be attributed to reflex action, since there was no opportunity for the exercise of nervous influence, were due simply to the contact of non-oxygenated blood, to prove which he relates the following experiment. The spinal marrow in two Guinea-pigs, which had reached the end of gestation, was destroyed from the sixth rib to the sacrum, yet labor began and ended shortly after a ligature was drawn tightly around the trachea. 278 LABOK. attendants noticed a strange noise about the corpse. A physician was hastily summoned, who found that twins, still inclosed by the intact mem- branes, had been just delivered. The children presented no traces of putre- faction, the placenta alone showing a commencing alteration. But. besides these, numerous other objections still remain against this theory: 1. The delivery exhibits nearly the same phenomena, at whatever period of gestation it takes place ; now, can any one suppose that the foetus, which scarcely moves at all in the early months, can at once acquire a sufficient degree of strength to overcome the great resistance made at that time by the uterine neck? 2. It is well known, that, if the child present by any other part than the head in labor at term, the presenting part is so high up, before the rupture of the amniotic pouch, that it can in no wise contribute to the dilatation of the os uteri. 3. Again, the foetal efforts cer- tainly ought to affect the bag of waters first, and therefore a rupture of the enveloping sac should always be among the earliest phenomena of the labor ; however, such a rupture often does not occur until the very last moments; sometimes even the ovum escapes entire. 4. Would it be possible for the most healthy and vigorous infant to make any exertions strong enough to surmount the resistance opposed to its delivery in some of the instances of tedious labor? &c, &c. From all which we may conclude that the foetus has no influence over its own expulsion, and that the efficient cause of the delivery evidently belongs to the contraction of the uterine walls, aided by that of the diaphragm and the abdominal muscles. Furthermore, to be convinced that the womb acts the principal part in this process, it is only necessary to examine a woman during labor, and, more especially, to introduce the hand into the uterus in a case of difficult version. It is its contractions alone which generally produce the dilatation of the os uteri, thus preparing a way for the child's passage ; and they also perform the most important part in the later periods of the labor. They are even capable of effecting the delivery themselves. Thus, for instance, the parturition does not the less take place in animals, where the belly is laid open, and the abdominal walls thereby rendered incapable of any further action. It also takes place in women affected with procidentia uteri,' as also in those who suffer from a paralysis of the abdominal muscles, in conse- quence of an affection of the spinal marrow, or some one of the nervou^ centres. Finally, the use of anaesthetics within certain limits, destroys the contractility of the voluntary muscles, together with the sensibility ; yet the uterine contractility remains, and the delivery is accomplished. Ordinarily, however, in the second or expulsive stage of the labor, the uterine contrac- tion is assisted by the simultaneous action of the diaphragm and abdominal muscles. At the moment when the head clears the neck of the uterus, especially when by pressing strongly upon the floor of the pelvis it distends the perineum, compresses greatly the lower part of the rectum and neck of the 'According to the report of Burdach, Wimmer has actually known the labor to take place regularly in a woman whose womb formed a tumor between her thighs, eleven inches long and seven and a half inches broad; the opening in which was directed downwards. CAUSES OF NATURAL LABOR AT TERM. 270 bladder, and opens and dilates the vulva, the pressure upon these parts ia so violent that instinctively, not to say involuntarily, the woman exerts herself powerfully, in order to relieve herself as SQon as possible from the insupportable sensation. Thus, fixing her feet firmly against the foot-board of her bed, and clinging to anything around that may offer a solid resist- ance, the patient takes a full inspiration, dilates her chest, and then, retain- ing the inhaled air in her lungs, she strongly contracts all the muscles firming the abdominal inclosure. This auxiliary contraction is so evident that nobody can doubt it, and authors only differ as to the kind of aid it brings to the uterine forces. Haller and others considered the uterine con- tractions as being merely secondary, and attributed to the abdominal muscles the principal part in the expulsion of the child ; thus they suppose that the contraction of the organ simply serves to support the foetal trunk, to embrace it properly like a cylinder, and to prevent the great pressure of the diaphragm from crushing it in, while at the same time the act of inspira- tion and the contraction of the abdominal walls force it outwards. But, from the facts before stated, we may judge of the value of this hypothesis. True, in certain cases of excessive feebleness of the uterus, and of a com- plete inertia of its walls, the abdominal muscles have proved sufficient to terminate the delivery; yet how much oftener has it happened that the woman, exhausted by antecedent disease, and left without energy or strength, has been unable to assist the womb by any voluntary contraction whatever! Again, some women have been delivered during hysterical or epileptic fits, in a state of total loss both of feeling and movement, where evidently the uterine contraction alone could accomplish it. This harmony of action is therefore useful but not indispensable, since the labor will often terminate under the sole influence of the uterine forces; but it will be nearly always impossible in cases of total inertia of the organ, however powerful the con- tractions of the abdominal muscles may be. The researches of Cloquet and Bourdon on the physiology of the process do not warrant the supposition of any active pressure by the diaphragm on the upper part of the uterus. They have proved, in fact, that the principal phenomena consist in a change of the acts of respiration, and that the object of such change is to furnish a solid point of insertion to the muscles passing from the chest both to the trunk and upper extremities. When the air has penetrated into this cavity, the glottis closes spasmodically; the abdominal muscles begin to contract; they press back the viscera, in the cavity of the peritoneum against the diaphragm; the latter contracts in turn; and, being sustained above by the resistance from the air contained in the lungs, gives to the base of the chest a degree of immobility and solidity, which affords a fixed point for the muscles inserted there; so that, in the effort of expul- sion, the diaphragm, by its contraction, only exhibits a power of resistance sufficient to sustain the thoracic parietes, but not an active force, which is to operate, like the abdominal muscles, directly on the uterus. On the whole, then, the efficient cause of labor is inherent in the Avomb itself. Its contraction alone is brought into play during all the first half of the labor; but it is aided in the second period by the abdominal muscles, which become more and more active as the labor draws towards its tormina* 280 LABOR. tion. Most generally the uterine contractions would be sufficient, but the abdominal contraction alone could scarcely ever c( mplete the delivery. § 2. Determining Causes. This name is applied to everything that can determine the action of the efficient causes ; and, as before stated, this class consists both of unnatural and natural causes. The second only claim our attention here. Ihe regular and almost fixed period at which the gestation terminates in the majority of women, has, in all ages, claimed the attention of physiologists. By some, the determining cause of labor has been attributed to the child, and by others to the womb. 1. According to the partisans of the first opinion, the foetus, having arrived at a certain stage of development, will have acquired such a degree of muscular power that the resulting movements of its limbs will produce such blows and shocks upon the uterine walls, as will irritate the organ and determine its contraction. 2. The weight of the infant might also lead to the same effect. 3. Being confined in the uterine cavity, whose dimensions have not augmented in proportion to those of the foetus, the latter will be incommoded. 4. Suffering from the prolonged accumulation of meconium in the intestinal canal, of urine in the bladder, and from its contact with the amniotic fluids, which ultimately acquire acrid and irritating properties, and no longer finding in the materials furnished by the mother the elements sary to its nutrition and respiration, the infant will experience a neces- sity of changing its residence, of seeking a medium more suited to its ulterior development; which necessity will prove an instinctive desire of escaping from the surrounding inconveniences, that will cause it to give itself, so to speak, the signal of departure. Surely, it is only necessary to present such reasons as these in a summary manner, to obviate the necessity of refuting them. In short, the foetus is as foreign to the determining as to the efficient cause of labor. The opinion favorable to the cause residing in the uterus rallies around it a greater number of partisans, but all of these do not explain the mode of action in the same way. Thus, according to some, the womb only possesses the faculty of distention to a certain degree, and, when carried beyond that limit, the walls react and contract; others believe that the term of nine months is assigned by nature for the fulfil- ment of the new organization of the womb; and having acquired at that period all the qualities necessary to the accomplishment of the great func- tion to which it is destined, it immediately enters into action. But most of the modern accoucheurs consider the following explanation as the rnor*- reasonable. Observation proves, say they, that the fundus and body of the uterus are tiir parts firsl distended, for the purpose of forming the cavity which incloses the product of conception; and the cavity of the neck subsequently par- ticipates in the dilatation, which begins at its upper part, then gradually descends, so that the ring formed of the external orifice has alone undergone but little alteration at the approach of labor. Again, the walls of the neck whose tissue is denser and more resistant than that of the body, undergo certain changes, which follow the same progression in dilating as the cavity CAUSES OF NATURAL LABOR AT TERM. 281 does ; their tissue is saturated with juices ; they soften and become supple; their fibres untold, as it were, are elongated and developed ; and, conse- quently, the resistance of the neck to the escape of the ovum progressively diminishes as the term of gestation draws near. According to this view, the fibres of the neck are considered antagonistic to those in the body, the contraction of which latter is therefore reduced to a simple tonic action, so long as the resistance of the neck is superior to their power ; but when this opposition is diminished by the progressive dilatation of the cervix, the orifice alone remaining, the fibres of the body then begin to act more evidently, and their contractions become more and more energetic. (Diet, de Med., en 25 v.) According to Ant. Petit, the body only will dilate prior to the sixth month ; but at that period it commences borrowing from the cervical fibres the elements of its ulterior distention, to which it can no longer contribute itself; and such contributions will continue to be drawn during the last three months, and then, when all the fibres held in reserve by the neck shall have yielded, the distention being carried to the utmost, the accouche- ment will take place. M. Velpeau adopts nearly the same opinion. On the other hand, M. P. Dubois, who originally advocated the opinions avowed by Desormeaux in the first edition of the Dictionnaire, has since taught, in his course of 1837-8, the following theory proposed by Jones Power, in 1819. The uterine tissue at term may be justly compared to that of the other hollow muscular organs: the bladder or rectum, for example; and, like these organs, it is formed of two muscular layers, the external of which has longitudinal fibres, and the internal has circular ones ; it also presents a superior cavity, a dilatable and contractile reservoir, to which the struc- ture just indicated principally belongs ; as also a closed orifice below, formed solely by the circular fibres arranged as a sphincter muscle. It likewise resembles the bladder and rectum in having two orders of nerves — the sympathetic and the spinal ; those coming from the ganglionic system are distributed to the body, while the others, derived from the nervous centres of animal life, go to the neck, which is a true sphincter for the uterus ; the similitude is further maintained by the presence of a mem- brane lining its interior, and by being covered externally, though at the superior part only, by the peritoneum. The agreements in structure are not the only ones claiming our atten- tion ; for the well-marked sympathies existing in the rectum or bladder, between the reservoir and its sphincter, are found quite as distinctly marked between the body of the uterus and its neck; for as an irritation of the neck of the bladder or the sphincter ani is capable of producing hn urgent desire to urinate, or to go to stool, so irritations affecting the cervix uteri also solicit the contractions of that organ ; moreover, it is well known that an extreme fulness or distention of the first-named organs acts me- chanically in two ways: 1. By irritating their walls by the direct contact of the contained substances; 2. By dragging or pressing on the fibres forming the, sphincter, and these latter reacting on those of the body. Now, who does not recognize in this resemblance, says Dubois, an easy 282 LABOR. explanation of tlie determining causes of labor? For, so 1. ng as the cervix uteri retains a certain length, its most inferior fibres, those especially sup plied by the nerves of animal life, and therefore enjoying a high degree of sensibility, are not exposed to any kind of excitation ; but, towards the end of the gestation, and in consequence of the successive expansion at the superior part of the neck, its whole length has disappeared by contributing to the gradual development of the organ ; a circular collar alone remaining, formed of the horizontal and the circular fibres, which appertain to zhe external orifice. The growth of the uterus cannot continue without producing a severe tension on the fibres of this collar ; and further, being brought immediately into contact with the amniotic sac, and consequently with the presenting part of the foetus, they must necessarily suffer, must be irritated and excited by this constant and unusual contact. As this double cause of irritation is constantly acting, it must inevitably happen with the fibres belonging to the body of the uterus, as it does with the rectal and vesical walls when their sphincter is irritated, i. e. they must immediately enter into contraction. 1 Dr. Tyler Smith, of London, has lately endeavored to prove, in accord- ance with the observations of Carus, Mende, and Merriman, that the deter- mining cause of labor must be sought for in the ovary ; that natural labor always corresponds with the tenth menstrual period, and that the congestion of the ovaries produced, by reflex action, first a simple irritation, and ultimately true contractions of the uterine parietes. Admitting as proved that the menstrual ovulation goes on during preg- nancy, it would still remain to be shown why it should be rather at the tenth than at the eighth or eleventh period that this influence of the reflex action of the ovary should be strong enough to excite the contractions of natural labor in the uterus. At one of the late sittings of the Biological Society (September, 1855), M. Brown-Sequard suggested a theory which doubtless is subject to objec- tions, but which certainly is one of the most ingenious of all that have yet been proposed in reference to the determining cause of labor. Like all the muscles, those especially of organic life, the muscles of the aterus are very sensitive to the contact of venous blood, and the carbonic 1 Mr. Power cites the following ca?e, communicated by his brother in support of his opinion, and which we bring forward as being interesting in many respects. A lady, the mother of several children, supposed herself near the term of a fresh pregnancy, and she felt two or three slight pains; but they soon passed off again, and hree months more elapsed without her experiencing any other pain. Becoming uneasy about her condition, she consulted several physicians, who, after having made the usual examination, declared she was not pregnant. The author's brother having been called in, participated at first in the same opinion; nevertheless, he found the ubdomen greatly enlarged, and much inclined forwards, so that it descended in front of the thighs, almost down to the knees, when the patient was standing. A distin- guished physician, a friend of the lady, who was present, then mounted on a chair above her, and by pa^sin^r a towel underneath the belly raised it up ; the vaginal touch being once more resorted to, the child's head was distinctly felt. A suitable bandage retained the *.umor in that position, and four or five days afterwards the painr came on, and the woman was happily delivered of a very large living infant. CAUSES OF NATURAL LABOR AT TERM. 283 aci 1 gas, which the latter contains in large amount, is capable of producing their contraction. Of the experiments tending to prove this, one certainly seems very conclusive. M. Sequard applied a ligature to the trachea of a pregnant rabbit. Six or eight minutes after the commencement of asphyxia, uterine contractions became manifest ; the ligature was removed, the con- tractions ceased ; it was again applied, and they reappeared. Now, according to M. Brown-Sequard, at the end of gestation, the irri- tability of the uterine fibre is very great, and the development of the venous apparatus of the organ such, that a considerable amount of venous blood is contained within its walls. These two conditions together constitute, he thinks, the determining cause of the first contraction, since the excitability must necessarily be awakened by the prolonged contact of carbonic acid. The effect of the first contraction would be to expel the blood from the veins, and the contractions would cease promptly with the exciting cause, did not the pain which it occasions stimulate the reflex action of the spinal marrow ; the latter, therefore, sustains it for some moments. But, as we shall state hereafter, the contractile power of a muscle of organic life is rapidly ex- hausted, its fibre relaxes, and repose soon succeeds to activity. This relaxation of the uterine fibre allows the venous blood to flow back into the uterine sinuses, so that after a time the series of phenomena just men- tioned recommences. I have contented myself with simply presenting the principal vieAvs that have been entertained as to the determining cause of labor, although it would be an easy matter to start numerous objections against all of them, which perhaps could not be set aside. Thus, the uterus is as much dis- tended, in some cases, at eight months as it is in many others at nine, with- out the term of pregnancy being anticipated. The muscular organization of the uterus is as perfect several weeks before the two hundred and seven- tieth day as it is at a later period. The sort of antagonism fancied by some authors to exist between the fundus and the neck of the uterus, is a pure hypothesis unsupported by evidence ; besides, this opinion, like that of Antoine Petit, rests upon a false observation, namely, that of the pro- gressive shortening of the neck after the sixth month. [It is universally admitted that delivery is effected by the contraction of the uterus, but the question has been raised, Why does this contract-ion take place at the end of gestation ? On this point, Power's theory seems to have gained the assent of the majority of accoucheurs. It does seem to us, however, that the ques- tion has been badly put, for how can we believe that the muscular fibres of the uterus do remain inactive for nine months, and enter into contraction only at the termination of pregnancy? We feel justified in asserting that the uterus contracts throughout the entire period of gestation, feebly at first, and rarely, it may be, but more decidedly as the time progresses, so that it may not infrequently be detected by palpation of the abdomen at various periods. The contractions are, doubtfess, very slight at first, though real, and every one knows that they accomplish the effacement of the cervix at the end of gestation. Should an accidental cause increase their energy prematurely, the result is either abortion or premature delivery. We would therefore, reverse the question and ask why, if the contractions take place throughout the entire period of gestation, do they expel the ryum only til 284 LABOR. term? The first reason to be adduced is, that the contractions, thi ugh fe/bie aud insufficient at the outset, grow stronger as the development of the middle layer of the uterus progresses, hut not until the end of the ninth month have the muscular fibres acquired sufficient contractility to effect the expulsion of the child. In the second place we would add, that the contractions which occur during the course of gestation, make a fruitless effort to dilate the firm and resisting tissue of the uterine orifice. It is, therefore, by a wise precaution of nature that the softening of the cervix, which takes place from below upwards, reaches the internal orifice only after the expiration of the eighth month. The internal orifice then yields to the contractions which produce the gradual effacement of the neck from above downward. The term of gestation lias now arrived, and the contractions increase greatly in strength. At this point only, would I have recourse to Power's theory, which seems to afford a true explanation of the recrudescence of the contractile forces of the womb aud the prompt establishment of labor.] CHAPTER II. OF THE PHYSIOLOGICAL PHENOMENA OF LABOR. For the purpose of facilitating the study of the phenomena of labor, most writers have divided them into several distinct groups, which they have denominated the stages of labor ; and each one has built up his own classification, so that we may now enumerate some twenty or thirty. Of all these, the division of Desormeaux appears to us the most simple, and we shall therefore adopt it. His first stage extends from the beginning of the labor to the complete dilatation of the cervix uteri ; the second includes all the interval from this time until the child is expelled ; and the third embraces the delivery of the placenta. Precursory Signs. — The term of gestation is most usually announced by a collection of symptoms, to which the majority of authors have applied the name of the " precursory signs of labor." Thus, during the last fortnight of pregnancy, sometimes a little sooner, at others, only five or six days before the delivery takes place, the uterus, which previously extended up to the epigastric region, sensibly sinks lower, and seems to spread out laterally ; and the mechanical obstruction to the respiration being thus removed, the latter becomes more free; the stomach is no longer compressed, and digestion, if hitherto impaired, becomes more easy; the patient, no longer troubled with nausea and vomiting, and respiring more freely, becomes, it is said, ".aver, more cheerful, and disposed to movement. How- ever true tins last proposition may be with regard to some women, it cer- tainly does not apply to all ; but, on the contrary, it has seemed to me that ''n proportion as the term approaches, their position becomes more and more distressing; and this, 1 think, may be easily explained; because if the respiration 1 onus more free, and the fundus uteri descends, the inferior part of the organ must also sink down in the same ratio. The head, when p r esenting, engages in the excavation, carrying the lover portion of the PHYSIOLOGICAL PHENOMENA OF LABOR. 285 uterus before it; it sometimes even reaches the pelvic floor, and consequently gives rise to an annoying sensation of weight about the fundament, to great pressure on the neck of the bladder and rectum, strainings at stool, ineffectual desires to urinate, vesical tenesmus, dysury, and sometimes even to strangury ; the oedema and varices of the inferior extremities and genital parts then augment considerably; the hemorrhoidal vessels swell up, and the tumors of the same name, if they existed before, become more voluminous and very painful ; at the same time copious glairy discharges escape from the vulva. About the same period the pelvic ligaments become softened, and the gliding of the articular surfaces being rendered easier, the joints are more movable, and consequently walking is uncertain, painful, and sometimes even impossible. Lastly, to all these inconveniences and pains, another is often added, which singularly aids in making the woman's condition still more distressing; it is this: the uterus, in the last periods of gestation, seems, by contractions, which are short and distant at first, but soon increas- ing both in length and frequency, to prepare, as it were, for the more violent contractions of parturition. Indeed, she often experiences the true pains from time to time, and should the accoucheur then examine the abdo- men, he, like her, will feel it hardening, and the uterus manifestly contract- ing. At times, these contractions are scarcely painful, are not attended with bearing down, and can only be detected by placing the hand upon the abdomen. We know that the uterine globe is contracting, from its greater hardness ; then, after a short time, relaxation occurs, and the walls regain their habitual suppleness. 1 In women who have previously had children, we ascei'tain by the vaginal touch, that the membranes bulge out during contraction, and engage slightly in the upper part of the cervix uteri. These precursory phenomena are manifested much sooner in primiparas than in others. - According to certain writers, the pains are felt first, and with more severity than at any other time, about four weeks before term ; so that some women, who have been pregnant before, do not hesitate then to affirm that their labor will take place in the course of a month. (Burdach.) Further, these pains are not wholly useless, for they tend to diminish the thickness of the neck, and generally bring on its dilatation ; thus, I have remarked that, when no cause of dystocia existed, the labor was usually much more rapid in those females who had been thus tormented by frequent pains during the last fortnight of their pregnancy. On the whole, therefore, contrary to the proposition reiterated in all the 1 These contractions, which are the precursory symptoms of labor, I regard as due to the changes which the upper part of the neck undergoes in t lie latter weeks of ges- tation. We have already stated that, in the last fortnight, the internal orifice softens and yields to distention, then expands from above, so thai the upper half of the neck gradually becomes confounded with the cavity of the body; the lower part of the ovum will evidently engage in the dilated portion, and soon come in contact with the parts in the neighborhood of the external orifice. This contact occasions a progres- sive irritation of the irritable fibres of the lower half of the cervix, which, by react- ing upon the body, excites its control lions, until finally, the entire neck bei the iiritation reaches its maximum, and labor commences. 286 LABOR. classical works, that women are more gay, cheerful, and disposed to actixn^ 1 have observed that they are in general more sad, and are greater sufferers, than at other times ; and although they appear to endure their pains better, it is simply because they are encouraged by the hope of a speedy delivery, the announcement of which is recognized in the very sufferings they endure. First Stage. — The term of gestation finally arrives, and the labor begins. In primipane, this is made known by the opening of the neck, which until that time had remained closed ; and in other women, by the total effacement of the rounded collar presented by the os tineas. The pains just mentioned as occurring in the last fortnight of pregnancy, suddenly become more acute and frequent, and while they last the abdomen retracts, and the uterus hardens, as may easily be verified by examination. If the fundus was here- tofore inclined towards the right or the left, it will now return to the median line; the inequalities of the foetus can no longer be perceived through the abdominal wall ; the cervix uteri, which is already somewhat dilated, closes partially during the pain, and its margins are tense and resistant, though growing thinner; the membranes are distended, press at first on the neck, then engage in it as soon as the dilatation is sufficiently advanced, under the form of a segment of a sphere, whose dimensions progressively increase with the dilatation. The organs of generation are more humid ; the glairy discharges are streaked with blood ; the pains continue to increase in force and frequency, each one being ushered in by a slight shivering, or horripilation ; while it lasts, the pulse is hard, frequent, and full; the countenance is flushed, the surface and tongue dry, and the patient very thirsty; nausea and vomiting often come on ; she weeps, desponds, and becomes quite irritable, and, being unconscious of the progress of her labor, because no advance is perceived, she cries out repeatedly, that she will never get over it. After the contrac- tion, she is less agitated ; still, however, the cessation of the pain does not seem to be perfect, the calm is not yet complete, and the poor sufferer, still under the influence of the last pain, dreads incessantly the arrival of its successor. During the interval, the margins of the os uteri again become nipple, thick, and rounded; the memhranes that were smooth and tense, while the pain lasted, are now flaccid, and hang in folds, and the foetal head, which was temporarily removed from the orifice, seems to return, and is much more accessible to the finger. In proportion as the contractions are repeated, the os uteri gradually dilates more and more, until at last it is completely opened ; the cavity of the uterus and the vagina thenceforth forming but a single uninterrupted canal. Some females are able to conceal these early pains, but most of them find it impossible to do so for any length of time ; for, if conversing, they will at once leave the phrase incomplete, and remain silent until the pain has diminished or stopped altogether; or, if they happen to be walking up and down the chamber, they stop short and lean on a chair, or the first article that comes to hand, until it passes over. The occurrence of violent shivering, and sometimes of general tremors, at the termination of this stage, is by no means unusual, and that, too, with- out any sensation of cold being perceived. The patient herself frequently PHYSIOLOGICAL PHENOMENA OF LABOR. 287 expresses surprise at her trembling. It is doubtless caused by one of the singular impressions produced upon the nervous system by the act of par- turition. Second Stage. — At length, under the influence of these first pains, the duration of which is very variable, the orifice is enlarged until it forms a sufficient opening ; and from that moment all the uterine forces are directed to the expulsion of the foreign body contained within the organ. Up to this time, the uterus alone was concerned in dilating the neck, but it now seems to call in aid the contraction of the abdominal muscles, and consequently both the pain and the bearing down are carried to a much higher degree. The heat of the surface is much more considerable, the agitation extreme, and in some instances there is even a marked disorder in the intellectual functions. The pains are stronger, and the intervals shorter ; nevertheless, the woman bears them with more patience, nay, she even assists them by voluntarily contracting all the muscles of the trunk ; and each pain is fol- lowed by a calm more perfect than that in the first stage. Indeed, when the interval is rather long, some females, exhausted by the previous fatigue, sleep profoundly, and thus get a refreshing repose that should be respected, but which is soon interrupted by a new pain. The inferior segment of the membranes gradually engages in the orifice ; the successive and repeated contractions cause the liquor amnii to flow towards this point; the amniotic pouch becomes tense and bulging at its lower part, and, being entirely unsupported by the parietes of the neck, it gives way, and the contained waters escape with more or less rapidity and abundance, according to cir- cumstances. Immediately, the foetus, urged on by the same contraction, applies itself to the os uteri, and the head, if that is the presenting part, engages like a stopple in the orifice, thereby preventing a further discharge of the waters. The head is then said to be at the crowning. The rapid discharge of a con- siderable quantity of the waters, which then takes place, suspends the uterine contractions for several moments, and, as the head no longer presses on the circumference of the neck, a small amount of fluid is again discharged. But a more energetic pain shortly comes on, by which the child's head advances and clears the circle of the uterine orifice, and just at this moment the patient very frequently gives a loud cry, an expression of the great pain caused by its passage. Next, the head descends into the vagina, the trans- verse folds of which become effaced, the canal enlarging and elongating for its reception. When a rupture of the membranes takes place before the os uteri is completely dilated, the head often descends to the pelvic floor, though still retained in the womb, and does not clear the uterine orifice until it engages in the inferior strait; though, whichever happens, the pains go on increasing in violence. Each one is announced by a general shivering ; the patient clings to anything around her, supports her feet against the mattress, throws the head backwards, takes a deep inspiration, and violently contracts all the muscles of her body. The foetal head, being thus forcibly urged on, presses against the floor of the pelvis, and causes it to prctrude at every pain ; and the consequent pressure on the rectum gives rise to illusory desires of going to stool. 288 LABOR After a greater or less resistance, the perineum at last yields, becomes distended and bulging in front ; the vulva partially opens, and the nymphse are effaced, the skin in the neighborhood contributing to the enlargement ; the head then appears in the dilated vulva, and the fseces as well as the urine are passed involuntarily; then the pain again ceases; the head, just apparent, now seems to re-enter the excavation ; the ovcrdistended perineum retracts from its own inherent elasticity : the labia externa approach each other, and the vulva again closes up; at each pain, the latter opens more and more, then retracts, until, at last, all these parts, from the force of the repeated con- tractions, become incapable of any further resistance; 1 finally, a horrible pain comes on, forcing loud cries from the woman, which is made up of two others of unequal violence, for which nature seems to have reserved all her powers ; this first brings the parietal protuberances to a level with the tuber- osities of the ischium, and then expels the head altogether from the parts. In some instances, the delivery of the body immediately follows that of the head ; but in the larger number, some seconds elapse ; then the pain is renewed, the uterus again contracts, and drives out the foetal trunk, together with the rest of the amniotic liquid. The rapid sketch of these phenomena, just given, has not afforded us an opportunity of dilating upon any of them ; nevertheless, some ought to be studied more carefully. For instance, the pain, the dilatation of the uterin6 orifice, the glairy discharges, and the rupture of the membranes, demand a more particular attention. We shall, however, be brief in the physiological considerations appertaining to each. § 1. The Pain, or Contraction. In most females, the pain is so inseparable from the contraction, that, in common language, the cause is readily confounded with the effect, and the two expressions are used, indifferently, to express the uterine contraction, its returns, duration, weakness, and intensity. We must remark, however > that although the intensity of pain is generally in relation to the contrac- tion, yet it is not always so, for the perception of pain thereby produced necessarily varies with the susceptibilities of the patient herself. Some experience trifling pains very acutely, and express themselves freely; others, on the contrary, whose sensibility seems more obtuse, scarcely complain at all of the strongest contractions. Again, there are certain females who have the happy privilege of being delivered almost without any or at least with but very inconsiderable pains. For instance, I had an opportunity of observing a young primipara at the Clinique, who was aroused by the pains at four o'clock in the morning, and was delivered at six ; she suffered so little during these two hours, that she did not consider it necessary to alarm any one, and the midwife was only summoned when the pain became a 1 Certain authors attribute the retreat, of the head after each pain to a winding of the cord around the child's neck, and therefore propose various measures for facili- tating its delivery. But this simply results, says Baudelocque, from the elasticity of the perineum and the reaction of the muscles contained in its substance, as also from the elasticity of the cranial bones. Consequently, we have nothing to do but to await the spontaneous expulsion PHYSIOLOGICAL PHENOMENA OF LABOR. 289 little more severe ; she soon arrived, and found the head delivered. This case was still more remarkable, from the fact of a partition existing in the vagina, which divided its cavity into two parts ; indeed it had been proposed to incise this septum when the hour of labor should arrive. It is highly probable that the dilatation of the neck goes on quietly in such cases, under the influence of contractions which are not perceptible to the patient from being unattended with pain. The pains have received different names according to the period of their occurrence : thus, the trifling ones appertaining to the precursory phenomena of labor are named mouches, from a comparison with the sensation caused by the pricking of a fly; those of the first stage, in which the neck is dilated, are termed preparative; those of the second are designated as the expulsive ; and finally, in the last moments of labor, when the head forcibly distends the perineum and partially opens the vulva, the pains are so violent in character as to have been denominated the conquassantes. 1 The pains are felt in the lower part of the abdomen ; and in the early stages, generally follow a line drawn from the umbilicus to the second bone of the sacrum, but when the head presses against the pelvic floor, they run more towards the coccyx. Sometimes they are felt in the lumbar and sacral regions only ; the women then call them the pains in the back ; and the patient has good cause for dreading them, for they do not much advance the delivery, and always leave behind them a feeling of discomfort and prostration. These lumbar pains often come on early in the labor, at othei times a little later, but they rarely continue till its close ; sometimes they coincide with a great obliquity of the uterus. According to Madame Lachapelle, they may generally be referred to too great a rigidity of the external orifice, either because this experiences a kind of cramp, or that owing to its unyielding condition it receives the full force of the uterine efforts, and consequently suffers more than when softened. These lumbar pains doubtless depend on the sensibility of the orifice, ana this can readily be explained by the origin of the nerves distributed to the neck, for the hypogastric and lumbar plexuses furnish them; whilst the ovarian plexus of the splanchnic nerve alone sends its branches to the fundus uteri. Various plans have been tried to assuage these pains: thus, venesection, emollient injections, and the opiates, have often succeeded ; but there is one which, of itself, may suffice in many cases to relieve the patient, that is, to raise her up by passing a towel under the loins. The pains have been divided by writers into true and false, according to wnether they are produced by a regular labor, or by some disorder in the uterine functions; but as we shall endeavor to establish the diagnosis carefully further on, we will only remark now, that a true contraction always com- mences in the fibres of the neck, and only reaches the fundus some second.- afterwards; and therefore every contraction beginning at this latter part i* irregular and abnormal. (See chapter on Attentions to the Woman during L^bor.) 1 I give these terms [mouches and conquass antra) as found in the original, because, in our American practice, they have no synonyms ; perhaps the words pricking and tearing would express their sense. — Translator. 19 290 LABOR. The question now arises, what is the cause of the lahor pain ? Some sup- pose that it is produced by the tension of the fibres of the neck ; others, by the pressure on the nerves distributed to the internal surface of the organ, which are necessarily compressed by the foetal walls during the contrac- tion ; and lastly, certain accoucheurs have thought that it was owing to the compression of the parts contained within the pelvis: the nervous plexuses, for example. But these opinions err in being too exclusive, since all of these causes evidently contribute to the production of pain ; indeed, there can be no doubt that the dilatation of the neck is painful during the first stage of labor, more especially when the head is clearing it, this being, according to Madame Boivin, almost the only source of suffering ; though, on the other hand, when the child is so placed that it neither rests against the uterine orifice, nor yet on the superior strait, the contraction is still painful ; and the pain must then be owing to the pressure on the nerves of the body of the womb. Again, in the last moments of parturition, when the head is passing the inferior strait, the perineum, and vulva, the enormous distention of those parts, and the pressure on each of them, must singularly add to the pain produced by the contraction, as well as contribute towards giving it that particular character known under the name of the conquas- sante, or tearing pain. "Without denying that these various conditions may be the first cause of the pain, M. Beau observes, that the suffering which they produce is not seated in the uterus, but in the lumbo-abdominal nerves. He regards the pains of child-birth as being, for the most part, a lumbo-abdominal neu- ralgia, precisely as though the case were one of pathological disease of the uterus. If, says he, a woman in labor be examined with the object of determining the existence of the five painful points which characterize the lumbo-abdominal neuralgia, there will then be found, as in disease of the womb, points which are painful on pressure in the lumbar, iliac, hypogas- tric, inguinal, and vulvar regions. In some cases, it is the lumbar point ; in others, the inguinal or iliac, &c. Pressure on the same points is much less painful during the interval of the pains ; in some cases, indeed, all tenderness then seems to disappear. Though the localization of the pain in the lumbo-abdominal nerves may not explain its intimate nature and first point of departure, it at least enables us to understand the numerous varieties which it assumes; just as certain grave lesions, and some extensive displacements of the organ, are in some women attended with no pain, whilst with others a trifling disorder, or a slight displacement, gives rise to extreme suffering. Thus, some women suffer very little from powerful contractions, whilst others complain bitterly of the slightest expulsive effort. Here, as in the pathological case, it is impossible to fix a constant relation between the intensity of the abdominal neuralgia and the contractile action of the uterus. The degree of pain, as M. Beau remarks, is owing here, as in all other neuralgias, to the nervous susceptibility of the female. We were, there- fore, right in saying that the pain is not intimately connected with the contraction. PHYSIOLOGICAL PHENOMENA OF LABOR. 291 I The pai.3 which accompanies the uterine contractions is not a unique fact in the organism, inasmuch as all rather severe involuntary contractions, in whatever organ they may take place, are attended with pain. I would mention in illustration, cramps in the muscles of the animal life, colic pains in the bowela, spasmodic contractions of the bladder, and palpitations of the heart. Under ordinary circum- stances, it is true that the muscles of the limbs, of the intestinal canal, of the bladder, and of the heart, are constantly contracting without pain, but the moment they become affected with severe involuntary contraction, pain is experienced. This would seem to be a law of pathological physiology which is as applicable to the uterus as to any of the other organs. We believe, therefore, that the pains of labor have their seat in the uterine Avails precisely as colic pains are situated in the walls of the intestines. The painlessness of the contractions which take place during pregnancy, is explained by their feebleness, and are comparable to the peristaltic motions of the bowels of which we are unconscious.] Still another question has been agitated by physiologists, that is, why is the contraction intermittent? and here far-fetched reasons have been adduced to explain a very simple phenomenon ; just as if any single muscle of the economy could contract permanently ; as if it were not the nature of all muscular contraction to be interrupted by the fatigue of a too prolonged exercise, and as if it must not have an interval of repose, in order to pre- serve its activity. Besides, if the uterine contractions are dependent upon the nerves of organic life, why should they not be subject to the periodicity which marks the muscular apparatus supplied by branches from the great sympathetic? We are doubtless ignorant of the cause of the rhythmic intermissions in the contraction of the heart, as well as of the stomach and intestines ; what cause is there, therefore, for greater astonishment at the interm ittence of the uterine action, subject as it is to the same nervous influence ? It is certainly very curious to study the influence of the contraction over the mother's circulation, which exhibits, according to Holl, the following peculiarities during a pain. In general, the pulse is accelerated as soon as the contraction begins, increasing in frequency as it goes on, then diminish- ing, and gradually resuming the normal type. Now there exists so intimate a relation between these two phenomena, that, where the pulse is gradual in its acceleration, where it arrives little by little to the maximum of its rapidity, is there sustained for a certain length of time, and finally recedes by degrees, the pain also follows an equally regular course ; it gradually attains its maximum intensity, remains a while stationary, and then decreases with the same regularity; but, on the contrary, if tho pulse accelerates by jerks, the contraction will be short and precipitate, and therefore without effect. Holl ascertained this regularity in the phenomeua, by counting the pulsations by quarters of a minute during the whole time a pain lasted. For instance, he noted the following variations in a con taction which lasted two minutes: First minute, Second minute, First and second quarters, each, . 18 pul ~;itioii9. Third quarter, . 20 " Last quarter, 22 " First and second quarters, . . 24 " Third quarter, 22 (1 Last quarter, . 18 a 292 LABOR. Ill proportion as the labor advances, the pulse accelerates the more ; so thai, n little while before delivery, it has the same frequency in the intervals as it had at first during the strongest contractions. We have already pointed out the modifications in the bellows murmur, noticed by the same obsti ver during the pain, and shall not repeat them now, merely remarking, how- ever, that they are sufficiently well marked to indicate the uterine contrac- tion, even when the woman herself may be desirous of concealing it. § 2. Dilatation of the Os Uteri. The foetus evidently has no part in the dilatation of the os uteri until the bag of waters is ruptured. It is not until after this event takes place, that the vertex, by engaging like a wedge in the uterine neck, can hasten the dilatation mechanically; and it is equally evident that, in any other than a vertex position, the presenting part being more voluminous and irregular than the head, cannot perform the same office, and therefore, costeris paribus, the orifice will open more slowly. Hence, it is not the foetus, at least during the fir^t part of the labor, which is the efficient cause, but here also the phenomenon is referable to the contraction of the uterine fibres. Now, in order to understand how this occurs, we must remember, says Desormeaux, that the walls of the womb are applied to an ovoid body ; that the longitudinal fibres are the most numerous, and that the circular fibres of the cervix, although capable of stoutly resisting their power, yet are gradually constrained to yield to the action of the longitudinal ones. If we now imagine these latter fibres to enter into contraction, we shall readily comprehend that, being unable to diminish the distended uterine cavity, all their power must be exerted in drawing upon those points of the circle which form the orifice, where each one is inserted, and thus remove them from the centre of the opening. Wherefore, every portion of the orifice being equally operated upon, it will present a circular form ; but if the foetus is placed transversely, and the womb dilated in that direction, the fibres being re- tracted more in the same diameter, the orifice will be elliptical. The rapidity of the dilatation bears a direct ratio to the force and fre- quency of the contractions. In general, it is very slow in the commencement of labor, but much more rapid towards its close : for instance, if the opening dilated to the extent of one inch in four hours, it would only require two, or at most three hours for its complete enlargement ; this progresses more slowly, however, in primiparse than in other women. Again, the softness, or the rigidity and tension, of the neck during the intervals of pain, has a great influence over the rapidity of its dilatation ; and the same may be said of the obliquity of the orifice; for when this latter is carried in front towards the pubis, or, what is still more frequent, is strongly directed back- wards towards the sacrum — in either case, the neck is no longer placed in the axis of the contractions, and the head is forcibly pressed towards some part of the uterine wall, against which all the expulsive force is lost. It is likewise important to bear in mind, thai the posterior obliquity of the neck may be owing to an anterior inclination of the womb, and may also exist without the latter being at all changed from its normal position ; this results from the head having been engaged a long time in the excava- PHYSIOLOGICAL PHENOMENA OF LABOR. 293 tion, and having pushed the anterior inferior uterine wall before it; the os atari being at the same time carried upwards and backwards. [When the orifice is directed very far backward, it is sometimes difficult to reach, and some practitioners make the mistake of supposing that the dilatation is com- pleted even -when the head is entirely covered by the anterior segment of the womb.' This eri'or is most liable to occur in first labors, for then the edges of the orifice are extremely thin, and when the head distends and presses down the lower segment of the uterus without interposition of the amniotic fluid, the sutures and fontanelles may be felt so easily as to lead to the supposition that the head is uncovered. A mistake of this nature may have serious consequences. I have myself seen attempts made to apply the forceps under these circumstances. To avoid misconception, the hips of the patient should be raised, the fingers passed very far back and moved over the contour of the head. If the orifice is really dilated, the finger will penetrate very deeply and pass alongside of the head with- out meeting any obstacle. If, however, dilatation has not been accomplished, the linger is soon arrested by the neck of the vaginal sac — especially in front.] The orifice, which is generally very thin in primiparae at the beginning of labor, becomes thicker towards the last half of the first stage ; then it gets thinner, and finally forms a thick, rounded collar, which the head pushes before it as far as the inferior strait. The reason of these various changes, says M. Guillemot, is very simple ; for the pressure upon the neck acts more forcibly on the periphery of the orifice than on any other part, and the consequent thinning will disappear as soon as the uterine circle yields, and is carried back towards the parts that have not suffered an equal pressure, but have maintained their original thickness; though soon af^er, in consequence of fresh pains, the tension on this new circle will destroy its bulk and reduce it to the condition stated. Finally, a period arrives when the neck maintains its thickness, notwith- standing the dilatation it undergoes, because the uterine fibres, being exces- sively shortened, give more density to this part. I will add that the thick- ness of the anterior lip is often greatly augmented, when the engagement is far advanced, by oedema of the part, due to its compression between the head and the symphysis pubis ; and further, that it is not at all uncommon to find the posterior lip quite thin, whilst the anterior one still remains con- siderably thickened. § 3. Of the Glairy Discharges. We have already learned that an abundant secretion takes place in the vagina during the latter periods of gestation ; but when the labor sets in, this secretion augments very considerably, and discharges of viscid mucus, resembling the white of an egg, designated as the glairy discharges, flow from the womb and vagina. In some women they become sanguinolent at the approach of the travail; but in others they are only so during labor. When blood is thus mixed with the other fluids, it is said to be an evidence that the dilatation of the orifice is advanced ; this, however, is not always true, since, in some instances, several days elapse before the commencement of parturition. In some cases, indeed, they are wholly absent, and the labor 1 Sometimes the orifice is so thin that the finger slips over it without perceiving it. 294 LABOR. is then said to be a dry one; the genital parts experiencing a degree of heat and dryness almost akin to inflammation. With regard to their origin, these discharges are not, as Ant. Petit and Baudelocque supposed, the product of a transudation of the amniotic waters through the pores in the membranes ; but they simply result from the more abundant secretion of the mucous cryptse in the neck and vagina ; a secre- tion which is augmented by the greater irritation in those parts, caused by the labor. As to the blood that colors them, whether before or during tho labor, it may come either from some slight laceration in the borders of the orifice, from a rupture of some of the minute vessels which run from the internal uterine surface to be distributed upon the membranes, or from the detachment of a small portion of the placenta ; or, according to Desor- meaux, it may escape from the extremities of the capillaries without any discoverable rupture. These mucosities, commencing as we have before seen in the latter weeKs of gestation, serve to lubricate the genital passages, and while relieving tho vaginal walls and the parietes of the neck from their engorgement, the;* have the further advantage of moistening those parts, of softening the perineum and the vulvar orifice, and thus rendering the extreme distention which all of them must shortly undergo more easy. Their abundance is always to be considered a good sign, presaging a prompt dilatation and an easy expulsion. § 4. Of the Bag of Waters. As the neck progressively dilates, the foetal membranes present and become engaged therein, forming a tumor of variable size in the vagina, which is tense at the moment of contraction ; and this is what is understood by the formation of the bag of waters. The sac varies in its shape with the figure represented by the uterine orifice ; it is generally rounded and hemi- spherical, though ovoid when the cervix uteri dilates more in one diameter than another ; when the membranes are formed of a loose, uncontracted tissue, and especially when they contain but a small quantity of liquid, they may form an elongated tumor in the vagina, without being a necessary sign of a presentation of either the hand or the foot, as some have incorrectly Bupposed. We must acknowledge, however, that the bag of waters is usually less voluminous in vertex presentations than in others ; and, consequently, that a very great protrusion of it nearly always announces an unfavorable posi- tion. This occasioned the remark of Madame Lachapelle : " I do not fear the flat sacs." As soon as the pain ceases the tumor disappears, the fluid that formed it re-enters the uterine cavity, and the flaccid, relaxed mem- branes hang in folds. [The bag of waters, says Prof. Depaul, sometimes assumes another form which I have called the double bag, and is indicative of a twin pregnancy. I first met with it whilst Interne at the Maternity Hospital in 1839, and waa much puzzled by it, inasmuch as I had never met with any account of it and became aware of its significance only after the birth of the twins. Some years after I met with the same thing at the lying-in hospital of the PHYSIOLOGICAL PHENOMENA OF LABOR. 295 Faculty, and remembering my former observation at the Maternity, did noi hesitate to assert that there were two children, — which, in fact, were soon born. These are, however, the only cases which I have met with, nor ought their rarity to be a matter of surprise when we consider all the conditions required in order that two ovums, which are liable to assume such various positions in the cavity of the uterus should be equally forced upon the mouth of the womb by the contractions. Still it is well to record the fact in order that it may be made available upon occasion.] The formation of the sac is easily understood. Fl °- 74 - The uterine cavity is gradually diminished, and the amniotic liquid, pressed on all sides, natu- rally flows towards the point that offers the least resistance, and such point is evidently the opening in the neck where no walls are found. The reason why so much difficulty existed in comprehending how the membranes could pro- ject into the vagina under the influence of this pressure of the liquid, was because the amniotic cavity was supposed to be distended to the utmost by the waters, and consequently that there must either exist a very great extensibility of the membranes, or else a trans- The form of the ba s of wate " ,. ft n • ^ i ii n n i when the os uteri is fully dilated. udation of the fluid through the walls of the ovum ; but both hypotheses are false. For it is only necessary to press upon the abdomen of a pregnant woman to become satisfied that in most females a very slight pressure will be sufficient to flatten the ovum, whether in its vertical, transverse, or antero-posterior diameters. This is what takes place in labor, excepting that the ovum can only elongate below, on account of the uterine pressure upon all other parts, and thus produces the amniotic tumor. When the dilatation is completed and the contraction energetic, the inferior part of the membranes, being no longer supported, soon yields to the impulse, and becomes ruptured, thereby permitting a variable quantity of liquid to escape. Where the pouch is voluminous, and gives way just at the moment of a strong pain, the rupture takes place with such a loud noise, that women in their first labor are often much alarmed, and then also the waters gush out in large quantity. But where the pouch is flat, and only a small quantity of fluid is interposed between the head and the membranes, the latter are lacerated without any noise, and but a little liquid oozes out after their rupture ; because, the head by engaging at once in the os uteri obliterates it completely and blocks up the waters. [When the membranes are ruptured, the following peculiarities mav be observed in the discharge of the amniotic fluid. At the beginning of each contraction, it is forced toward the lower segment of the uterus and a small quantity is discharged from the vulva. At the height of the contraction the flow is arrested, because the direct application of the head against the orifice stops it completely. Finally, when the contraction subsides, the head will close the orifice imperfectly and allow afresh quantity to escape externally.] In the vast majority of cases, the membranes are lacerated on that pc rtiou 296 LABOR. of the bag corresponding to the uterine orifice. But sometimes the rupture occurs much higher up; and this fact, which is almost inexplicable in the present state of our knowledge, should nevertheless be known, because it accounts for the circumstance of the inferior segment of the ovum being then found intact after the discharge of a certain quantity of water, and of our having to puncture the membranes subsequently in this part. Some- times thev are ruptured in the beginning of the labor, which is thereby usually rendered longer and more difficult for the mother, as also more dangerous for the child, especially when a considerable quantity of water escapes at the same time. Besides these varieties, I have several times noticed a remarkable peculiarity that seems to have escaped the attention of practi- tioners generally ; I allude to the occurrence of a rupture before any con- traction of the uterus whatever. This constitutes in a fe-.v females the first- phenomenon of the labor ; but the pains do not come on for some time afterwards, occasionally not for several days. Now, this premature lacera- tion has seemed to me to be coincident with a presentation of the vertex that is deeply engaged in the excavation ; for although the patient felt no previous pain, and even in certain cases was sleeping profoundly when the waters escaped, it is highly probable that the uterus had already been con- tracting for some time, and the occurrence may be referred to those non- painful contractions hitherto described ; unless, perhaps, it may possibly depend on an excessive distention of the amniotic pouch. Sometimes the membranes are very hard, thick, and resistant, the rupture only taking place at an advanced stage of the labor, when the head clears the vulva, for instance ; or it may occur in a circular manner, and the head escape covered by a kind of hood. The child is then said to be born with a caul, and the vulgar, from that circumstance, prophesy a happy future. The infant may also be born hooded, when a rupture of the membranes first occurs at an elevated point, one not corresponding at all with the uterine neck ; and should the head then push before it a portion of the amniotic pouch, serious accidents might result in consequence : for instance, this late rupture might delay the labor, or the tension experienced by the membranes, extending to the placenta, may cause its premature detachment, especially when it is inserted on the sides of the organ, and thus produce a uterine hemorrhage. In ordinary cases, the rupture takes place at the commencement of the second stage. The subjoined is a statistical summary made by Churchill, at the Western Lying-in Hospital, during the years 1841 and 1842, which will enable the reader to judge of the varieties that may be met with. The period elapsing between the commencement of the labor and the rupture of the membranes has been noted in 984 cases. Thus: [n 167 females, this time was o b ours. " 335 << " from 2 to 6 " " 165 << " « 6 " 10 " " 113 u i< « 10 " 14 " « 71 it a » 14 " 18 " «• 88 '• 46 n " 18 " 22 "22 " 26 " PHYSIOLOGICAL PHENOMENA OF LABOR. 297 In 23 female3 this time was from 26 1 30 hours. « g 30 « 38 " .< 9 38 ' 40 " 4 " •' about 50 " 2 " " " 60 " .« 4 70 " „ 3 80 " " 1 female " 105 " 984 The same observer noted the time from the rupture of the membranes ontil the child's birth in 812 cases. In 396 women, this time was 1 h our " 142 (i " 2 hours » 120 << " 4 " " 50 (< " 6 si " 34 " •' 8 it « 17 " " 10 " « 26 » " 15 " " 11 " " 20 « " 3 »« " 28 " » 4 (< " 35 << 1 woman " 40 " " 1 < < << 50 " " 1 » " 150 " 812 § 5. Of the Duration of Labor. The duration of labor is exceedingly variable, even when no obstacle opposes its natural course. Some women are delivered in an hour or two, whilst others are not for several days ; and between these two extremes, there is every intermediate grade. The published statistics are hardly reliable, for most of them have been collected in hospitals ; and it is a fact, that the majority of women, dread- ing to be taken into the apartment devoted to the patients in labor, conceal their first pains, and give up only when they can restrain themselves no longer. Therefore, when interrogated after delivery, their statements are not found to coincide with their record, and make their labor appear much longer than the latter would indicate. This correction seems to me of importance, for most physicians of limited experience, having learned that the duration of labor is from five to six hours, are apt to become alarmed unnecessarily when they find it continuing even longer than from ten to twelve hours. In general, it is longer in primiparse than in others ; and this difference is chiefly owing to the resistance of the perineal muscles, which is much greater in the former, though it is also influenced by the dilatation of the neck, which is effected in them very slowly. The whole length of their labor is usually from ten to twelve hours, but it should be known that, in at least one case in five, it may not terminate under fifteen, eighteen, or even twenty hours, and this without any injury 298 LABOR. whatever resulting either to the mother or the child. "Women who have* had children are delivered much sooner, only suffering, in ordinary cases, about six or eight hours. According to Alph. Leroy and Velpeau, the pains are apt to observe periods of six hours : that is, the labor lasts either six, twelve, eighteen, twenty-four, or thirty hours. I think, if their obser- vation be correct, it will be found subject to very numerous exceptions. But, supposing the labor has really commenced, can we predict the hour of its termination with any degree of certainty? This question, which is nearly always addressed to the accoucheur, is oftentimes a very difficult one to answer, for habit alone can enable us to judge by the dilatation, or the suppleness of the neck ; by its tension, its hardness, and resistance ; by the frequency and intensity of the pains ; by the time it has already existed, and by the greater or less resistance of the vulva and perineum, of the probable length of the labor. It must also be remembered, in regard to the duration, that the first stage of labor is to the second, as two, or even three, to one ; and, further, this difference is still more marked in women who have had children, than in primiparae; and that the first half of the dilatation of the neck is much slower than the second. But how many exceptions are there to this law! For instance, the dilatation is sometimes regular, and sufficiently rapid, everything seeming to promise an easy and prompt termination ; yet all at once the pains become feeble and languishing, and our art is often obliged to interpose in aid of the uterine contractions ; while, on the contrary, it not unfrequently happens that the neck is expanded with an excessive degree of slowness, after which, a few moments will suffice to effect the delivery. The form of the vagina, according to Wigand, should also be taken into consideration, in making a prognosis as to the probable duration of the labor: thus, if this canal is large throughout, the whole time will be short; and, on the other hand, the dilatation of the cervix, and the expulsion of the child will be very slow, should the vaginal cavity be regularly con- tracted throughout its extent; again, if the vulvo-uterine canal is large and spacious superiorly, but contracted and unyielding near the external orifice, the first part of the labor will be prompt, but the last slow and difficult ; and, finally (though more rarely), if its upper extremity is very narrow, the inferior being at the same time largely dilated, we may conclude that the parturition will progress slowly at first, but will then terminate speedily. It is a very singular fact, that an hereditary influence is sometimes mani- fested in the process, it being not at all uncommon to find the same pecu uarities transmitted through three or four successive generations ; the mother, the daughter, and the granddaughters being remarkable either for the slowness or rapidity of their labors. In general, it is impossible to predict with any degree of certainty the hour of its termination ; yet most people seem to imagine that the physician is bound to give the most particular information on this point. He must, however, always be very guarded in his replies, for should the labor over- run the fixed time by some hours, it would give rise to the most anxious solicitude, and it is therefore prudent not to be too precise. When such PHYSIOLOGICAL PHENOMENA OF LABOR. 299 questions are addressed to me, I am in the habit of saying, that, if the contractions are regular, and no accident occurs, if, in a word, all things go on right, the delivery will take place at the hour I name. In fact, it is absolutely impossible to foresee all that may happen ; be cause, in certain cases, the dilatation of the os uteri, which, perhaps, only amounted to one inch, after five or six hours of labor, is suddenly com- pleted ; and, at other times, this process being very little advanced, the margin of the orifice is lacerated under the influence of a strong pain, and the delivery effected, perhaps, just as the physician has announced that the labor will still last for several hours. In examining a young woman, preg- nant for the first time, I found the orifice dilated to the size of a quarter of a dollar, and, supposing that the labor would last for some time, I with- drew, but scarcely had I reached the foot of the staircase, when a messenger came running after me in great haste; I immediately returned, and found the head on the point of clearing the vulva, which was already considerably opened. After the labor was over, I ascertained that the whole left side' of the vaginal portion of the neck had been lacerated. A young primiparous female experienced the first pains at four o'clock in the morning. Throughout the day the contractions were very feeble, with intervals varying from a quarter of an hour to an hour. The dilatation was so slow, that at four o'clock in the afternoon the orifice had barely attained the size of a dime. After five o'clock, the pains were rather stronger and quicker ; at nine P. M., the neck was very thin, and presented an opening of three-quarters of an inch in diameter. Being obliged to leave the patient for an hour, I thought I might do so with safety, but imme- diately after my departure the contractions became powerful, and at a quarter before ten, she gave birth to a very small child, which barely weighed five pounds. The small size of the foetus accounts for the rapidity of the labor ; and yet this lady had enjoyed good health during her preg- nancy, besides having reached her full term. The woman's age has not the unfavorable influence upon the duration of labor, even in primiparse, which is accorded to it by some authors. " There has always," says Madame Lachapelle, "been an opinion prevalent on this point which I can by no means adopt ; it is, that the dilatation of the pas- sages is more difficult in women advanced in years than in others, and there is not an accoucheur who does not dread the first labor in a female of thirty or thirty-five years of age ; nor is there a woman in that condition who does not anticipate with terror the hour of her delivery. My expe- rience has, however, so often proved the fallacy of such prejudices that 1 cannot adopt them. "No doubt, the labor is often slow and painful in middle-aged women who have had no children, yet the same is the case with the youngest. I dare affirm, indeed, that there is no more difficulty in the one case than in the other, and that if four young primiparous females out of ten have easy labors, four out of ten if the oldest will also be delivered with promptitude and facility." 300 LABOR. § G. Of the Effect of Labor upon the Mother and Child. a. Effect of the Labor upon the Mother. — Independently of the numerous accidents which are liable to occur, and which will be studied hereafter under the head of Causes of Dystocia, the parturient process has a decided effect upon the physical and moral condition of the female, which, unfor- tunately, almost uniformly escapes attention. This effect may be exhibited in both the first and second stages, and even continue for a few hours or days after delivery. The commencement of labor is preceded in many females by a state of anxiety and prostration, and often by feelings of fear and disquietude. This usually ceases after the first pains are experienced, all the powers of the organism seeming then to be devoted to the accomplishment of the great function about to be performed. All others are modified or suspended, the appetite is lost, and if the patients have eaten shortly before, they not un- frequently reject all that has been taken by vomiting. If much time be occupied by the process of dilatation, they weep, and become irritable and despairing. This excitability diminishes as soon as the second stage commences, and the patient begins to feel that her labor has really begun. From that time her attention seems concentrated on a single object, and she is indifferent to everything else. During the expulsive pains, her condition approaches that which characterizes inflammation or fever ; thus, the circulation is quickened in a degree which seems connected with the force of the contrac- tions ; the heat and moisture are sensibly augmented, and the red and even livid features sometimes covered with profuse perspiration ; again, in some cases the skin may be dry and hot. The intensity of the pains occasionally throws the patient into a state of extreme agitation, and so disorders her faculties that she commits acts of violence upon her attendants. This agitation, which is very moderate when the labor progresses regu- larly, becomes extreme when the latter is retarded or prolonged inordi- nately. The beginning of each pain is then marked by an almost convul- sive trembling of the extremities. The face is burning, and the entire body bathed in perspiration, the eye is fixed and haggard, and the features changed ; the unfortunate sufferer screams, laments, desires to die, and begs to be either killed or relieved of her agony. The well-marked disorder of the intellectual faculties is sometimes carried to complete delirium, during which the patients utter the most extravagant expressions. Two such cases have come under my own observation. The delirium is almost always pre- ceded and accompanied by great loquacity, and the pains are hardly felt. I knew a young lady, after a rather lengthy labor attended with extreme suffering, suddenly to cease complaining, assume a smiling expression, and after a few incoherent phrases, to sing in full voice the grand air of Lucia di Lammermoor. I cannot express the terrifying effect produced by this song upon myself and the attendants. (A bleeding, followed by the imme- diate application of the forceps, had the effect of calming the patient, and chere was no recurrence of delirium.) Montgomery also states, that he has known women to be completely delirious for a few moments, just as the brad was escaping from the mouth of the womb. PHYSIOLOGICAL PHENOMENA OF LABOR. 301 These great disturbances of the economy are not confined to cases of very tedious isibor, for the same symptoms have been witnessed in very short onea with powerful and very rapid pains. The cerebral excitement which their violence produces, may be carried even to the point of insanity ; so thai medico-legal jurists have accounted for infanticides by this momentary dis- order of the intellect, which would otherwise have been inexplicable. The disorder is sometimes confined to the affective faculties. I have seen a mother, says Ed. Rigby, after a very short and painful labor, exhibit an unconquerable aversion to her child, and express herself in reference to it in terms which contrasted strangely with the tender and affectionate remarks which she had uttered but a few moments previously. These disorders of the intellectual and affective faculties generally last but a short time, and are not significant of great danger; sometimes, how- ever, the shock to the system is so great, that death takes place suddenly, either during the course of the labor, or shortly after delivery. A poor woman, in the Charity Hospital, says Davis, had been in labor for five hours ; the membranes ruptured, and a large amount of water escaped ; the discharge was immediately followed by a feeling of great weakness ; having a desire to go to stool, she sat down upon a chamber, made a few efforts, and fell fainting. She was placed in the horizontal position as soon as pos- sible, but had hardly been replaced in bed before she had ceased to live. The autopsy revealed nothing which would account for the death. Denmau also mentions several cases of sudden death during labor, which it was impossible to explain. In some of these instances, however, the sudden discharge of a large amount of water might, to a certain extent, lead us to attribute the morcal syncope to the same cause which is thought to produce it so often after de- livery : namely, the sudden afflux of a great quantity of blood to the abdominal vessels, which had been suddenly relieved from the pressure to which they were subjected during pregnancy. An undue importance has, I think, been attributed to this too rapid depletion of the organ as explanatory of sudden death after labor. In some instances, it may have all the influence accorded to it, though it is certainly incapable of accounting for all known facts. The violent efforts made by the woman in the second stage of labor may also occasion a rupture of some part of the respiratory organs. This ex- plains the cases of emphysema of the face, neck, and upper part of the breast, mentioned by several authors (Martin, of Lyons). In a serious case related by M. Depaul, death resulted apparently from double pulmonary emphysema occurring suddenly during the violent expulsive efforts of a long and painful labor. The fatal effect of the process of parturition upon the nervous system of the mother, after as well as during labor, cannot be mistaken ; and I believe with Churchill that it consists in a shock of greater or less intensity to the cerebro-spinal system. This shock, which is an effect of the extraordinary agitation produced by parturition, is altogether similar to that occasioned by extensive wounds, and which sometimes destroys unfortunate workmen who have had a member crushed by a machine, or to that ] rod (iced by an 302 LABOR. extensive burn. The sudden death, which neither the circumstances of the accident, nor the lesions discovered at the autopsy are capable of explain- ing, is attributed by surgeons to nervous shock. Not only, says the author just cited, may such a nervous shock take place in certain labors, especially difficult ones, and have a disastrous result, but it exists to a greater or less extent in almost every case. Moderate atten- tion will make this manifest. Thus, after an ordinary labor, the general sensibility is almost always extreme: although the senses are more acute than usual, the eyes have lost their lustre, and are weak and languishing ; the least light hurts them, as the slightest sound offends the ear ; and if this extreme delicacy be not respected, serious accidents may ensue. Under ordinary circumstances, patients recover from this slight collapse after a few hours' rest ; but when the labor has been protracted, or an opera- tion, such as turning, has been demanded, the symptoms are much more severe. The patient is much weaker, and the expression of features is fixed and dull ; she lies motionless in bed, with closed eyes, or opens them from time to time, without, however, fixing them upon any object in particular ; she pays no regard either to her child or to herself; the limbs are in a state of complete relaxation ; the pulse is sometimes slow, at others frequent and irregular, though always weaker than usual, and the breathing slow and difficult, or quick and panting. The patient may remain in this condition for a long time, and recovers from it slowly and gradually. If the shock has been too great, she may grow Aveaker and weaker, until the prostration ends in death. The autopsy, under these circumstances, fails to throw any light upon the cause of death. This singular state of affairs is not always manifested immediately upon delivery ; for sometimes considerable time elapses, during which the patient expresses herself as feeling very well, then suddenly complains of unusual weakness, exclaims that she is about to faint, and yet is unable to account for the cause of her condition. There are no particular abdominal symp- toms, no evidence of hemorrhage, and the uterus is well contracted ; still the disorder increases, the pulse grows weaker, the face becomes pale and assumes a cadaverous expression, and the patient is so prostrated as to be able to express her feelings only by a groan. Suddenly she experiences a sensation of violent constriction of the chest, and expires before anything can be done for her relief. Opium, says Churchill, has seemed to me the most effectual remedy in these cases. Five drops of laudanum may be given every half hour, then every hour, and finally at longer intervals. It appears to calm the general disturbance, diminish the cerebral shock, and give to the whole system suf- ficient time to recover its exhausted forces. Small quanties of wine and brandy may, at the same time, be given at intervals, in doses sufficient to assist in re-establishing the strength, but not in such quantity as to produce a general reaction. The induction of sleep will be assisted by entire quiet- ness of both body and mind, and when so fortunate a result is obtained, the strength is recruited, and the pulse and respiration become calm ; if, on the contrary, the prostration continues, the case is one of the most danger- ous character, and demands the increased use of external and internal slim- MECHANICAL PHENOMENA OF LABOR. 303 ulants. Ramsbotham recommends that pressure should also be made upon the abdomen, doubtless with the object of preventing the afflux of fluids towards the abdominal vessels. If the agitation, spasm, and delirium, of which we have spoken, appear during labor, blood should be taken immediately from the arm, provided the general condition of the patient admit of it, and the delivery be accom- plished as soon as possible. The same course is also indicated by the sudden occurrence of a marked disorder of one of the organs of the special senses, — amaurosis, for example. B. The effect which labor may have upon the foztus depends upon a multitude of circumstances, most of which will be studied hereafter. Thus, having described the mechanism of labor in each presentation, we shall treat of the effect which each is liable to have upon the health and life of the child. The various causes of dystocia are quite as unfavorable to the latter as to its mother. We have but these observations to make in this place; namely, that all things else being equal, the mortality of male infants is much greater than that of females, which is due, as we have said before, to the greater size of the former, and the proportionally longer duration of the labor in conse- quence ; the extreme slowness of this process, which so often proves fatal to the foetus, has this unfortunate effect only when it affects the second or ex- pulsive stage. Until the membranes are ruptured, and even until the dilatation is completed, the labor may be prolonged indefinitely without injury to the foetus, provided a certain amount of fluid remains in the uterus. It were hardly necessary to observe that any cause of dystocia is liable to affect the mother's health injuriously, and she is more liable to consecutive inflammations and other unfavorable complications of labor when delivered of a boy than of a girl. 80-4 LABOR. K CHAPTER III. OF THE MECHANICAL PHENOMENA OF LABOR. ARTICLE I. OF THE PRESENTATIONS AND POSITIONS. When speaking of the child's attitude in the uterine cavity, we stated that it was generally so situated that the cephalic extremity formed the most dependent part. But it may also happen, under the influence of causes hereafter to be studied, that some other point of the great axis shall correspond to the uterine neck : that is to say, the upper or cephalic extre- mity, the inferior or the pelvic extremity, or even some part of the middle portion or trunk, may first present itself at the superior strait. Now, it is very evident that such different circumstances of presentation must neces- sarily influence the mechanism of the labor, as also the facility and the promptness of the delivery, and it is therefore highly important to understand well all those diverse situations before commencing the study of the me- chanism proper. This study comprises the presentations and positions, as they are called ; and in using these terms we wish to designate by the word presentation the part that first offers at the superior strait; and by that of position, the relations of this presenting part with the different points of the same strait. The older accoucheurs only endeavored to recognize the presenting part, without investigating its relations with the various points of the circumfer- ence of the strait ; but since the days of Solayres, and more especially since those of his pupil Baudelocque, everybody has had a classification of his own ; and the number of presentations and positions, considered as so many separate and distinct ones, varied with each author who wrote on the obstetrical art. We give, in the following tables, the classification of Baudelocque, and the principal ones of those who have succeeded him. MECHANICAL PHENOMENA OF LABOR. 305 CO O i—i H <1 O w < Q w H O W h3 PQ <1 H h? >»; °? d -2 £> © >» o -J • ~ £> .a o T3 o "3 O ;= S 6 « >» o ! .SP S .5, D 3 8 J J » £ ^ .SP-i -3 3 &Z 3 ? Sf § § 1^3^*J-w*-» CO 'ij 'O -*J D'O'O «J OJ'^'O « O) "^ "^ — 00 00 >Voo C-_a £ 93 £? a a 3 .a cj ^ 3 3 |3 _£ ■„ faO „ a r, 5 ^?? o in &J3 -a _j- u o> SO^ " 'So § a cs E 3 IS "a o> 3 ^3 3 ~ ~ o to c ^3 1 hn B m ■ h o =3 ft ? _ c3 h ° o " a b i 0> 0) o> O) 0) >> e3 .a .a .a ,a .a «j *_>>>» i ^ ■" -^ s j,3C . -tJ -t-» -*J *J *D — -h t> C3 03 3 >>> 53 o =*.a X « " .a a -~ .2 .5 « CO oq -*> 03 o> o) 03 B.2 * = .2 -2 o> "co £-i _3 &. O -3 S 5? bfl 5. ° t, oo CO •3-3-3 ej =3 a "2 S °? 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P* M ©' 5 * HE ^ o.H"os J= 0,0* u w s: eg — — — -^ O rj2 . . 03 .« d C O 03 O K « IB w < w z os > &< Esh W « ,- o 1 ~ ■ S : 1 ij o >% o ? °2 i o ■3-000 ~ 0, •&- r » 0. - 5'5 &£ g g o o g o> S o *j — o £ ^ w — J3 ^ *a J3 »-■ be cjo t >- C- fcju 4) ■— .^ 4> 4) .-h S 2 Sin-! S 0, s ^> _- 5 o 00 5^.2 o _~ o o P - r- h hn CO CD •fJL? . £ 0, E o CO 5 « o 3 — cs cs o -7 53 x 3 ^3 -3 „j fcJO fcCV. ■r 1 -r o c3 cc — r: „ ^_ ~ o o o o —1 •« -2 "2 o u u - — ^z _r _r OOOOOOUO MECHANICAL PHENOMENA OF LABOR. 307 'o "3 r -j » fa x H fa V 3 ■ "cj -£ ' — (N ?: -r if i — - - 5>3 >> o c O ? ? o o © r ♦" .5 © o .: oo. eg ■ — i •■-• o ~ -o -2 ja, c — — ©-, — ' Ch'o 'O ft ft' § s § 'g g § a § § O-^-u O O-^jhJ E ^ *j ,a ,5 4> +s o £ Tc bD«E £ fac"5jv»' c "tb B B sg "bcC - o ja Oh - = ft ^a - O " J j?. * o 3 3 e= " 73 - -J .3 w flCM fcJ&=£ " S £ 1-4 <" g, (- -a §JI CO Cv 3 © © - 2 'J ft-r ■w 'oj •- o PS -4 — co s o CO CO Bo, >> = 9-2 jl ~ ae -p -2 S 2 2 • " H tcC OS *= m tec - ^ t: t! 60 *-, o - o « O £ ft :" 4-4 <" 2 © c: - c — £ 2 = ft TT i-i l^jOO^tO CO CO 4> CB*2*J* > " — J2"E-" ,3J,a,ag?>» >»-"=' _H-*J-»iP— 1-— 04)0 ; » 4 -w j, 5 - 3 S 3 a -5 -5 O © S V cca 0,0, '3 '3 '3 o 5 .s oooo©o^:^3o©oo 000000004hlh]4 faMpq •-4 pi ,-r -B ^ c bC 00 ,4 U C CP 4> o2 ft— © hk a > t. i. ^ pa 308 LABOR. CLASSIFICATION OF PROFESSOR MOREAU. TWO CLASSES. FIRST ORDER. Presentation of the -{ cephalic extremity. SECOND ORDER. Presentation of the ■{ pelvic extremity. THIRD ORDER. FIRST ORDER Accidental artificial labor. 1st genus. Vertex presentation. 2d gems. Face presentation. 3d genus. Presentation of the sides of the head. 2 subdivisions. Right side. _ Left side. 1st position. — Left occi- pito-ilium. 2d position. — Right oc- cipito-ilium. I NATURAL LABORS. 1 ARTIFICIAL LABORS. FIRST CLASS.— Nat URAL Labors. anterior, transverse, posterior. anterior, transverse, posterior. 3d position. — Occipito-pubic. 4th position — Occipi to-sacral. , , ... t>. , , ( anterior. 1st position. — Right mento-ilium. 2d position. — Left mento-ilium. J transverse, ( posterior, anterior, transverse, posterior. 1st position. — Lobulo-pubic. 2d position. — Left lobulo-ilium. 3d position. — Right lobulo-ilium. , . ... T e , ( anterior. 1st position. — Left sa- cro-ilium. 1st gents. Breech presentation. 2n genus. 1st position. - 2d position. - 3d position - Lobulo-pubic. ■Left lobulo-ilium. -Right lobulo-ilium. 2d position.— sacro-ilium. trans\ erse, posterior. t>. , . ( anterior, Right b 1 transverse, ( posterior. 3d position. — Sacro-pnbic. 4th position. — Sacro-sacral. 1st position. — Left calcaneo-ilium. 2d position. — Right calcaneo-ilium. Foot presentation. ] 3d position. — Calcaneo-pubic. -It 1] position. — Calcaneo-sacral. i 1st position. — Left tibio-ilium. J 2d position. — Right tibio-ilium. 1 3d position. — Tibio-pubic. [ 4th position. — Tibio-sacral. ( Single genus. — Presentation of the I trunk. (See below.) 3d genus. Presentation of knees. the natural Accidental labor. SECOND CLASS. — Artificial Labors. 1st genus. Accidents on the mo- ther's part. 2n genus. Accidents on the part of the foetus. SECOND ORDER Essentially labor. THIRD ORDER Labors which are the ■ result of malforma- tion. f SINGLE GENUS. Presentation of the trunk, "tificial "I - subdivisions. 1st. Right side. . [ 2d. Left side. . . 1st genus. On the part of the child. 2d genus. On the part of the mother. f 1 terior occipito-iliac positiou. 318 LABOR. forwards and towards the left side ; while its anterior plane is directed backwards and to the right; the right shoulder is in front and to the right side; the left one is behind and towards the mother's left. Before the bag of waters is ruptured, the child's head is slightly flexod on the front of the chest, and the following are the relations of its diameter with those of the superior strait: the occipito-frontal corresponds to the left oblique of the strait, and the bi-parietal to the right oblique j 1 and, of course, the occipito-frontal circumference of the head is parallel with the periphery of the abdominal strait, and the axis of this strait corresponds with the trachelo-bregmatic diameter 2 of the head. When the membranes are ruptured, a variable quantity of liquid escapes ; then the uterus contracts and applies itself more directly to the foetal trunk; nevertheless, as but little fluid passes away in vertex positions at this time, there usually remains a sufficient quantity of it to render the pressure of the uterine walls on the child far from being immediate. After the rupture, the object of the contractions is to expel it from the womb ; the foetus becomes more curved anteriorly, and its superior and inferior extremities more closely folded up ; and from that moment, properly speaking, the mechanical phenomena of labor begin. [The various movements communicated to the foetus during lahor tend to facili- tate its expulsion, as will appear from the description of them about to be given under the usual term of the stages of labor. * We may remark, however, with M. Dubois, that this last relation is not absolutely exact. For instance, if the head of the foetus at term be found at the superior strait, so that the occipito-frontal diameter is parallel with the left oblique, the shape of the head will prevent the bi-parietal one from corresponding with the right ohlique diameter. In fact, in this position the posterior extremity of the bi-parietal diameter is at the left sacro-iliac symphysis, but the anterior extremity, instead of terminating opposite the ilio-pectineal eminence, is found very near the middle of the horizontal branch of the pubis. 2 M. Nsegele and Professor Dubois (who adopts, at least in part, the views of the Heidelberg Professor) do not believe that the head presents at the superior strait, in the majority of cases, so regularly in all its relations as we have just described, for they say the head does not offer perpendicularly to the plane of the strait, but on the contrary, in an oblique direction; whence the right parietal protuberance, which is also the anterior one, would be lower, relatively to the plane, than the left ; and the bi-parietal suture, instead of being found in the direction of the axis of the head, would be a little behind it, according to M. Dubois, and would even look towards the second bone of the sacrum, agreeably to M. Naagele. But, notwithstanding these imposing authorities, we Relieve the occipito-frontal cir- cumference is closely parallel to the plane of the strait in most cases, although the parietal boss is certainly one of the most dependent parts of the head, and the finger first strikes upon it in practising the vaginal examination. But those facts by which M. Nsegele sustains his views prove just the contrary; because the plane of the abdominal strait, being directed very obliquely downwards and forwards, the portion of the head in contact with the anterior arch of the pelvis should be its most dependent part; and further, the finger first encounters the anterior parietal protuberance, because the introduction take3 place under the symphysis pubis, that is to say, almost perpen- dicularly to the superior strait, and therefore the index can only reach, in a very oblique direction, the anterior portion of the head, whose greatest circumference ife parallel to the plane of the superior strait. MECHANICAL PHENOMENA OF LABOR. 310 Five principal stages have hitherto been reckoned in vertex present xticns ; they are, following the order in which they occur: 1st. flexion; 2d. descent; 3d. rota- tion; 4th. extension or disengagement ; 5th. restitution. To these five stages we think it proper to add a sixth for the expulsion of the body. At the end of thi9 chapter (see Recapitulation of the Mechanism of Labor), we shall state more fully the reasons which induce us to alter the number of stages as usually described, remarking only for the present, that we think it gives the advantage of a classifica- tion which is both more rational and applicable to every presentation. In the account of the mechanism of expulsion for each presentation we shall, therefore, describe six stages. It will be seen that this innovation does not call for a change in the generally received opinions, inasmuch as we have only to reunite the fifth and sixth stages to restore the old classification.] These phenomena, or stages of the mechanism, are five in number, as follows : in the first, the head is more strongly flexed on the chest ; in the second it traverses all the space between the superior and inferior straits, and reaches the floor of the pelvis ; there it experiences a movement of rotation which carries the occiput behind the symphysis pubis, thus con- stituting the third period ; in the fourth, the head undergoes the process of extension, by which all the superior and anterior parts of the vertex and face become completely disengaged at the anterior commissure of the perineum ; and then, after its perfect expulsion, the child's cephalic extre- mity performs a fifth and last movement, designated by Baudelocque as the period of restitution, but which M. Gerdy has proposed to name the exterior rotation. A. First Stage, or Stage of Flexion. — After the rupture of the membranes, the foetal trunk, being compressed on all sides, transmits to the head, through the spine, the impulse derived from the uterine contractions. The head, being forcibly pressed on, has a tendency to clear the uterine orifice, and to engage in the Fw. 76. excavation. But it then encounters resistances, either from the os uteri, which is not yet suffi- ciently dilated, or from the superior strait, or the walls of the excavation; and being thus placed between a power and a resistance, the head must naturally become still more flexed on the chest; in fact, the force of expulsion transmitted by the vertebral column, falling upon the occipital foramen, that is. on a point much nearer to the occiput than the chin, must uecessarily (the resistance being equal at the two extremities of the occipito-mental diameter) act more powerfully on the occiput than on the The , ' ,,i,,, '" ,h " sam " >' "* i,ion - """'s' 1 .... , . , more flexed. chin ; in other words, must press down the occiput into the excavation. But, by depressing this part, the chin is forced to ascend, thus producing the flexion of the head. 1 1 In orler to prove that t lx. > movement of flexion results from the position of the occipital foramen, relatively to the chin and occiput, which represents the two extre- mities of the lever whereon the spine is articulated, let us suppose, for a moment, that 820 LABOR. The head being in this way forcibly flexed, its relations are changed . that is, the occipito-bregmatic diameter has taken the place of the occipito- frontal, and has become parallel to the left oblique of the strait ; but the bi-parietal remains unaltered : the occipito-bregmatic circumference is now on a level with the periphery of the strait, and the axis of the pelvis, which before corresponded with the trachelo-bregmatic diameter, now traverses the head very nearly in the direction of the occipito-mental diameter. This movement of flexion, therefore, evidently places the child's head in the most favorable position for its passage, by constraining it to offer its smallest diameters to those of the pelvis. B. Second Stage, or Stage of Descent. — The head, pressed on by the con- tractions, enters the excavation and reaches the floor of the pelvis. In making this descent, the occiput presses in front against the internal and anterior face of the body of the ischium, the obturator internus muscle, and the external obturator vessels and nerves, which pass out through the upper part of the obturator foramen ; while the forehead or bregma presses behind on the internal border of the psoas and pyramidal muscles, the sciatic plexus of nerves, together with the gluteal and the internal pudic vessels and nerves. The left side of the head likewise comes into mediate relation with the same parts, and also glides over the anterior surface of the rectum. But the descent of the head is not completed until the occipito-bregmatic circumference is nearly parallel to the plane of the inferior strait : that is, when the two parietal protuberances have attained this level. Now, it is evident that, to reach this point, the left parietal boss (which is found behind) must traverse the whole anterior face of the sacrum, whilst the anterior one has only to clear a much shorter space ; the first must there- fore describe the arc of a much larger circle than the second. Perhaps a more exact idea of the actual movement of the head will be formed by imagining the anterior extremity of the bi-parietal diameter to remain nearly stationary in front and to the right, while its posterior extremity descends rapidly and traverses the whole posterior plane of the excavation. the vertebral column is attached to the occiput alone, when it is evident that the latter only will descend; on the other hand, let it be made to the chin, which -will then descend the first, and lastly let it be done at the centre of the interval between these two extremes, and an equilibrium will be produced, the same as results from equal weights or resistances placed in the dishes of a balance having equal arms. But where the articulation takes place nearer one extremity than the other, the descent will occur at this extremity, just as it would happen in the above-cited balance, if, without altering anything else, the arms were rendered unequal in their length. To conclude, lest the foregoing should not satisfactorily explain the phenomenon, I propose the following rationale: the head, urged on by the uterine contraction, com- municated to it by the spine, meets with resistance from the os uteri, which is not yet sufficiently dilated. Let us change, for an instant, the order of forces, making the vertebral articulation a fulcrum, and the opposition on the part of the neck the power; low, this power is evidently equal in all points of the periphery of the neck; but let us observe that, as the interval between the chin and the occipital foramen is greater than that betwixt the latter and the occiput, the resistance against the chin operates on a longer lever than that against the occiput, and consequently the first must be the more powerful of the two, and therefore it forces the chin to ascend. Biit raising the latter has the same effect as depressing the occiput: that is, still producing a flexion tf the head. MECHANICAL PHENOMENA OF LaBOR. 321 C. Third Stage, or Stage of Rotation. — The head, being arrested by the floor of the pelvis, executes a movement of rotation, during which the occi- put passes from left to right behind the symphysis pubis, or rather behind the left ischio-pubic ramus, and the bregma rotates into the concavity "f the sacrum, though remaining a little towards the right. The posterior superior part of the right parietal bone then appears plainly under the pubic arch ; the posterior fontanelle is behind the ischio-pubic ramus ; and the sagittal suture crosses the coccy-pubal diameter very obliquely. Being forced on by the energetic contractions of the womb, the vertex then depresses the soft parts of the perineum, and by gradually dis- tending them, succeeds in converting the pelvic floor into a part of a canal which prolongs the posterior wall of the pelvis downwards and backwards. It is during this time that the rotation is accomplished : that is, the sagittal suture becomes parallel with the antero-posterior diameter of the inferior strait. The occiput engages in the arch of the pubis, and projects beyond the lower part of the symphysis, until the back part of the neck comes into contact with it, when the anterior progression of the occiput is arrested. D. Fourth Stage, or Stage of Extension. — Just at the moment when the occiput engages in this manner in the pubic arch, the shoulders and upper part of the body enter the excavation, and in engaging there, the fetal trunk, which is flexible, accommodates itself to the direction of the canal, and consequently bends over a little on its posterior plane. [The head then presses upon the perineum, distending it and transforming it into a groove or gutter which conducts the occiput to the vulvar opening, so that if the patient be uncovered the accomplishment of the fourth stage may be witnessed by the observer. At each contraction the head descends and the perineum is elongated ; then, as the pain subsides the perineum contracts, at the same time pressing the head a little upward. Finally, during a fresh effort the vulva opens and the occiput 6hows itself beneath the arch of the pubis. At this moment the head is still flexed, but soon the nucha seems to fix itself behind the pubis, and the head, by executing a movement of extension, escapes completely from the vulvar orifice, bringing sue cessively into view after the occiput, the vertex, forehead, nose, mouth, and chin ; the latter, which is the last to emerge, remains applied against the posterior com- missure of the vulva and directed toward the anal region. This movement has received what seems to us a curious explanation, for, accord- ing to the commonly accepted view, the pressure transmitted by the spinal column to the head is divided at the occipital foramen into two forces, one of which is applied to the occiput, and the other to the chin. Therefore, when the occiput is engaged beneath the pubic arch, the portion of force which is transmitted to it is lost upon the point of contact between the vertebral column and the posterior part of the pubis, whilst the force directed upon the chin continuing to act depresses it, causing it to depart from the breast and thus producing the movement of extension Now, this explanation seems to us fallacious; for is it not evident that whilst the occiput is beneath the pubic arch, all the soft parts which make up the perineum press the anterior part of the head against which they are applied upward and backward, so that the movement of flexion is, at this juncture, at its utmost limit? Our own view of the disengagement of the head is as follows: The body descends into the cavity of the pelvis, whilst the head is depressing and distending the perineum, and the chin remains applied to the breast not merely until the moment when the occiput takes its place behind the pubic arch, but even until the bregma makes its appearance at the posterior commissure of the vulva. Then it is that the 21 322 LAROR. perineum acts like an elastic splint which, on the one hand, presses the head up- ward beneath the pubic arch, -whilst on the other it slips rapidly over the face which it leaves uncovered, and retracts toward the coccygeal region where it is attached The disengagement of the occiput and vertex begins only when the head is pressed downward sufficiently by the body; but at this moment the perineum, which unti' then was 1 ut passively distended, resumes its action and retracts as just stated, imparting to the whole head, whilst slipping over the face, a movement of extension which has the arch of the pubis for its centre. Therefore, it is only in this second period of the process of disengagement of the vertex, that the movement of exten- sion is truly evident. If the perineum were entirely absent, the head would disengage at the outlet of the inferior strait, without exhibiting its movement of extension. In the normal condition, however, and especially in primiparse, the perineum, converted into an elongated gutter, arrests the downward progress of the head and directs it forward as upon an inclined piano. Do we not also know that in breech cases, especially in primiparas, the pelvic extremity in emerging from the vulva is directed just as obliquely upward and forward as the lateral flexion of the body will allow? This flexion, which no one will deny to be produced by the soft parts of the perineum, is, in our opinion, suffi- cient to prove that the movement of extension in delivery by the vertex is effected only by the curvature and elasticity of the genital passages, for, if the movement of the head at this time is very extended, it should be attributed to the great mobility of the articulations which permits the occiput to rise up in front of the pubis. In breech cases the same phenomenon occurs, though the extent of motion is greatly restricted by the rigidity of the spinal column in the lumbar region.] Whatever explanation be accepted, if we observe what takes place during this movement of extension, the following points are seen successively to appear at the anterior commissure of the perineum, viz., the bi-pari- etal suture, the bregma (or fontanelle), the coronal suture, the nose, mouth, and, last of all, the chin. During this process, the sub- occipito-bregmatic, the sub-occipito-frontal, and the sub-occipito-mental diameters succes- sively pass the antero-posterior diameter of the inferior strait. As soon as the occipito- bregmatic circumference is beyond the vulva, the anterior border of the perineum, yielding to its natural elasticity, retracts strongly, slips over the face, and embraces the neck ; and just at that moment the head, which was before forcibly turned up in front of the mons veneris, falls back from its own specific weight towards the anus. E. Fifth Stage, or Stage of Exterior Rotation. (Restitution.) — The head remains for a few seconds in this position, and then it is seen to describe a nf'tli and last movement, namely, the occiput inclines towards the interna) Burface of the left thigh, and the face turns towards the right thigh. This process is usually denominated the restitution, for the following reason- Before the researches of M. Gerdy, it was generally supposed that when Fig. 77. Tim head Is seen in various degrees of extension, the nape of the neck rest- ing first behind, ami then under, the fymphysis pubis. MECHANICAL PHENOMENA OF LABOR. 323 the head executed its movemeut of rotation within the pelvis, the trunk did not participate therein, and that the operation could only take place through the aid of a certain degree of torsion in the neck ; and, further, that the head becoming completely disengaged, the neck untwisted, and the head was restored to its natural relations with the trunk. M. Gerdy was the first to demonstrate the fauliiness of this explanation; for, in fact, the trunk does participate in the head's rotation, in such a way that the shoulders, which, in the beginning of labor, corresponded to the oblique diameter, are nearly transverse after this movement (the right shoulder, nevertheless, remaining always a little more in front than the left). The shoulders then reach the inferior strait in a transverse position, presenting, therefore, their great, or bis-acromial diameter, to the smallest one of this strait; but here they encounter some resistance, under the influ- ence of which the rotation is effected in the opposite direction to that of the head; the right shoulder, passing from the right side towards the left, approaches the apex of the pubic arch, while the left one gets into the perineal concavity, and the head, being free externally, necessarily follows the movement communicated to the shoulders. The rotation of the head is not therefore an isolated movement peculiar to itself, as Baudelocque supposed* but one secondary to the rotation of the shoulders. I must remark, however, that, in some cases, the head has appeared to me to execute a double movement ; for, immediately after its expulsion, it turns very slightly ; the occiput passing a little to the left, the forehead towards the right ; after remaining some seconds in this position, it then undergoes the secondary movement just described, which is due to the rota- tion of the shoulders. The first of these movements has already seemed to me to result from the untwisting of the neck, and is the true movement of restitution of Baudelocque. F. Sixth Stage, or Stage of Expulsion of the Body. — The shoulders present at the inferior strait soon after the head, and, as we have just stated, nearlv always in a transverse position. The right one gets under the right ischio- pubic ramus, while the left one lies in front of the left sacro-sciatic lio-a- ment. The bis-acromial diameter is rarely found in the direction of the antero-posterior diameter of the inferior strait. The anterior or sub-pubic shoulder is the first to appear in the vulvar Assure ; although, as a general rule, the posterior one, after having traversed the perineal curve, is first disengaged at the anterior commissure of the perineum, and the right one is subsequently delivered. 1 1 Contrary to the generally received opinion, M. P. Dubois supposes that the anterior shoulder is the first delivered. That is certainly true in a great number of cases, but we have most usually observed the opposite fact; besides, there is a theoretical view which militates in favor of our opinion, that is, the left shoulder, being placed in con- tact with the posterior plane of the excavation, is situated, much more than the ante- rior one, in the direction of the uterine axis, or the axis of the superior strait, and therefore being subjected to a more energetic uterine impulse, consequently must be delivered first; further, it was necessary this should be so, as the posterior shoulder has much the longer course to traverse. Again, if I might refer to my own observa tions. I would say that in women who have before borne children, more especially ir 824 LABOR. During the disengagement of the shoulders, the fottus bt corals Hexed on its right lateral region so as to accommodate itself to the curvature in the pelvic canal ; and very soon after the remainder of the trunk is expelled, sometimes describing a very prolonged spiral course in its passage. 2. Mechanism of Natural Labor in the right Posterior Occipito-iliac Posi- tion. (The fourth of Baudelocque, and the third of M. Capuron.) In the vast majority of cases, the mechanism of labor in this position scarcelv differs from that just described, and therefore we only need allude here to the principal peculiar phenomena of the travail, without repeating all the preceding details. It, likewise, is composed of five periods, or stages ; before the membranes are ruptured, the diameters of the head correspond with the same diameters of the pelvis, as in the foregoing case, and the only difference to be re- marked is, that the occiput corresponds to the right sacro-iliac symphysis, and the forehead to the left ilio-pectineal eminence. The child's posterior plane looks backwards and towards the mother's right, while its anterior plane is in front and to her left ; its left side is placed in front and on the right, its right side behind and to the mother's left. A. First Stage, or Stage of Flexion. — The head is flexed by the same forces as in the preceding case, and this flexion determines similar changes in the relations of its diameters with those of the pelvis. B. Second Stage, or Stage of Descent. — This stage presents nothing worthy of particular notice. C. Third Stage, or Stage of Rotation. — The head having reached the floor of the pelvis, undergoes a movement of rotation, in consequence of which the occiput traverses the whole right lateral moiety from behind forwards, in such a way that it passes successively towards the right extremity of the transverse diameter, behind the cotyloid cavity and under the right ischio- pubic ramus, while the forehead, or bregma, revolving in an inverse direc- tion, goes from before backwards towards the hollow of the sacrum ; and thus, the position which was originally occipito-posterior, becomes converted into an occipito-pubic, or anterior one, and the labor then terminates just as it does in those cases where the occiput was primitively in front. [d. Fourth Stage, or Stage of Disengagement. — This presents nothing peculiar. e. Fifth Stage, or Stage of Restitution. — The movement in this case is entirely analogous to that already described in connection with the left anterior occipito- iliac position, and is due to the same causes. It is the left shoulder, however, which gets behind the arch of the pubis, and the occiput is directed toward the right thigh. F. Sixth Stage, or Stage of Expulsion of the Body. — This takes place under the e inditions already described.] Irregularities in the Disengagement. — In some instances, which are rare, however, this conversion does not take place, and the occiput remains be- hind until the termination of the labor. The delivery is then concluded in the following manner: the head is strongly flexed on the chest, and re- those who have suffered from rupture of the perineum in former labors, the posterior Bhjulder is the first delivered; and, on the contrary, in primiparse, the sub-pubic one hid the precedence, the other btxng retained by the resistance from the soft partp. Plate V Fi§3. <"...J5v„.^ iS&s*" PLATE V. Fig. i. Section of the Frozen Body of a Woman in labor during the period of Expulsion. a. Aorta, d. Duodenum. F. Bag of Waters. M. Stomach. L. Liver. H. Bladder. Pa. Pancreas. n. Urethra, r. Rectum. v. p. Vena portae. PL Placenta, o. e. o. e. External Os Uteri, o. i. o. i. Internal Os Uteri. Fig. 2. Relations of the Muscular Floor of the Pelvis to the Last Stage of Labor. /. Upper Margin of the Vaginal Ring. 2. Ischio-perineal Ligament and Superficial transverse Muscle. P. Perineal body. A. Anus, flattened and carried back towards the Coccyx. Fig. 3. Engagement of the Head. u. Urethra. a. Anus. //. Bladder. 2 k. Second Sacral Vertebra r. Rectum. Fig. 4. Commencing Expulsion of the Head. MECHANICAL PHENOMENA OF LABOR. 325 tains its oblique position ; the forehead, corresponding to the body of the left pubis, first reaches the inferior strait, and the left coronal boss then engages under the pubic arch, where we can sometimes distinguish the superciliary ridge just below the symphysis; and I even saw the upper eye- lid in one case. But though the forehead first Fia 78# appears at the exterior, the occiput, urged on by the spine, which transmits the force of the uterine contraction, traverses the whole curvature of the perineum (which is greatly distended in such instances), and becomes disengaged the first at the anterior commissure. While the occiput is thus passing over the anterior surface of the sa- crum and perineum, the coronal boss and eye- brow, that originally appeared at the vulva, reascend and become concealed behind the sym- physis. The occiput is scarcely clear, when the peri- neum by gliding Over the inclined plane formed Disengagement of the head in the , , „ ,, , i-i occipito-posterior positions. by the nape or the neck, retracts strongly, and thus facilitates the subsequent delivery of the anterior portions of the head ; therefore, the head may be observed to undergo the process of extension around the nape as a centre, and to appear below the symphysis in the fol- lowing order : namely, the anterior fontanelle, the coronal suture, the fore- head, nose, mouth, and chin. Lastly, the head, placed in the right posterior occipito-iliac position, may, when once down in the excavation, depart from the chest, and the vertex presentation be thus spontaneously converted into one of the face, at the inferior strait ; Ave witnessed a case of this kind at the Clinique in 1838. This transmutation takes place, says M. Guillemot, in the following manner : the occiput being arrested by some point on the posterior part of the excavation, instead of advancing along the perineum towards the inferior strait, ascends in the curvature of the sacrum by executing the movement of rotation backwards, and being at the same time thrown back upon the posterior part of the chest. While this is going on, the forehead and face descend behind the pubis and pass downwards and backwards, until the chin engages under the arch, and then the head, which is completely turned back, traverses the perineal strait, as in a face presentation. The disposition which the inclined plane of the cervix uteri impresses on the vertex in this position, continues M. Guillemot, is a, frequent cause of a similar transmutation above the abdominal strait. The slight backward inclination of the head, which always exists in these positions, may correct itself when the uterine contractions, by acting on the foetus, keep the chin applied to the neck ; but, on the other hand, the reversion may be carried still further, or be entirely completed, if any obstacle impedes the descent of the occiput into the excavation ; finally, in cases of uterine obliquity, where the inclination of the vertex is greater, the backward tendency, instead of disappearing, would be increased, and the occiput would then ascend and ihe forehead descend. 326 LABOR. Like the author quoted, I admit the fact, though I think it rare; but 1 cannot acknowledge, like him, the truth of the following proposition, i. e. that if the conditions of transmutation which then exist may he appreciated by a comparison of the face labors with those of the occipito-posterior posi- tions, we should not depart far from the truth (I believe it would be a wide departure*) by announcing that, in every three occipito-posterior positions, one of them would give rise to a face presentation. Lastly, whatever may be the mode of the delivery of the head in the right posterior occipito-iliac position, the occiput always inclines towards the internal surface of the right thigh, and the face is directed to the left one ; this external movement (restitution) results from the internal rotation of the shoulders, in consequence of which the left shoulder, which was originally the anterior, gets under the arch of the pubis, and the right one into the hollow of the sacrum, and then the shoulders and the remaining part of the trunk are expelled in the manner already stated. Observations relative to the Mechanism of Delivery in Vertex Presentation . — The great care we have taken in describing the natural labor in these two varieties of the two fundamental positions, will absolve us from repeating it anew in the other varieties. In fact, the left transverse occipito-iliac position does not differ from the anterior one ; unless, perhaps, the movement of rotation, which brings the occiput in front, is somewhat more extended ; and what we have stated con- cerning the two modes of termination in the right posterior occipito-iliac position applies equally well to the left posterior one; but we must add that the movements of rotation will then take place from left to right, since the occiput is primitively turned towards the left side. Lastly, in the other two varieties, the right anterior and the right trans- verse occipito-iliac ones, the mechanism is still the same as in the corre- sponding varieties of the left occipito-lateral position, the occiput, however, turning from right to left so that the rotation occurs toward the right thigh. From the foregoing, the reader will see that, in order to study the mechanism of labor in the vertex positions, we have been obliged to con- sider each of the periods, or stages, composing it separately. Thus, we first examined the movement of flexion, then of descent, next the internal rota- tion, the extension, and the external rotation ; but it must not be supposed that these different movements occur successively, one after the other, in the order just described. 1. The forced flexion spoken of as happening before the descent, frequently only takes place simultaneously with the latter. Often, indeed, the head is not* flexed until the descent is completed, and it encounters the resistance from the floor of the pelvis ; and then only, in the majority of cases, is the flexion carried to its highest degree. We can imagine that this would nearly always be the case, since the head is engaged in the excavation in most women long before the commencement of labor; and even in those cases where it is still above the superior strait at the time of the membranes being ruptured, the presenting diameters will allow it to traverse the upper oart of the excavation without meeting any marked resistance. The movement of flexion likewise presents some irregularities : for instance. MECHANICAL PHENOMENA OF LABOR. 327 it is not at all unusual, more especially in the occipito-posterior positions, lor the chin, instead of approaching the chest, to depart from it ; and, con- sequently, for the head to become more extended, and the anterior fonta- nels gradually so get towards the centre of the excavation. However, this anomaly is usually temporary, for the head is flexed anew when it reaches the pelvic floor. . In some rare cases, the opposite of the preceding, the posterior fontanel le occupies the centre of the excavation, either because the flexion has gone beyond its usual limits, or else, because the trunk is inclined backwards ; but here, also, the resistance from the perineum gradually brings back the head to its regular situation. (P. Dubois.) 2. The rotation sometimes commences prior to the arrival of the head at the inferior strait, and before the descent is completed. So that, in such cases, the three first stages of the labor occur at the same time ; thus the head is flexed, descends, and rotates all at once. Some curious varieties of rotation are occasionally met with, which should be known to the student. For instance, it may be incomplete, the head still retaining a great obliquity pending the whole duration of its disengage- ment ; or it may not take place at all, which happens, as we have already seen in certain occipito-posterior positions, or it may also occur in the transverse ones. In this latter variety, which is the rarest of all, the occiput and the forehead disengage alongside of the internal surface of the ischiatic tuberosities ; the occiput escapes first, and then the forehead by a movement of extension analogous to the ordinary mechanism. Madame Lachapelle reports having observed three cases of this kind. In some exceptional instances, the rotation exceeds the ordinary limits : thus, for example, if the occiput is placed in relation with the right sacro-iliac symphysis at the beginning of the labor, it may successively correspond with the right extre- mity of the transverse diameter, the posterior face of the right acetabulum, the symphysis pubis, and the left cotyloid cavity; and then, after a moment of repose, it retrogrades and places itself once more behind the symphysis. M. P. Dubois originally pointed out this fact, and I have twice since had an opportunity of verifying its truth. Again, the rotation, by which the occiput is brought in front, sometimes only'takes place just as the head is overcoming the final resistances from the soft parts; on one occasion, I observed and pointed out this fact, in a primiparous woman, to all the students then present at the Clinique ; the child's head was in the right posterior occipito-iliac position, and it had descended to the pelvic floor and had cleared the interior strait without rotation taking place ; the perineum was forcibly distended, the vulva widely dilated, the parietal protuberances were engaged, and the occiput had but a few lines to pass over in order to escape at the anterior perineal commis- sure ; when, under the influence of a new pain, the head rotated briskly, the o'eciput gained the front, the forehead simultaneously rolling into the perineal concavitv, and the labor terminated almost immediately. The rotation within the excavation is certainly one of the most curious movements executed by the fetal head during the whole process of a natural labor- indeed, from what we have hitherto stated, it must be evident that. 328 LABOR. whatever be the primitive relations of the occiput with the various points of the circumference of the superior strait, it finally succeeds in getting under the symphysis pubis. 1 Now, the physical cause of this movemeiit is nowhere given in the writings that have been published on the subject prior to M. P. Dubois, who has paid particular attention to this point, and who, after refuting the influence of the inclined planes, advanced by the older accoucheurs, as the cause of the movement, adds, "This cause evidently resides in the combination of a great number of elements, viz., on one hand, the size, form, and mobility of the parts which are expelled, and, on the other, the capacity, the shape, and the resistance of the canal traversed by them ; and such is the influence of this association, that the foetal parts place themselves in the most favorable conditions for delivery ; thus, if an active resistance is made to them at one point, they withdraw from that, and seek another where there is more space and liberty. The mobility of the traversing parts, and the extreme lubricity of those which are traversed, render all this very simple and intelligible. In fact, every accoucheur must have remarked that, in those instances where the sacro-pubic diameter is contracted, the foetal head, if oblique before the labor, constantly places itself then in a transverse direction, that is, in the one offering the least possible dimension to the shortened diameter; and this fact is nothing else than a very simple effect of those same causes, of which the rotation, when extensive, is a very complicated consequence." (Journal des Connaissance? Medico- Ch irurgicales.) M. P. Dubois further relates the following experiment in support of his explanation of the process of rotation : " The flaccid and voluminous uterus of a woman, who died soon after delivery, was freely opened near the os uteri, and her foetus was placed in it near the soft, gaping orifice, in the right posterior occipito-iliac position of the vertex ; then several midwife students, by pushing the child from above downwards, caused it to enter the excavation without difficulty ; but it required a much greater effort to make the head traverse the perineum and clear the vulva ; and it was not without some surprise that we noticed, in three different trials, that, as soon as the head passed the external genital parts, the occiput was in front and to the right, while the face turned backwards and to the left. Again, we repeated the experiment a fourth time ; but now the head passed the vulva, with the occiput remaining posteriorly. We then took a still-born child, delivered the preceding day, which was much larger than the other, and placed it in the same conditions as the first, and on two successive trials the head cleared the vulva after having performed the rotation ; on the third «ind succeeding essays it was disengaged without executing this movement : that is, the process of rotation continued until the perineum and vulva had 1 M. Naegele has only known the occiput to disengage posteriorly seventeen times »ut of twelve hundred and forty-four occipito-posterior positions; and even in those ca°es it was always possible to appreciate the exceptional circumstances that had favored this irregularity: such as, an amplitude of the pelvis, or numerous former labors, lacerations of the perineum, or the softness, flexibility, rednaibility, and want of consistence of the head, or an extreme smalluess of the child, the presence of •wins, 4c, l. Cti~r. Fourth Stage. Disengagement of the Breech. — As the right buttock approaches the posterior commissure of the labia externa, and engages in FlO. 83. Fig. 8-1 The same position after the internal rotation is accomplished. The delivery of the breech. this opening, the breech, or rather the bis-iliac line of the foetus, which had already cleared the lower strait in a somewhat diagonal position, now assumes an exactly antero-posterior direction, so as to correspond with that of the longitudinal diameter of the vulva. However, this is not constant, as the breech sometimes retains its diagonal position throughout ; the thighs closely applied on the belly already begin to appear, and, pending the dis- engagement, the fetal trunk, by accommodating itself, as above stated, to the direction of the pelvic axis, is strongly flexed on its anterior (left) side. The rotation executed by the hips, when they reach the inferior strait, may either be a partial movement, or else one in which the whole trunk partici- pates. In the former case, it can only take place by the aid of a certain degree of torsion in the lumbar vertebral column, and then the pelvis, immediately after its delivery, undergoes the process of restitution, whereby it once more regains its primitive diagonal position. As soon as the hips are clear, the breast engages in the excavation, the arms always remaining applied against the anterior lateral parts of the thorax, and the shoulders soon arrive at the inferior strait in an oblique position, supposing they have not previously participated in the rotation performed by the pelvis of the child. The shoulders observe the same mechanism in disengaging as the hips ; that is, they turn in such a manner as to place the anterior one, here the left, behind the right ischio-pubic ramus, and the posterior one just in advance of the left sacro-sciatic ligament, whence they both clear this strait diagonally ; but when this is passed, and there is no other resistance than that of the soft parts to overcome, they complete the rotation and 23 354 LABOR. become placed, the oue directly in front, the other behind. As to the other parts, the sub-pubic shoulder and elbow are the first to a t pear exter- nally ; but it is still the posterior ones that are first delivered. 1 Prof. Dubois contends that, in breech deliveries, the anterior hip and the front shoulder, in the disengagement of the upper part of the trunk, are expelled before the corresponding part in the rear; but I may be permitted to repeat again, that, although matters often do occur in the way described by the professor, still it has seemed to me that the view above given holds true in the majority of cases. E. Fifth Stage. Rotation of the Head.— Whilst the shoulders are travers- ing the pelvis in the manner just indicated, the head, being flexed on the breast, clears the upper strait in the direction of its left oblique diameter: that is, the forehead is turned towards the right sacro-iliac symphysis, and it retains that position until it reaches the inferior strait. The diameters of the head, which are then found in relation with those of the inferior strait, will necessarily vary according to the greater or less degree of the flexion of the head. For instance, when it is only moderately flexed, which is generally the case, the occipito-frontal diameter corresponds to the left oblique one, the bi-parietal to the right oblique, and the axis of the inferior strait traverses the head very nearly in the direction of its trachelo-bregmatic diameter. If we suppose the head to be more strongly flexed on the chest, the sub-occipito-bregmatic diameter takes the place of the occipito-frontal, and Delivery by the breech. Disengagement of the head with the chin behind. tne occipito-mental corresponds very nearly to the axis of the inferior strait. In a word, we find the same relations as in a vertex presentation, only the head presents by its base instead of its summit. It then performs a movement of rotation, whereby the face is carried into the hollow of the sacrum, while the occiput gets behind, and the neck under the symphysis pubis ; whence the sub-occipito-bregmatic diameter approaches the antero-posterior one very closely, still retaining, however, a certain obliquity. P. Sixth Stage. Expulsion of the Head. — At that time, the womb can act but very feebly on the head (see Prognosis), which is altogether down in the vagina, or nearly so ; but the tenesmus, says Velpeau, occasioned by its pres- 1 Many books, on the subject of shoulder-delivery, assert that the arms are retained tjy the ^nrders of the excavation, and thereby get up alongside of the head; though, MECHANICAL PHENOMENA OF LABOR. 355 sure oq the rectum and the bladder, constrains the woman to collect all her powers, and to redouble her courage, and then the contractions of the abdo- minal muscles soon come to the aid of the powerless womb ; these forces, acting conjointly, flex the head more and more, and whilst this process of flexion is going on around the neck or the sub-occipital region as a centre, the chin, the forehead, the bregma, and occiput will be found to appeal successively in front of the anterior commissure of the perineum. During the flexion, the head represents a lever of the first kind, whose power is at the occiput, the fulcrum at the sub-occipital point, or that por- tion of the neck situated under the arch, and the resistance at the chin, or rather at the forehead, which, being arrested by the perineum, must distend the latter and render it thinner. Hence, if radii be drawn from the sub- occipital point of the head, situated beneath the symphysis, as a centre, and terminating at the median line of the face and vault of the cranium, those radii will exactly represent the diameters which successively clear the antero-posterior one of the inferior strait ; the principal of which are the sub-occipito-mental, the sub-occipito-frontal, and the sub-occipito-bregmatic. 2. Mechanism of Natural Labor in the Might Posterior Sacro-iliac Position. (Fourth of Baudelocque and third of Capuron.) — In this position, the child's sacrum is turned towards the right sacro-iliac symphysis, its back is behind and to the mother's right, and its anterior plane is to the left, in front ; the right side looks forward and to the mother's right, while the left side is behind and towards her left ; and the great or bis-iliac diameter of the child's pelvis corresponds to the right oblique diameter. [Here also the mechanism of the labor may be divided into six stages analogous to those just described for the left sacro-iliac position, — to which the reader is referred in order to avoid repetition.] Let us suppose, when the membranes are ruptured, that the lower extremi- ties, swept along by the gush of liquid, are completely unfolded, and that the feet present first at the vulva. In this case, the limbs are soon delivered, under the influence of the uterine contractions, without offering any pecu- liarity, and the hips easily reach the inferior strait, where they engage, sometimes preserving their primitive diagonal position, while at others the anterior one gets slightly in advance towards the symphysis pubis, and the other or posterior goes behind to the median line of the sacrum. The arms and shoulders present in turn, and their disengagement is nearly the same as in the preceding case. After the delivery of the shoulders, the head alone remains in the exca- vation, and its expulsion may take place in several different ways ; some- times, indeed, the occiput remains posteriorly throughout the whole delivery, as Desormeaux very justly remarked, this scarcely ever happens when the delivery is left entirely to nature, and no traction whatever is made on the pelvic extremity; consequently, when the labor progresses regularly, the accoucheur should overcome the temptation to aid nature a little by drawing on the parts, for such imprudent traction must certainly straighten out the arms, since there is no counteracting power in these cases to press them outwardly ; for, being retained by the friction, they remain above the excavation, and the head descends between them, rather than that ihey mount up on its lateral parts: and fortunate indeed will it be if extension of th* 'head is n )t produced by these tractions! 356 LABOR. though at others, and indeed in the great majority of cases, it comes round in front so as to place itself behind the symphysis pubis. A. TJie Occiput comes in Front. — This conversion may begin as soon aa the hips have cleared the inferior strait ; thus it often happens, as before stated, that the whole foetal trunk participates in the rotation of the haunches, whence the posterior plane of the child, which was primitively situated behind, is brought in front by describing a kind of a spiral, that commences in the hips and terminates at the occiput. The head also has participated in the rotation of the trunk, so that, when the former descends into the excavation, the occiput becomes placed behind the symphysis pubis. But when the occiput retains its posterior position, after the delivery of the trunk, this rotation of the head may even take place in the pelvis or at the inferior strait. In such cases, after the shoulders are born, the back of the child resumes its posterior direction by a sort of restitution, and the head, remaining alone in the excavation, becomes placed in the direction of the left oblique diameter, the occiput being behind and to the right, and the forehead or bregma towards the mother's left, in front. It then per- forms a movement of rotation, by which the occiput, after having traversed the whole right lateral half from behind forwards, locates itself behind the Fia. 86. Delivery by the breech; disengagement of the head. The chin sliding beneath the pubis, the occiput remaining behind. symphysis, and the forehead, by rolling from front to rear, is carried into the hollow of the sacrum Though, whatever may have been the mode by which this mutation is effected, the labor terminates, just as in the pre- ceding case, as soon as the occiput gets behind the pubic symphysis. B. The Occiput remains behind. — When the occiput remains behind until the end of labor, the delivery of the head may take place in two ways : thus, in the majority of cases, this part engages in the excavation in a state of flexion, where it soon undergoes a very slight movement of rotation, which carries the occiput towards the concavity of the sacrum, and the forehead or bregma behind the symphysis pubis; then, as the uterine contractions and the abdominal muscles force the head to become more and more flexed. MECHANICAL PHENOMENA OF LABOR. 357 the following parts are found to appear in succession below the symphysis and through the vulva ; first the whole face, then the forehead, the bregma, the vertex, and last of all the occiput. The head is therefore delivered by a process of flexion, having the neck, as a centre, resting against the anterior commissure of the perineum. (Fig. 86.) Finally, it may happen that, instead of remaining applied on the fhest the chin is arrested, and continues above the pubis, while the occiput is carried more and more backwards by a well-marked movement of exten- FlQ - S7 - sicn. The head engages in the strait by its occipital extremity, which then traverses the whole posterior part of the excavation by a see-saw move- ment, and is born first at the perineal commissure ; after it come, succes- sively, the vertex, the anterior fon- tanelle, the forehead, and the entire face. Consequently, the head disen- gages by a process of extension, hav- ing the prsetracheloid region as a centre, which is placed at first behind, and then under the symphysis pubis. Cases of this kind are reported by Leroux, Michaelis, and Asdrubali, but they are very rare (Fig. 87). — The mechanisvi of labor in the left transverse, and in the right anterior, and right transverse sacro-iliac posi- tions, is analogous to that just de- scribed for the left anterior, and of the right posterior iliac position. [We would observe, however, that the left hip, which in all left sacro-iliac posi- tions ought to appear under the arch of the pubis, turns from right to left in the left anterior sacro-iliac position, and from left to right in the left posterior sacro- iliac-position. The right hip will, in like manner, be found to disengage the first in the right sacro-iliac-position, by turning from left to right in the anterior variety and from right to left in the posterior one.] § 4. Prognosis. Breech presentations are not, usually, much more dangerous than those of the head ; still, in order to arrive at an intelligent prognosis, the labor should be studied in reference to its effect upon the mother and upon the child respectively. Though, from the manner of its expulsion alone, the life of the child is seriously endangered, the parturition is certainly less exhausting and less painful for the mother. 1. As regards the Mother. — As a whole, the labor is somewhat longer in breech presentations; though, fortunately, the delay is experienced almost exclusively during the first stage, and is the cause of but little additional suffering to the mother. The slowness of the process of dilatation is readily explained by the conditions which have been already pointed out. Before Delivery by the breech ; the occiput behind, and disengaging at the posterior commissure of th« vulva, whilst the chin remains behind the pubis. 358 LABOR. the membranes are ruptured, the presenting part, having neither the firm, roundness, nor regularity of the top of the head, cannot adapt itself to the regular concavity of the inferior segment of the uterus, and being separated from the neck by a considerable amount of amniotic fluid, is therefore in- capable of hastening its dilatation. Should the membranes happen to rup- ture long before the dilatation is completed, the size or irregularity of the breech prevents its engaging readily, and the neck, not being supported as it is by the top of the head in vertex presentations, collapses, and contracts, so to speak, the opening which it had just before presented. In cephalic presentations, on the contrary, the head engages like a wedge, and each expulsive effort tends to increase the dilatation. When the nick is once thoroughly dilated, the expulsion has always seemed to me to be effected more rapidly than in vertex presentations. The breech, the trunk, and the shoulders are generally delivered with ease, but the head sometimes meets with obstruction, and may be arrested at the superior strait. Generally, however, it is detained for but a short time; for if the efforts of the female are not capable of expelling it, it becomes the duty of the accoucheur to interfere promptly, in order to remove the child from the danger which threatens it. The course to be pursued under these circumstances, exposes the mother to no danger whatever, the entire risk falling upon the foetus. As regards the mother, therefore, the breech presentation is perhaps even more favorable than that of the vertex; I would add, that it is certainly more so for her than a face presentation. It is important to observe, that all the varieties of breech presentation are not equally favorable. Some authors think that the labor is usually longer when the foetus presents by the breech than when the feet are the first to descend into the excavation. The size of the parts that constitute the pelvic extremity, it has been said, do not permit it to engage so readily ; and hence, the uterine contrac- tions must operate a longer time in order to adapt those parts to the diame- ter of the pelvis. This is true ; but, as Madame Lachapelle has observed, their softness is such that, when once engaged, they easily conform to the passage ; and besides, as M. P. Dubois declares, the greater their volume is, the more will the labor resemble that of the vertex presentations. Con- sequently, the professor teaches, contrary to the opinion generally adopted, that a delivery by the breech is far preferable to that in which the feet come down first : the truth of which proposition will be better understood when we shall have pointed out the inconveniences attending this latter cir- cumstance. A.- the footling presentation does not exhibit the same unfavorable ap- pearances in respect to volume, it is preferred by some persons ; for then the foetus, presenting by its smallest extremity, will, in their estimation, be more easily expelled, since the dilatation of the parts, from being slow and gradual, will be much shorter and less painful. If you wish, they say, to drive a cork into the neck of a bottle, you would present its smallest ex- tremity, and then it would enter more readily, and the same is true of the child in the foot presentations; for the foetal ovoid may be considered as a cone, whose base is at the cephalic, and whose summit is at the pelvic ex- MECHANICAL PHENOMENA OF LABOR. 359 tremity. In the case of the bottle this is true, but only so, because the efforts you use to make it penetrate, will be redoubled as the larger extrem- ity approaches the neck of the bottle ; that is, the force will increase with the difficulties to be overcome ; but this last condition does not hold good in the delivery by the feet. Because, as the inferior parts of the child be- come successively disengaged, there is less left remaining in the uterine cavity, and there is even a period when the head, having reached the exca- vation, is almost entirely out of the cavity of the cervix; but the uterus, during its evacuation, retracts, and, like all contractile muscles, loses a great portion of its power by this retraction ; and it is therefore just at the mo- ment when the great extremity of the cone, represented by the foetus, has to overcome the resistance of the soft parts, that the uterine contractions are the most enfeebled, and often, indeed, they cannot aid at all in the ex- pulsion of the foetal head : consequently, the powers here diminish in an inverse ratio to the obstacles in the delivery. If the reader now recalls what takes place in vertex presentations, he will readily comprehend the difference between the two ; no doubt, the largest part of the child then presents the first, and its expulsion requires violent and long-continued efforts ; but remark that, up to the moment when the head clears the vulva, the uterus yet contains in its cavity a considerable quantity of amniotic liquid, and also the largest part of the fcetal trunk ; wherefore, it is still sufficiently distended not to have lost its power of contracting, a power that can be exercised over a large surface, and upon which it is forcibly applied until the end of labor. Again, the head having once reached the exterior, the parts which have been freely dilated by its passage offer but a feeble resist- ance to the expulsion of the trunk and lower extremities ; and hence, the retraction of the womb may diminish its expulsive forces without this diminu- tion having any unfavorable influence over the termination of the labor. 2. As regards the Child. — The delivery by the pelvic extremity is very dangerous to the child ; thus, the statistical results furnished by Madame Lachapelle prove that, in eight hundred and four presentations of this class, one hundred and two children are born feeble, and one hundred and fifteen are still-born: the proportion of deaths to the whole being rather more than one-seventh ; whilst, in twenty-six thousand six hundred and ninety-eight vertex positions, there were only six hundred and sixty-eight still-born children, which gives one in thirty, or about one-thirtieth. As to the particular prognosis in each of the three varieties of this presenta- tion, it has been remarked that, when the buttocks advance first, the num- ber of deaths is about one in eight and a half, or a little less than an eighth; for footling presentations, one in six and a half, rather less than one-sixth ; and for the knees, one in four and a half, or not quite one-fourth. But M. P. Dubois has justly remarked that this proportion is not perfectly correct, since all the children born by the pelvic extremity are included in the registers of the Maternity, without making any allowance for circum- stances foreign to the position, but which nevertheless may have produced the child's death. Therefore, by laying aside all the cases where the chil- dren seemed to have been lost under the influence of causes that evidently did not attach to the presentation itself, he has arrived at the conclusion that, in delivery by the pelvic extremity, about one child in eleven dies; 360 LABOR. whilst in vertex presentations, only one in every fifty proved fatal. The difference still, as here shown, is frightful. Other things being equal, the labor is much more dangerous for the foetus in primiparae, than in those who have previously borne children ; because the resistance of the perineum which is sometimes sufficient in the former to arrest the labor, even in vertex' presentations, has here a still greater tendency to arrest the head, the uterine contractions, as just demonstrated, being weaker. But what is the cause of the child's death? For a long time it was sup- posed that, when the foetus presented its smallest extremity, each part, as it came down, being more voluminous than the one which preceded it, had to overcome new resistances ; that it underwent, in consequence, a certain amount of compression, and this compression, being exercised from below upwards, would necessarily drive back the fluids, and thus give rise to a cerebral congestion, the anatomical signs of which are detected at the autopsy of the little corpse. But this supposed pressing back of the fluids is altogether inadmissible : 1st. Because the uterine neck is alternately in a state of relaxation and constriction, whilst such an explanation would require it to be permanently contracted ; 2d. Because, however great the contraction, it would not be sufficient to compress the large vessels situated deep in the extremities, and in the centre of the great cavities ; 3d. Besides, by recalling what takes place in the vertex and face presentations, we shall see that it is not in the parts which are still contained in, and compressed by, the uterine cavity, that a more considerable afflux of fluid would be likely to occur, but rather in those which, from being already free, are thereby relieved from all further compression. AVe think this mortal con- gestion can be explained in a much more satisfactory manner by a com- pression of the cord ; for, after the breech is disengaged, the cord is stretched from the umbilicus to its placental insertion, and is placed, both in the excavation and uterine cavity, between the pelvic wall and the trunk, or even, a little later, betwixt this wall and the child's head. Hence, we can easily understand how liable it is to be compressed ; and as the delivery of the upper parts, and more especially of the head, often takes place with difficulty, how this pressure may exist for a long time, and thus necessarily interrupt the circulation in the cord. Indeed, it is now generally admitted that the placenta is the seat of the child's respiration ; or, rather, that the blood of the foetus comes there directly into contact with that of the mother, whereby it experiences certain modifications closely analogous to those which the blood of the adult undergoes in the lungs, by its contact with the atmo- spheric air ; the circulation being interrupted in the cord, the foetus then finds itself in the condition of an adult deprived of respirable air, and it dies asphyxiated ; now it is well known that cerebral congestion is one of the most constant anatomical phenomena of this state. 1 I am of the opinion 1 Most of the older writers have explained the child's death somewhat differently, in these cases; thus, according to some, the pressure interrupts the circulation in the umbilical arteries, but leaves the calibre of the vein entirely free, whence the foetus continues to receive blood through the latter, without being able to send it back again by the former; and it then dies from a superabundance of this fluid, from apoplexy. Others, on the contrary, supposed that the stricture acted more particularly upon the vein, leaving the arteries free, and therefore that the infant died of anaemia or syncope MECHANICAL PHENOMENA OF LABOR. 361 that asphyxia of the foetus might take place in still another mannei, and yet without the cord being necessarily compressed. It was stated above, that, when the head gets down into the excavation, no portion of the child is left in the uterine cavity, and the empty womb then retracts of its own accord ; which retraction determines, as is well known, the separation of the placenta, whereby the utero-placental vessels are inevitably torn, and the foetus placed in the same condition as if the cord was compressed, and, should the expulsion of the head be at all delayed, it might die asphyxiated. It is not necessary, however, that the placenta should be separated in order to produce this effect ; for, as Van-Huevel remarks, if the head be retained for some time in the cavity of the pelvis, the retraction of the womb would of itself obstruct, or even stop the utero-placental circulation, and destroy the foetus by asphyxia. ARTICLE V. PRESENTATION OF THE TRUNK. At the commencement of this chapter, we gave the reasons that induced us, like Madame Lachapelle, Nsegele, and Dubois, to admit but two pre- sentations for the trunk, and therefore shall not now repeat them ; for, doubtless, the reader will bear in mind that all the varieties of the trunk presentations may be referred to the two following, namely, one of the right and one of the left lateral plane. When the former presents at the superior strait, the child's head, which, in these cases, is taken as the point of recognition, may be found placed over some portion of the left lateral half of the pelvis, and this constitutes the first position of the right lateral plane (or of the right shoulder, Lacha- pelle) ; or, the head may be situated over some point of the right lateral half, and this is the second position. We have, therefore, two positions of the right shoulder, or right lateral plane ; and, in the same way, there are two for the left shoulder, or left lateral plane ; in the one, the head is to the mother's left (the left cephalo-iliac), and in the other it is at her right (the right cephalo-iliac). It is a very common circumstance in trunk presentations, to find the arm and hand hanging down in the vagina, or even the latter appearing at the vulva. This, although regarded for a long while as a much more serious affair than a proper shoulder presentation, should be considered as very nearly similar in its character to the deflexion of the lower extremities in certain cases of pelvic presentation; the older accoucheurs have therefore erred in describing it as a distinct variety, under the title of the presenta- tion of the arm and hand, it being merely an additional phenomenon asso- ciated with the presentation of the child's lateral region, and scarcely deserving consideration as a variety of these positions ; we shall see, further on, wherein they were mistaken on this point of doctrine. Neither of these theories will bear the slightest examination, since it is all-sufficient lo examine the cord, and the intertwining of its vessels, to be convinced that this partial compression cannot exist, except under peculiar circumstances ; that such pressure must interrupt the circulation, both in the arteries and veins, and that it neither aug- ments oor diminishes the quantity of the child's blood. Death by asphyxia, therefore, is the only possible mode. 862 LABOR. The tr ink presentations are comparatively rare, being a little less so, how- ever, than those of the face ; thus, Madame Lachapelle met with sixty-eight cases in fifteen thousand six hundred and-fifty two labors, or one in about two hundred and thirty ; and, in the two thousand two hundred deliveries reported by M. P. Dubois, there were thirteen trunk presentations. Dr, Bland observed it in the proportion of one to two hundred and ten ; Dr. Joseph Clark, one in two hundred and twelve ; Merriman, one in two hun- dred and fifty-five, in his private practice ; M. Nsegele, one in one hundred and eighty ; and Dr. Collins, one in four hundred and sixteen. As to the relative frequency of the presentations and positions, it would appear, from the statistical tables of Madame Lachapelle, that the right shoulder, or the right lateral plane, presents a little more frequently than the left ; and that the dorso-anterior positions, that is, the first one of the right shoulder, and the second of the left, in which the back corresponds to the anterior part of the uterus, are more frequent than the dorso-posterior positions, or the first one of the left and the second one of the right shoulder, where the child's back is directed towards the mother's loins. (Nsegele.) § 1. Causes. We have but little to say concerning the cause of trunk presentations, excepting that the smallness and mobility of the child, a rounded form of the uterus produced by a large amount of amniotic fluid, obliquity of the womb, or of the straits of the pelvis, and distortions of the superior strait, are generally regarded as predisposing thereto. We can readily understand that, in the latter case, the contraction of the pelvic entrance might render the engagement of the head impossible, and by causing it to glide toward one of the iliac fossae, favor a presentation of the shoulder. The insertion of the placenta upon the neck of the uterus, also, seems to predispose to presentations of the trunk, inasmuch as out of ninety cases of this character, there were twenty-one in which the shoulder presented. M. Danyau thinks that a more plausible explanation may be found in the shape of the uterus, whose transverse diameters he supposes to be greater under those circum- stances than usual. In support of his view, he alleges the following case of Dr. Lecluyse. A woman had her children to present the shoulder in three successive labors, and on the third occasion, the latter physician dis- covered that the womb, so far from being pyriform in the vertical direction, was shaped, so to speak, like an ellipsoid, whose major axis was transverse, whilst the fundus of the organ was but slightly elevated above the pubis. The same explanation was proposed long ago by Wigand. How is it pos- sible, says he, for a well-formed child, whose body represents an oval, to assume, without being compressed or incommoded, an oblique or transverse position, in a womb of an ovoid shape? Supposing that, impelled by cer- tain causes, it should assume these defective positions for a moment, what magical power could keep there a foetus, whose mobility is so highly favored both by the fluid in which it swims, and the polish of the internal surface of the ovum ? What is there to prevent it, in obedience to physical laws, from changing its inconvenient position by bringing its long diameter to coincide with the longitudinal one of the uterus? No better reply, he adds MECHANICAL PHENOMENA OF LABOR. 863 can be given to these questions, than by admitting that these defective posi- tions are due to an irregular shape of the womb, rather than to the move- ments which it may have performed. Remembering the unfortunate perseverance with which defective positions recur in the cases of certain females, there is a strong disposition to seek for the cause in a peculiar shape of the uterus ; and had a peculiar conforma- tion of the organ been discovered before the first gestation, it might, per- haps, be admitted, that notwithstanding the development undergone during pregnancy, the irregularity of shape would be preserved. Still, we may be allowed to ask whether the increase in size transverse] v, near the end of gestation and at the beginning of labor, may not be the effect rather than the cause of the unfavorable position of the foetus. As to the determining causes, the only ones recognizable are fortuitous and accidental ; thus, any violent commotion, any trifling shocks, kept up for a long time, such as those produced by carriage riding, or by exercise on horseback, the perturbation from the upsetting of a coach, and even sud- den fright, may change, according to authors, the child's position in certain cases, and convert spontaneously a vertex presentation into one of the shoulder. Indeed, many accoucheurs have supposed that irregular or par- tial contractions might convert, during labor, a favorable position in one of the trunk ; this is barely possible. But I cannot as readily admit the sup- posed influence which, according to some others, those uterine contractions may have, that torment the woman during the last few days, or sometimes even weeks of her gestation, and which have before been considered as the preludes of labor. The following is a case in point : A patient, in whom the foetus presented by the shoulder five times successively, had always suffered from these pains during the last few days of her pregnancies; Pro- fessor Naegele, under whose care she came on the sixth accasion, endeavored this time to calm the pains, which again appeared with the same energy as in the preceding gestations. After the ineffectual administration of various remedies, he finally ordered opiate injections, when, to his great satisfaction, the spasms ceased almost immediately, and were not again renewed, and the woman was delivered at full term of a living child, which presented in a favorable position. But what does this prove? simply that, whatever may be the child's position, these pains, the preludes of labor, may appear, and that vicious positions may be reproduced in the same woman with a most deplorable perseverance. It must be evident that such contrac- tions are too feeble to change the child's position in any way, especially when we remember that the integrity of the amniotic sac, and the presence of the waters, likewise protect it from any influence they might have. § 2. Diagnosis. There is sometimes reason to suspect a trunk presentation, even before the commencement of labor, from the following signs : the abdomen is much larger in its transverse diameter than usual, and when its walls are soft and flabby, they can often be depressed enough to detect the fetal head in one of the iliac fossae, presenting there as a hard, rounded, and resistant tumor; then by placing the hands opposite each other in the lumbar regions, ;< 364: LABOR. greater and firmer resistance offered by the two extremities of the foetal ovoid will be felt at these points, and the solid body, formed by the child, may be readily moved from side to side, thus proving that its long axis lies transversely above the superior strait. Finally, the tumor formed by the head, in the vertex presentations, is no longer detected by the vaginal touch, and it is almost impossible to reach the presenting part ; in some rare instances, the elbow, or the little hand of the child, may be recognized and bal lotted, and this sign, accompanied by the first two, renders the diagnosis quite probable. The form of the abdomen is then very irregular, especially if the uterus should contain but a small quantity of amniotic fluid. It has, however, been observed, that after the discharge of the waters, the longitudinal diameter gradually becomes greater than the other ; because, as M. Hergott remarks, the transverse position has no longer a real existence, for the body of the foetus is so curved upon itself that one of its extremities is lodged in the fundus of the uterus, although the other does not correspond to its orifice. [Although the use of auscultation in breech presentations is but of doubtful advantage, M. Depaul thinks that it may enable one to arrive at a correct diagnosis when the back of the foetus is directed forward. In this case, he says, everything is arranged favorably for the recognition of the maximum intensity of the sound, which will be found at the anterior part of the lower segment of the uterus as in head presentations. In proportion, however, as the position assumes a transverse direction, the difference becomes much more decided, inasmuch as the sound, instead of being heard in a lessening degree toward the fundus of the womb, then extends in an almost horizontal direction, from one iliac fossa to the other, for example, and will be absent from a large portion of the upper region of the organ.] Though M. Depaul's opinion is rational and founded on fact, it is none the less true that trunk presentations would almost always remain unde- tected if we had to depend upon auscultation for their recognition. Sometimes, however, it may prove a useful auxiliary. If, for example, a email member of the foetus be detected by the touch, and the pulsations of the heart are heard in the hypogastric region, we may conclude almost cer- tainly that the member belongs to the upper extremity. Should the heart be heard on a level with the umbilicus, it would most probably prove a pelvic extremity. Before the membranes are ruptured, the elevation of the part renders the vaginal touch very difficult; and so, of course, the form of the bag of waters, or that of the uterine orifice, can be of but little service. Accord- ing to .Madame Boivin, the os uteri dilates more slowdy, but as this slowness ul' dilatation is met with in all presentations, excepting those of the vertex, it forms a sign of minor importance; the touch, therefore, can only give a positive certainty after the rupture of the membranes. When the side is the presenting part, the shoulder (Lachapelle) is very frequently found at the centre of the superior strait, as also the elbow, or the side of the chest (P. Dubois), and hence will be the first encountered by the finger in making an examination ; and we therefore have to point out the characters, suc- cessively, whereby these several parts may be recognized. MECHANICAL PHENOMENA OF LABOR. 365 1. When the shoulder presents, the finger first detects the rounded tumor formed by its summit, upon the surface of which a small osseous projection, constituted by the acromion, is distinguished ; then, behind or in front, according to the position, the clavicle and the spine of the scapula are felt, and below the clavicle the intercostal spaces are easily made out, whilst under the spine of the scapula there is only a plane surface, terminated by the acute inferior angle of this bone, which is movable and permits the finger to slip under it ; lastly, on the sides of the tumor formed by the shoulder, the axillary space can always be distinguished, and some- times also (though on the opposite side) the depression in the neck can be felt. The shoulder being once recognized, we must next determine which one it is, and what is its position. I will remark, in advance, that we have admitted but four positions of the trunk, namely, two for the right shoulder and two for the left, and that the relation existing between the situation of the head and that of the child's posterior plane is different in each of these four. Thus, there are two positions where the head is to the left, namely, the first position of the right and the first of the left shoulder ; and remark that, in the latter, the child's back is turned towards the mother's loins; in the former, on the contrary, it is in front ; and, therefore, whenever the head is to the left and the child's back is behind, we have to treat with a first position of the left shoulder. In the same way, there are two positions in which the head is to the right, to wit, the second of the right and the second of the left shoulder ; but again observe, that in the latter the back looks forwards, while in the former, on the contrary, it is directed posteriorly. Hence, to recognize a second position of the left shoulder, it will only be necessary to ascertain that the child's head is turned towards the mother's right side, and that its back looks anteriorly. In a word, to satisfy ourselves which is the present- ing shoulder, and what is its position, we only have to find out where the head lies, and the position of the posterior plane of the child. The shoulder presenting and being recognized, it is evident that if the axillary space looks towards the mother's right, the head will be to her left, and vice versa; consequently, the situation of the head is readily known by the direction of this space, and, as regards the child's dorsal plane, the omoplate will clearly indicate its position. 2. When the elbow alone is accessible to the finger, it may be recognized by the three osseous projections (the olecranon and the two condyles), which it presents by the transverse concavity in the bend of the elbow, and by the vicinity of the chest and intercostal spaces. The elbow having been dis- tinguished, it will be necessary to make out the position to ascertain where the fcetal head and its dorsal plane lie, but this is now comparatively easy, since the elbow is always directed towards the side opposite to that where the head is found, and the forearm is always placed on the anterior plane. Again, as above stated, it happens at times that the forearm is not doubled up, but that, on the contrary, the hand hangs down in the vagina, or even appears at the vulva. Now, to determine which is the presenting hand in those cases, it is necessary to turn it in such a way as to place its pal mat 366 LABOR. surface in front and above, for, in this position, if the thumb be directed to the mother's right thigh, it is the right hand, but if to the left thigh, it is the left hand ; and then, to find out where the head is, the accoucheur must slip his finger up to the axillary space. [The advice just given would enable us to recognize -with certainty the projecting hand ; the misfortune is that it is so easily forgotten. Therefore we think it better that the operator should simply observe which of his own hands would fulfil pre- cisely the conditions of that of the foetus as to position, for then the diagnosis would be just as certain, inasmuch as, with the exception of the size, the right hand of an adult is formed precisely like the right hand of the child, and so with the left hands of both, whilst marked differences exist in the reciprocal arrangement of the parts composing a right hand and a left one.] When the hand comes out at the vulva, a careful inspection of it will most generally be sufficient to establish the diagnosis. Thus, if its dorsal surface is turned towards the patient's right thigh, the head is at the right, and if to the left thigh, the head is at the left. The little finger, directed towards the coccyx, indicates that the child's dorsal plane corresponds to the mother's loins, and the same finger pointing to the pubis, is an evidence of this plane being in front. "We have been thus particular in the diagnosis, because it is all-important in trunk presentations to understand clearly which side presents at the strait, since the accoucheur must always endeavor to turn; and if the details just given prove difficult of comprehension from a single reading, we hope they will become clearer by practising on a mannikin. § 3. Mechanism. When the trunk presents at the superior strait, the labor nearly always requires the intervention of art ; though, in some rare cases, which may be considered as altogether exceptional, nature alone is adequate to accom- plish the delivery, which may then take place in one or two ways; for either the presenting shoulder is driven from the superior strait under the influence of the uterine contractions alone, to make room for one of the child's extremities, thereby producing a change in position, and giving rise to what is designated as spontaneous version, or else the presenting shoulder descends into the excavation and engages at the inferior strait ; notwith- standing which, the breech sweeps along the whole anterior surface of the Bacrum and of the perineum, and is delivered the first at the posterior vulvar commissure ; this latter mechanism is called spontaneous evolution. 1. Spontaneous Version. — Where the membranes are not ruptured, though the labor has actually commenced, the foetus sometimes enjoys a great lati- tude of motion in the amniotic cavity, in consequence of which it might, in such cases, readily change its position before the discharge of the waters took place ; and it has been known to present, in this way, different points of it3 surface during the first period of the labor. Sometimes the head ascends in the womb while the breech descends ; at others, on the contrary, the nates mount up towards the fundus uteri, and the head becomes located at the superior strait. Consequently, two varieties of spontaneous version have been adnrtted, i. e., the cephalic and the pelvic. MECHANICAL PHENOMENA OF LABOR. 367 This phenomenon usually occurs either just before or else soon after the membranes are ruptured; in some instances, however, it takes place a long time after the waters are discharged. The following case, reported by M. Velpeau, will give a very correct idea of what occurs under such circum- stances : "A young woman, pregnant for the second time, came into the hospital at ten o'clock in the morning. The os uteri was very little dilated; nevertheless, I could recognize a second position of the left shoulder. The waters did not escape until three in the afternoon, and I did not wish to go after the feet, as the pains were neither very strong nor very frequent, and I had some confidence in the assertions of Denman on this subject. At eight o'clock in the evening, the shoulder had sensibly moved towards the left iliac fossa, and I could then readily detect the ear at the right. At eleven, the temple had almost gained the centre of the orifice ; the contrac- tions were augmented in energy ; and the cervix was entirely effaced. At midnight, the vertex had become lower; the head engaged; and, in the course of an hour, the vertex was delivered in the right occipito-cotyloid position." 1 This case, in which the progress of the labor has been followed and described, step by step, is well suited for explaining the mechanism of spon- taneous cephalic version. The reader will easily comprehend that the same phenomena would take place, if the breech, instead of the head, descended towards the superior strait ; and, in the above instance, for example, the shoulder, instead of being driven towards the left iliac fossa, would be forced to the mother's right, and then the side of the chest, the loins, the left hip and thigh, would successively appear at the upper strait, and the breech finally engage in the excavation. In a shoulder presentation, the arm and hand may hang down in the vagina, or even protrude beyond the vulva ; but this last circumstance does not preclude the possibility of a spontaneous version, only it is well to bear in mind that the arm may then ascend again into the uterine cavity, and this will almost certainly happen if the pelvic extremity descends into the excavation, but it may also lodge on one side of the pelvis, and thus permit the head to descend alongside of it ; the presentation of the cephalic extremity being then complicated by a procidentia of the arm and hand. In the present state of our science, it would be a very difficult matter indeed to point out the various causes, under the influence of which it is sometimes the head, and sometimes the breech, which thus, in cases of spon- taneous version, take the place previously occupied by the shoulder, at the superior strait. Nevertheless, I am inclined to believe that irregularity of the uterine contractions is not wholly foreign to such an effect. In fact, when we shall speak hereafter of what the German accoucheurs have 1 With regard to the case in the text, I may say briefly, that the course of M. Velpeau was legitimized by the desire he had of testing the opinions at that time (1825) in dis- pute ; but young practitioners should be very cautions how they make such experi- ments ; for although, in the hands of a man like Velpeau, the version, at an advanced period of labor, would have been comparatively easy, yet it must never be forgotten that, in trunk presentations, the soonest possible period after the rupture of the membranes is the most favorable for the artificial version. 368 LABOR. described under the name of Partial Contraction of the Womb, it will be seen that, in some cases, the organ appears to contract in but a limited part of its extent, the remainder contracting with much less force, or even per- haps remaining entirely inert. Now, without being able to cite a single instance in support of my opinion, I am strongly inclined to believe, that it is in such a condition of the uterine walls that spontaneous version would he the most likely to take place. Let us suppose, for example, that when the child is placed in a left cephalo-iliac position of the right shoul- der, the left side of the uterus alone contracts, the right remaining passive ; it is manifest that the whole expulsory effort, being then exercised on the head, would necessarily depress it towards the centre of the superior strait; and this movement of the cephalic extremity will be easy, in proportion aa the inertia of the right lateral wall of the womb shall oppose no obstacle to the elevation of the pelvic extremity. But if, on the contrary, (in the same position of the child), the right side of the womb only contracted, it is evident the breech alone would receive the impulse from the uterine efforts, and then a spontaneous podalic version would be observed to take place. 1 2. Spontaneous Evolution. — The mechanism of spontaneous evolution is much better understood, and we shall find embraced in its descriptions all the divisions of the mechanism of natural labor in the vertex and face pre- sentations. Here, also, M. Velpeau has admitted two varieties, that is, a spontaneous cephalic, and a spontaneous pelvic evolution. But Ave cannot conceive how a spontaneous cephalic one can take place, unless it be in cases of abortion, or in those where the child is completely putrefied ; hence we shall treat of the pelvic variety alone, taking, as an example, the first or left cephalo-iliac position of the right shoulder, in which the child's head is placed in the left iliac fossa, the breech in the right iliac fossa ; the dorsal plane being in front, and the sternal one behind, and the long axis situated very nearly in the direction of the transverse diameter of the upper strait. Under such circumstances nearly all the Avaters escape immediately after the membranes are ruptured; then the uterus contracts forcibly, and by compressing the foetal trunk on all sides, has a tendency to make the pre- senting part engage in the excavation. A. First Stage. Doubling up of the Child. — Under the influence of the uterine contractions, the child is sti - ongly bent in the direction of its long axis towards the side opposite to the presenting one ; for instance, in the case before us, the head is bent to the left side, and the breech towards the hip of the same side. b. Second Stage. Engagement. — A second stage, the period of descent, then sets in ; that is to say, in proportion as the contractions are renewed, tli' -boulder approaches more and more towards the inferior strait, and the foetal trunk, being bent double, engages deeply in the excavation. But the same difficulty is here met with as in the face presentations (see Posi- tion* of the Face) ; that is, the body being thus placed transversely, it is impossible for the shoulder to reach the lower strait unless the head engages simultaneously with it in the excavation ; or, indeed, unless the neck should 1 Taylor (Am. Jour, of Ob., July, 1881) uses the word rrtraeiion to describe the physiological motive power or action of the uterus, which takes place after contrac- tion and during the relaxation by which the shoulder of the child, or any other part, is lifted or drawn up or back from its position in the pelvis. MECHANICAL PHENOMENA OF LABOR. 369 be long enough to subtend the height of the lateral wall of the latter, which we have already seen is impossible (see Mechanism of Face Position* i. The descent of the shoulder is therefore limited to the length of the neck. o. Third Stage. Rotation. — A movement of rotation next occurs, by Fio. 89. First position of the right shoulder with the arm hanging down. The game position during the descent. which the long axis of the child, that was originally placed transversely. is brought very nearly into an antero-posterior direction, so that its cephalic extremity is placed above the horizontal branch of the pubis close to the spine of that bone, and the breech above, or rather in front of the sacro- iliac symphysis. This process of rotation being once effected, the descent may now be completed, since the side of the neck is placed behind the symphysis pubis, whose whole length it can subtend; consequently, the forearm and arm are found to appear at the vulva, and the shoulder to get under the arch of the pubis. D. Fourth Stage. Disengagement of the Trunk. — The trunk, being now bent double, is forced en masse into the excavation, under the influence of the powerful uterine contractions, but the shoulder can descend no further, because it is arrested by the shortness of the neck ; hence, the expulsive force acts on the pelvic extremity, which is pressed more and more towards the floor of the pelvis, and traverses the whole anterior face of the sacrum. It then rests against, depresses, and forcibly distends the perineum; the vulva soon dilates, and the acromion remaining always fixed under the sym- physis, the following parts are observed to appear successively at the ante- rior perineal commissure: tirst, the superior lateral parts of the chest; next, its inferior part, the loins, the hip, the thighs; and lastly, the whole length of the inferior extremities; and there remain only the head and the left shoulder in the excavation. This last movement may be considered as the fourth stage of the labor, and it is therefore named the period of deflexion or disengagement. It takes place around the shoulder, situated under the symphysis as a centre, and therefore, if lines be drawn from this centre, ter- minating at the various points on the child's side, we shall have all the radii, or the foetal diameters, which clear the antero-posterior one *f thtf inferior strait. 870 LABOR. [e. Fifth Stage. Rotation of the Head. — "When by spontaneous evolution the body has been disengaged, the conditions have become the same as in breech presen- tations In the fifth stage, therefore, the head rotates so as to bring the occiput behind the symphysis pubis. f. Sixth Stage. Expulsion of the Head. — In the last stage the head is delivered as in breech cases.] Such is the exact mechanism of the spontaneous evolution in those e?»ses where the child's posterior plane was originally in front ; or, in other words, Fib. 90. Fio. 91. Fig. 90. Position of the child after the rotation, and just at the moment when thd process of disengagement lie^ius. Fio. 91. The same position with the delivery more advanced. in a first position of the right or a second of the left shoulder, for there is no difference in this last, excepting that the movement of rotation must take place in the opposite direction, that is, the head must pass from right to left and from behind forward, and the breech from left to right and from before backwards. But when the sternal plane of the foetus is primitively directed towards the mother's front, as in the first position of the left, and the second one of the right shoulder, the process takes place somewhat dif- ferently. M. P. Dubois, who had an opportunity of seeing two cases of this nature, informed me that, at the moment when the breech disengaged at the anterior perineal commissure, the child's whole trunk underwent a movement of torsion that again brought its dorsal plane forwards and up- wards, which plane, without this process of torsion, would still have been directed towards the anus; whence we find, even here, remarkable as it may seem, the influence of that general law which was observed to regulate all natural labors, namely, that, whatever may have been the original rela- tions of the child's posterior plane, it ultimately comes into correspondence with the anterior parts of the pelvis. A variety of spontaneous evolution is described by Roderer as "evolutio conduplicato corpore," in which the trunk is so greatly flexed that the beacl and thorax enter the pelvic cavity simultaneously, and are expelled fol- lowed by the breech and legs. This occurs most frequently in those cases in which the tutus has been softened by putrefactive changes. Dr. Taylor Plate VII. Ti§.3. E& Caaeauz and Tarnier'i Obstelru i. PLATE VII. Figs. 1-4. The different stages of Spontaneous Expulsion. (After Spiegelberg.) Fig. 5. Labor with the body bent double. (After Kleinwachter.) MECHANICAL PHENOMENA OF LABOR. 371 advises the division of the perineum freely and laterally, to the extent of three or four inches, to allow the breech to be delivered, and thus avoid the sacrifice of the child if living. § 4. Prognosis. We again repeat, for it seems highly important that this should be firmly impressed on the mind, that in trunk presentations a spontaneous expulsion of the child is wholly an exception to the general rule, and one upon which no reliance can be placed, unless in a case of abortion ; and that the resources >f our art are demanded in every case just as soon as the neoessary condi- tions exist for such intervention. (See Version.) In fact, by consulting the published cases, or indeed by simply reflecting on the mechanism by which the delivery is effected, we realize how this must expose the woman to a very long and painful labor, and the foetus to 60 violent a compression that its death must often result in consequence. According to the statistics furnished by M. Velpeau, one hundred and twenty-five children, in one hundred and thirty-seven, were still-born. It must not be supposed, however, as some persons appear to have done, that this mode of delivery is only possible in cases of abortion ; for facts too numerous militate against this opinion for it to be any longer tenable. Burns justly remarks, in endeavoring to demonstrate the physical possi- bility, that the greatest diameter measures five inches and a half; sometimes the distance is barely five inches, and continued force may make it less ; hence, provided the dimensions of the pelvis are slightly greater than in their normal condition, there is nothing here physically impossible, as has been affirmed and reaffirmed, doubtless without mature reflection. The favoring circumstances which render a spontaneous evolution easier and more likely to take place are : a premature labor, the smallness of the child, a large pelvis, strong contractions, diminished resistance from the soft parts, numerous antecedent labors, and the readiness with which the woman has heretofore been delivered of large-sized children. The opposite circum- stances would render it exceedingly difficult, if not wholly impossible. ARTICLE VI. REVIEW OF THE MECHANISM OF LABOR IN GENERAL. A curious fact in the mechanism of labor, and one which has claimed the attention of all modern accoucheurs, amongst whom we may mention especially MM. Dubois and Jacquemier, is, that whatever the presentation may be, the movements undergone by the foetus during its expulsion are always the same. Finally, Professor Pajot made a clear statement of this single mechanical law, and applied it to all the presentations. " AVe main- tain," he says, "that all labors, so far as the mechanical phenomena which they present are concerned, are governed by the same law. There is, in fact, but one mechanism of labor, whatever the presentation and position may be, pro- vided the expulsion takes place spontaneously, that is to say, without the intervention of art and at term, for in cases of abortion the expulsion is not of the regular character." (Pajot, Dictionnaire Ency eloped iuue des Science* Medicales.) 372 LABOR. We accept fully this view of the subject, and repeat that all spontaneous labors obey the same law as respects their mechanism. The presenting part of the fcetus is first modified, as to its size or direction, in order to adopt it to the opening of the superior strait ; then it descends into the cavity of the pelvis, and having reached the inferior strait turns, so as to present its longer diameters to the longer diameters of the pelvis, and not until it has undergone this series of movements is the vulva cleared and the expulsion complete. We have thought that the transition would be easier from this simplicity of facts to the region of theory, if the classification of the different stages of labor were somewhat modified. Although the most recent classifications are wonderfully simplified, they still fall short of entire uniformity, present- ing here and there some omissions and a few contradictions. For instance, in deliveries by the vertex or face five stages are described, the first four of which are really executed by the head, then the rotation of the body is described as the fifth and last time, without considering its final expulsion, which is merely mentioned. The disengagement of the body being thus disregarded, students are liable to forget an important cause of dystocia described by Jacquemier, viz., the large size of the shoulders. In cases of delivery by the head, a fifth stage, that of rotation of the body, is described, why, therefore, not be logical throughout and admit a sixth stage for its expulsion ? In breech labors, four or even five stages are commonly described. It is well, indeed, to recognize, as do MM. Dubois and Pajot, a first stage for the diminution in size and modelling of the presenting part ; then the engage- ment, rotation, and expulsion of the body will correspond with the second, third, and fourth stages. Up to this point there is entire uniformity between labors by the head and breech, but for the fifth stage in breech cases we have a confused account of the internal rotation of the head and its final expulsion. The fifth stage, which in a uniform nomenclature ought to recall similar things, would, in this case, seem to imply a notable difference between the various kinds of delivery ; for, in the same stage in vertex presentations, the body rotates without being expelled, whilst in breech cases the head rotates and is expelled at the same time. In order, therefore, to remove this apparent difference, it were better to divide the fifth stage of delivery by the pelvis into two stages, the fifth for the internal rotation of the head, and the sixth for its final expulsion. The throwing of these two stages into one, is essentially the same as confounding the third and fourth stages of delivery by the vertex. In order to remove these imperfections and contradictions we have, there- fore, described six stages in the mechanism of labor in each of the presenta- tions ; an innovation which has the advantage of showing clearly that this mechanism is uniform throughout. These views have been taught in our lectures, in the text of the Atlas Complementaire de tons les Tra'des d'Ac- couchements, by Lenoir, and one of our students has made it the subject cf his inaugural thesis. (Granier. Theses de Paris, 1863, No. 98.) For the clear understanding of this uniformity of the general laws of the mechanism of labor, we should observe in the first place that the fcetus, MECHANICAL PHENOMENA OF LABOR. 373 doubled up as it is in the cavity of the uterus, with its limbs pressed closely against the chist, and the neck concealed between the base of the head and the upper part of the chest, forms really but two distinct parts, the head and the body. Now let us for a moment imagine these two parts to be sepa- rate and independent, and that they presented themselves one after the other ; then we should have four stages for the expulsion of each. The head would be flexed, engage, rotate, and be delivered ; nor would this suc- cession of phenomena be in any respect altered whether the engagement of the head should precede or follow that of the body. The delivery of each of these two parts of the foetus would then present similar phenomena to the observer; nor will there be the least occasion for surprise, when we con- sider that the section of each presentation gives an almost oval figure, the longer and shorter diameters of which are adapted in the same way to the curvature and form of the genital passages. Setting hypotheses aside, if we examine a foetus closely, we shall be at once struck with the fact that it represents two superposed masses, the head and the body so united by the neck that one cannot progress without the other; and that whilst the presenting part undergoes its four movements of compression, engagement, rotation, and disengagement, the remaining part has also become flexed and engaged, in other words, has performed its two first movements. On the other hand, we observe, whilst examining a foetus, that the long diameters of its two superposed parts (head and body) have opposite direc- tions, from before backward for the head, and transverse for the bod v. These two diameters are also at right angles to each other, whence it happens that when one of the two parts has a direction adapted to its ready exit from the pelvis, the other will have an opposite direction. For example, when the head disengages from before backward at the vulva, the shoulders are situated transversely at the inferior strait; which renders it necessary that the head and body should perform successively the same mechanical movements of rotation and disengagement. If we note, therefore, such mechanical phenomena only as are apparent and palpable, such, in fact, as the accoucheur is expected to detect at any moment, we shall have in the first place to observe successively the four motions performed by the part which engages first, and next the final move- ments of rotation and expulsion of the second part of the foetus. We have thus to describe six stages in the delivery: 1st Stage Compression ") 2d Stage Engagement I of the first foetal part. 3d Stage Rotation J 4th Stage Disengagement | 5th Stage Rotation I of the second foetal part. 6th Stage Expulsion J In the following table are recapitulated the six stages in the mechanism of labor for all the presentations. TABLE of the six Stages of Labor in all the Presentations. 1st Stage. L ,- , • f°S ^ e I erteX !'- v "" xi "" Adaptation of \ lukm 6 P lace m I oi »he face by extension. ,, ' ' , ,. 1 presentations I of tin- breech bv folding. the presentation ^ . .. . . ,.-,.- r of the body \>y iolding. 74 LABOR. fof the vertex by sliding, of the face by sliding, of the breech Iiy sliding. of the body by sliding. occiput for the vertex. :ice. eech. a shoulder for the body. of the vertex by extension. ace in J of the face by flexion. ations 1 of the breech by progression. of the body by lateral flexion. i ~- — j j j , . f n • . , fthe occiput for the vt 3d Stage. Bringing under fa ^ f ^ fa >tation of the- 1 , the arch of the-^ , . . • ,, > \ , . I a hip tor the br resentation. pubis , r , . « ,, , Rot P 4th Stage. Disengagement, J Taking pi \ presental C a shoulder in cases of vertex presentation Bringing under | a shoulder in cases of face presentation. 5th Stage. o a ion o e | ^ arc j, f tne j tue 0CC ip U t in cases of breech presentation. second foetal ■> \ ■ „ . , * part . 6th Stage. Final expulsion. pubis By disengage- ment the occiput in cases of body presentatioii (spontaneous evolution]. of the body in cases of vertex presentation. of the body in cases of face presentation. of the head in cases of breech presentation. of the head in cases of body presentation (spontaneous evolution). By applying this general classification to each presentation separately, we obtain entire uniformity for the mechanism of every k.'nd of labor. VERTEX. 1st Stage Flexion of the head. 2d Stage Engagement of the head. 3d Stage Rotation of the head. 4th Stage Disengagement of the head. 5th Stage Internal rotation of the body. 6th Stage Expulsion of the body. FACE. 1st Stage Extension of the head. 2d Stage Engagement of the head. 3d Stage Rotation of the head. 4th Stage Disengagement of the head. 5th Stage Internal rotation of the body. 6th Stage Expulsion of the body. BREECH. 1st Stage Folding of the breech. 2d Stage Engagement of the breech. 3d Stage Rotation of the breech. 4th Stage Disengagement of the breech. 5th Stage Internal rotation of the head. 6th Stage Expulsion of the head. BODY. (Spontaneous evolution.) 1st Stage Folding of the body. 2d Stage Engagement of the body. 3d Stage Rotation of the body. 4th Stage Disengagement of the body. 5th Stage Internal rotation of the head. 6th Stage Expulsion of the head. TWIN LABORS. 375 CHAPTER IV. TWIN LABORS. Although the expulsion of the child often takes place in twin pregnancies with as much facility or sometimes even with greater rapidity than in ordi- nary labors, yet it must not be supposed that the whole duration of the labor is always shorter; for very often, on the contrary, the parturition will be found to drag along, and become tedious. Indeed, by reflecting on the circumstances which then cornjdicate the process, it will not be a difficult matter to explain this unusual delay, since it is well known that an exces- sive distention of the womb greatly diminishes both the force and frequency of its contractions ; and, as the labor often comes on before the end of the ninth month, the cervix uteri has not yet undergone those modifications which usually render its dilatation at term quite easy ; besides which, the elevation of the presenting part, whose engagement is impeded by the pre- sence of the second foetus, also assists in retarding this dilatation. The stage of expulsion, which the small size of the twins would at first sight seem to facilitate, is often delayed by the feebleness of the contractions, and also by the decomposition and considerable loss of the force occasioned by the presence of an ovum, still remaining intact within the cavity of the womb ; and such is the unfavorable influence of this latter circumstance, that it is only through the thickness of the second ovum that the contrac- tions of the greater part of the uterine fibres can possibly reach the body of the child that first presented at the upper strait. But when the first child presents by the pelvic extremity, the escape of the head is particu- larly apt to be attended with difficulties; for, if the perineum be resistant, even in a slight degree, as in priruiparae, for example, the intervention of art will nearly always be indispensable, because the uterus, being wholly occupied by the other ovum, can have no further influence on the head of the first. The following table, which gives the presentation of both children in three hundred and twenty-nine cases of twin pregnancy, will serve, as a matter of curiosity, to show the relative frequency of the positions. IN 329 TWIN PREGNANCIES, THE TWO CHILDREN PRESENTED AS FOLLOWS : Both by the head. 134 times. The 1st by the head ; the 2d by the breech. 55 times. Both by the breech. 12 times. The 1st by the breech : the 2d by the head. 31 times. The 1st by the breech; the 2d by one foot. 11 times. Both by the feet. 8 times. The 1st by the feet; the 2d by the head. 29 times. The 1st by the breech : the 2d by the elbow. once. The 1st by the head; the 2d by the shoulder. 7 times. The 1st by the face ; the 2d by the head. once. The 1st by the feet; the 2d liy one hand. onee. The 1st by the feet: the 2d by the breech. once. Nearly always the twins present one after the other at the superior strait, and the expulsion of the first is promptly followed by the birth of thf 376 LABOR. second ; and the same is true of the others when there ire more than two But it occasionally happens that the labor does not progress so regularly and that the children may be born at a considerable interval from each other, and their expulsion rendered difficult by the attendant delays and dangers. It most generally happens that the womb, being fatigued by the efforts necessary for the expulsion of the first-born, retracts a little after this partial depletion, and remains in a state of rest for some minutes, in conse- quence of having lost a part of its contractile properties ; still retaining, however, a greater volume than usual. By placing the hand on the ante- rior abdominal region, the accoucheur will be able to verify the abnormal size of the organ, and to detect, through this wall, the inequalities apper- taining to the foetus ; besides, another amniotic pouch, or the presenting part of a second child, can readily be detected at the upper part of the uterine neck by the vaginal touch. In general, the repose of the womb is but momentary, and in about a quarter of an hour, sometimes at the end of five or ten minutes, though rarely later than twenty or thirty minutes, the patient, feels the pains coming on again ; at first feeble and slow, but soon becoming stronger and more energetic. Care should be taken to rup- ture the membranes, if this had not already occurred, and then to abandon the rest of the labor to the powers of nature. This second delivery is soon over, as a general rule, when the foetus presents in a natural position, for the parts have been so enlarged by the passage of the first child, that they offer but little resistance to the escape of the second. But in some cases, the pains which have been suspended after the birth of one of the twins do not reappear for some hours, and sometimes even not for several days. 1 Now, what is to be done in cases of this kind ? " When the two children present well, and the expulsion of the first is effected naturally, and without great fatigue to the woman, I wait," says Merriman, "until the pains of the second childbirth come on; ordinarily, this happens shortly after the escape of the first-born. If efficacious pains do not occur in the course of a quarter or half an hour, I provoke the con- traction by rubbing the abdominal tumor gently with the hand, and by titillating the os uteri with the finger ; if these irritations, made simul- taneously on the body and neck, are ineffectual, and several hours elapse without the womb contracting, I deem it advisable to excite the contractions, by rupturing the membranes, after having previously administered the ergot. This course is based on the two following reasons : where we have delayed too long a time, the pains have always appeared to me more severe than they would have been if the action of the uterus had been solicited sooner ; and the expulsion of the second child has commonly seemed to me more easy through the parts recently dilated by the first delivery." 1 Four women, registered in the Dublin Hospital, were delayed ten hours in the delivery of their second child. The reader will also find, in the Medical and Physical Journal (April, 1811), the details of a case in which the second child was not born until fourteen 'lays after the firs! : and the author of thai communication states, that another case had come to his knowledge, in which six weeks had elapsed between the birth of the twins. A woman was delivered mi the 4th of March, 181 I. of two children: she found herself so well on t lie second day that *he rose to attend to her affairs, but, on the sixth, she was again delivered of two more. (Gentleman's Magazine, 1814.) PREMATURE AND RETARDED LABORS. 377 In all such cases, our rules of conduct should be based on the condition of the womb itself, rather than on the length of time that may have elapsed since the birth of the first child ; because it must be evident that relaxation and inertia of this organ would forbid all attempts at extraction, and that we should never endeavor to deliver the second child before having excited the organic contractility of the uterus, by all the available means. If, by chance, these measures prove inadequate, it will be better to wait several hours, or, if necessary, even for several days, rather than expose her to the terrible consequences resulting from inertia. [The presentation and position of each child in twin labors are detected by the same signs as when one child only is present, observing, however, that it is neces- sary to be careful in respect to the data supplied by palpation and percussion, for the presence of two children in the womb alters greatly the results afforded by the former; so that although these measures may sometimes prove helpful, they may also very easily lead into error. That auscultation is equally unreliable and may be deceptive, will be understood from the fact that the idea of the position of the first child may be formed from the maximum intensity of the cardiac pulsation of the one which is born last. What has been already said in regard to the touch, will suffice for twin cases also, although difficulty may arise from the simultaneous engagement of both chil- dren — for which case we refer to the subject of dystocia. (See Dystocia.) The expulsion of each child is subject to the usual laws which govern the mechanism of labor as already described, so that we have only to add that as twins are often small and born prematurely, the inequalities in the mechanism of labor are more common, especially as regards the second child, which traverses the genital passages which have been enlarged by the first one. In short, we have only tc regard a twin labor as two successive deliveries.] CHAPTER V. OF PREMATURE AND RETARDED LABORS. ARTICLE I. OF PREMATURE LABOR. When a woman is delivered in the seventh or eighth month of her gesta- tion, the labor is said to be premature. Now a great number of causes may determine the expulsion of the child, before the ordinary term of its intra- uterine life; such, for instance, as an excessive distention of the womb, whether this be occasioned by too great a quantity of the amniotic liquid, by hydror- rhea, or by the presence of two or more infants in the uterine cavity ; the accidental death of the foetus; the artificial evacuation of the liquor amnii ; any violent muscular effort ; the abuse of strong purgatives; various acute diseases, more especially those of the skin; and certain conditions of the animal economy, as plethora, great debility, or an excessive irritability and sensibility. Finally, in a singular case already mentioned, premature labor occurred eight times consecutively, in consequence of extreme itching of the Surface. 378 LABOR. Delivery before term is said to be often preceded by a severe chill Burns supposes that this chill occurs Immediately before or after the death of the foetus. I have no recollection of having observed anything of the kind In some cases, the uterus is fully developed prior to the ordinary term of gestation, and then the contraction commences and goes on as regularly as usual ; but in most instances, the organ has not as yet undergone all the necessary modifications for the proper accomplishment of labor, and the 'atter, consequently, exhibits numerous irregularities in its course. The uterine neck and orifice are not yet properly effaced and softened. For example, it is not at all uncommon to find the neck sufficiently dilated, during the primary pains, to permit the introduction of the finger, and this notwithstanding the lips are still thick and of a considerable length. This length of neck must greatly retard the dilatation, for the latter cannot really commence until after the effacement is completed, which often proves a tedious process. This first, or preparatory, stage is marked by pains that are very irregular both in their duration and intensity, accompanied by a feverish state ; the patient experiences a very distressing sensation of weight about the belly, and she is usually restless and agitated. When the cervix is once effaced, the os uteri begins to dilate; but this dilatation is much slower than at term, because the neck has not yet attained the same degree of softening, and therefore offers more resistance to the contractions of the body. But, although the first stage is somewhat longer, the second, or that wherein the expulsion occurs, is generally shorter than in labor at term, owing to the small size of the child ; nevertheless, this advantage is often counterbalanced by the irregularity and the spasmodic nature of the con- tractions, which are then more apt to assume this form than under ordinary conditions. For, as the muscular organization of the uterus is not yet com- plete, we can understand why its contractile powers are less perfect; and also, on the other hand, how the morbid cause which has developed a premature action in it must necessarily influence the regularity of their contractions. The vertex presentations are far from being so frequent here as in the natural labor at term, and those of the breech, according to M. P. Dubois, are proportionally more common as the labor is more premature. For instance, in ninety-six still-born children, delivered during the last two months of gestation at the hospital of La Maternity seventy-two presented by t he head, twenty-two by the pelvic extremity, and two by the shoulder; whilst in seventy-three living children, who had only reached the seventh month of intra-uterine life, sixty-one presented the head, ten only the breech, and two the shoulder. Hence, it is evident that the number of pelvic pre- sentations in premature parturitions is comparatively greater where the children are born dead, ami also that, when the iVetuses are living, the podalic extremity presents first much oftener than in ordinary labors. Finally, according to Burns, women who are taken in labor before term are more exposed than others to hemorrhages during its progress, and the delivery of the after-birth is both more difficult and more liable to accident than usual. PREMATURE AND RETARDED LABORS. 379 " When a wcman is threatened with premature labor," continued the author just named, " we ought, unless we are sure of the death of the child, to endeavor to check the process, which is done by keeping the patient cool and tranquil in the horizontal position, bleeding her in the arm if she be plethoric, or the pulse be throbbing; but above all, by administering opiate injections immediately (forty to sixty drops of Sydenham's laudanum, in two or three doses, in the course of a couple of hours)." When the labor is once established, it is to be conducted much in the same way with parturition at the full time ; nevertheless, says Burns, the following observations should be carefully attended to: 1. The patient must avoid much motion, lest a hemorrhage be excited ; 2. Frequent examina- tions are hurtful by retarding the process, and tending to produce spas- modic contraction ; and, if this takes place, a full dose of the tincture of opium should be given at once; 3. A rigid state of the os uteri requires venesection to a moderate extent ; 4. The delivery of the child is to be re- tarded rather than accelerated in the last stage, in order that the uterus may have time to contract on the placenta ; 5. This is to be further assisted by rubbing and gently pressing on the uterine region after the child is born ; 6. The delivery of the after-birth requires more than ordinary care (see Delivery of the After-birth) : thus, we are not to pull on the cord, for it is easily broken ; besides, it is often necessary to introduce the hand in the uterus to aid the detachment of the placenta artificially, and to prevent its being retained by the irregular contractions ; and lastly, great attention is to be paid to the patient herself for some days after the delivery, for it has justly been observed that she is, from the mere fact of having had a prema- ture labor, more exposed than others to those inflammatory affections which so often complicate the parturient state. With regard to the premature labors brought on by the accoucheur we shall say nothing at present, as we shall have to treat of them more particularly under the head of Opera- tions. ARTICLE II. OF RETARDED LABOR. As an ordinary rule, the pregnancy terminates about the two hundred and seventieth day after conception. However, labor often occurs at an earlier period than this, and, on the other hand, it may not appear until some time in the course of the tenth month, or even at the termination of this period, although the latter is a much more unusual circumstance. In making this statement, we decide a question in advance that gave rise to some very sharp and animated discussions during the last century; and, still more recently, the tribunals of England have summoned to their bar the most celebrated physicians of Great Britain, and have listened to nume- rous and protracted pleadings for and against the legitimacy of retarded labors. But this question no longer presents to the medical jurist the same diffi- culty that it did in the past century, for the French law has now declared every child to be legitimate that is burn alter the one hundred and eightieth 380 LABOR. or before the three hundredth day of marriage ; and, as if it were possible, in the eye of the law, for a pregnancy to continue more than ten months, it further adds that the legitimacy of a child born three hundred days after tl e dissolution of the marriage contract may be contested. Although a legal decision has thus deprived the question of retarded labors of its greatest interest, yet we, as practitioners, may be permitted to recall briefly the principal reasons that militate in their favor. At first, it was very natural to study the process in those animals which approach the nearest to man in this respect, in order to judge of the possi- bility of a retarded birth in the human species. Among the numerous observations made on this subject, those submitted by M. Tessier, in 1819, to the Academy of Sciences at Paris, of which the following is a summary, are probably the most exact, namely: out of one hundred and seventy-one cows, fourteen calved from the two hundred and forty-first to the two hundred and sixty-sixth day : three on the two hun- dred and seventieth ; fifty, from the two hundred and seventieth to the two hundred and eightieth ; sixty-eight, from the two hundred and eightieth to the two hundred and ninetieth ; and five, on the three hundred and eighth day, which gives a difference of sixty-seven days between the births, if we compare the shortest with the longest period. Of one hundred and two mares : 3 foa led on the 31 1th day. 1 ' " 314th " 1 ' C (t 325th " 1 ( n 326th " 2 ' i 330th " 47 ' ' from the 340th to the 350th day. 25 « C tt 350th •' 360th " 21 < 360th " 377th " 1 ' ' on the 394th day. 102 Making a difference of eighty-three days between the two extremes. Nine months and ten days being the average term for cows, and eleven months and ten days for mares. These well-ascertained variations in the terms of gestation in animals, certainly afforded a strong presumption of their existence in the human species also ; for if cows and mares, whose gestations are not disturbed by the various causes that may lead to changes in a woman, may thus defer for some time the ordinary period, how much more would human females. who are subject to so many diseases, and upon whom the moral and social relations exert so powerful an influence, — how much more likely would they be to exhibit numerous varieties in the duration of their pregnancies? But all this was a mere probability; and the question would still remain undetermined, if careful observations directly made, and well made on the human species, had not removed all doubts on that point ; for several cases bearing on this subject now enrich our science, where a single well-estab- lished instance would suffice to produce conviction. Take, for example, the following case, reported by Desormeaux : A lady, the mother of three chil dren, became affected with insanity, for which all the resources of thera- DELIVERY OF THE AFTER-BIRTH. 381 peutics were tried in vain. As her physician thought that another preg- nancy might possibly re-establish her intellectual faculties, the husband consented to note on a register the time of each sexual union, which only took place every three months, lest a previous conception (then uncertain; should be disturbed. Now, this lady, who was closely watched by her domestics, and was besides endowed with the most rigid principles of reli- gion and morality, was not delivered before the expiration of nine months and a half. Merriman furnishes a summary of one hundred and fifty gestations, in each of which he has noted the precise day of the. last appearance of the menses. From this table it appears that — 5 women were delivered in the 37th week — t. e. from 252 to 259 days. 16 ■' " " 38th " " 262 to 266 " 21 '« » " 39th " " 267 to 273 " 46 " " " 40th " " 274 to 280' " 28 " " " 41st " « 281 to 287 " 18 " " 42d " " 288 to 294 " 11" •' " 43d " " 295 to 301 " 5 " " " 44th " " 303 to 306 " 1 50 The foregoing statement exhibits the great variety in the length of gesta- tion. There is, in fact, a difference of fifty-six days between the two extremes ; and, supposing that each woman became pregnant five days before the return of her courses, five of them, at least, would overrun the average term of nine months by ten or twelve days. CHAPTER VI. OF THE DELIVERY OF THE AFTER-BIRTH. This comprises the natural or artificial expulsion of the fcetal append- ages from the mother's womb, and is the complement of the labor. Like the latter, it is generally accomplished by the unaided powers of nature, though in certain cases, which are fortunately very rare (about one in two hundred), it is attended by difficulties or complicated by accidents that may require the intervention of art. We shall, therefore, have to treat of the natural and the artificial delivery of the after-birth, the former of which, only will be described in this place and the latter included in the article Dystocio. Whilst the expulsion of the foetus is being completed by the spontaneous exit of the breech and lower extremities, or immediately after the expulsion, the walls of *he uterus retract in virtue of their inherent contractility of tissue, and its cavity diminishes ; but the placenta, being a spongy and non- contractile mass, does not follow this action of the organ. Consequently, it becomes puckered up, and the cellular and vascular tissues, that connect it to the internal uterine surface, are rendered tense and then torn, as the 382 LABOR. difference in the respective size of the two bodies becomes greater under the force of the repeated contractions. A rupture of all these bonds of union is soon effected, the placenta is completely detached and forced down upon the os uteri ; the latter, being irritated by its presence, reacts on the body of the organ which is immediately thrown into contraction; the internal orifice, which was closed after the delivery of the child, again dilates, and the placenta, being driven from* the uterine cavity, passes into the vagina, whence it is forced outwards by the contraction of the vaginal walls aided by the abdominal muscles. Hence there are three distinct stages in the delivery of the after-birth ; which we may divide, like Desormeaux, into the detachment of the placenta, its expulsion from the uterus, and its expulsion from the vagina. The detachment of the placenta is not always accomplished in the same way ; the process varying with the part of the uterus to which it is united. For instance, when attached to the fundus, the separation first begins near the centre of the mass, because this is the thickest part, and can least accommodate itself to the retraction of the uterine walls ; whilst its thinner margins, being more easily wrinkled, are less liable to rupture the tissue connecting them with the womb ; a lenticular cavity is thereby created, which is bounded externally by the still adherent borders of the placenta. A quantity of blood is gradually effused into this cavity, which contributes, with the uterine contractions, to effect the separation ; thus, in this case, the detachment is effected from the centre towards the circumference. The placenta, being wholly detached, then descends to the orifice, its foetal sur- face corresponding to the latter, and becoming the external face, whilst the uterine surface is the internal face, which, together with the inverted mem- branes, constitutes a pouch, wherein such a quantity of fluid or coagulated blood is occasionally collected, as to seriously impede its delivery. When it is attached to the anterior, the posterior, or the lateral portion of the womb, the separation commences at one of the margins ; or, if at the centre, it is soon propagated towards one border, generally the superior, though, in some instances, the inferior one. In the former case, the process advances in the way just described, and the placenta again presents, by its foetal surface, at the cervix uteri; but, in the latter, being suspended on the uterine wall until the detachment is completed, it presents at the neck by its inferior margin. It is then generally folded upon itself, and engages in the orifice rolled up in a conical form. When the placenta presents its fcetal surface at the os uteri, it plugs up the orifice by its bulk, and prevents the blood from escaping ; wherefore, its delivery in such cases is usually followed by the expulsion of numerous large coagula. But where only one border engages, there is no obstacle to the issue of the blood, and hence the discharge of this fluid commences with I he detachment of the after-birth, is increased at every pain, and persists throughout the whole process. From the description just given, the reader would naturally suppose that the detachment of the placenta only begins after the child is born; this, however, is not always the case. In fact, the following phenomena are more usually observed to take place: as soon as the labor-pains are developed DELIVERY OF THE AFTER-BIRTH. 383 and the dilatation of the os uteri has commenced, the separation of the ovum hegins in the neighborhood of the uterine orifice, and then gradually progresses over all parts of its surface, although not in a perfect and com- plete manner. After the membranes are ruptured, and the waters are partially discharged, the uterine cavity diminishes ; the ovum becomes wrinkled, and its detachment is carried to a still greater extent; even involving the after-birth, as proved by the fact that the fluid or coagulated blood is frequently expelled simultaneously with the foetus, in cases of pro- tracted labor ; which blood must evidently come from that portion of the uterine surface in contact with the placenta. A separation of the greater part of the placental mass is particularly apt to occur in the breech pre- sentations in consequence of the gradual contraction of the womb, a.s the lower parts of the foetus are delivered. The interval between the child's birth and the delivery of the secundines is very variable. Dr. Clarke, from a great number of observations, estab- lished its mean duration at twenty-five minutes ; but if by this a perfectly spontaneous delivery is to be understood, one in which no traction is made on the cord, we believe he is in error, for this interval is generally much longer. At the instance of M. P. Dubois, we made some experiments, in 1836, with a view of determining this question ; and those researches proved that, when the delivery was left entirely to nature, the final expulsion of the placenta did not usually occur under an hour or an hour and a half after the birth of the child. It is true, the detachment of the after-birth, and its removal from the uterine cavity, is effected, as Clarke states, in the course of fifteen, twenty, or twenty-five minutes ; but, having passed into the vagina, it some- times remains there for several hours without causing the least irritation by its presence, the least tenesmus, or bearing-down effort. This circumstance is easily explained by the fact that the sensibility of the vaginal walls is blunted, as it were, by the long pressure they were subjected to from the head and other parts of the child. Besides which, as Levret long since remarked, the after-birth will be the sooner expelled in proportion as the patient is stronger, and the contractions more energetic ; as the quantity of water in the womb was smaller, and as the period between the rupture of the membranes and the delivery of the child was the longer. Although its delivery may generally be left to the powers of nature with- out any serious inconvenience, yet it is equally true that it will be delayed a long time in a large number of cases. Now, such a delay would force the patient to remain on a bed, which is poorly adapted for repose after all the fatigues of labor ; and besides, so long as the delivery is not completed, she still considers herself exposed to numerous dangers, and her fears may have an unfavorable influence over her condition. On this account, most of the accoucheurs of the present day believe it advisable to accelerate the extraction a little, for the purpose of relieving the woman from her anxiety, and of sparing her unnecessary pain ; without, however, attempting to deliver the secundines immediaiehj after the child's birth. But, before making any traction on the umbilical cord, it is necessary to ascertain the situation of the placenta, and especially the condition of the uterus. If the latter is small, hard, and contracted, and situated in the lowest part of the 38-i LABOR. abdomen, it is infinitely probable that the placenta is. in great part at leasi, expelled from the cavity of the womb into the vagina. This, however, may be easily ascertained, for the finger introduced into the vagina readily detects the mass, and even distinguishes the insertions of the cord. There is then, generally, nothing to prevent its being extracted at once, and simple tractions upon the external end of the cord are all that are required for this purpose. "When, on the contrary, the uterine tumor continues on a level with, or even above the umbilicus, and has a soft doughy feel, due to its imperfect contraction, the placenta is very probably still within the womb, and the first object should be to ascertain whether or not it is detached. Now we know that the separation is usually accomplished by the fresh contractions that reappear after the apathy which follows the expulsion of the child ; and hence, there is every reason to suppose it is completed when these con- tractions have repeatedly occurred. A little blood usually escapes from the vulva during the process. Finally, if one or several fingers be passed up to the uterine orifice, the after-birth is found presenting there, and, if it should not be met with, the accoucheur may rest satisfied that the separa- tion is not yet completed, and therefore he ought to wait. Should the detachment be delayed too long, frictions over the fundus uteri are resorted to, for the purpose of rousing the pains, or the same object is produced by titillating the cervix uteri with one or two fingers. Great care should be :,dken not to make frequent tractions upon the cord, for unpleasant conse- quences might result. Thus, if the placenta is completely adherent, the tractions are liable to detach a part, and give rise to hemorrhage, or they might tear away a portion of the after-birth and leave the remainder in the womb ; again, the organ might be inverted or the cord ruptured thereby. Certain writers recommend a ligature on the placental extremity of the cord after the child's birth, for the sole purpose of facilitating the detach- ment of the after-birth. The easy separation when this has been done, says M. Stoltz, is caused by the weight and turgescence of this organ, which, when expelled, is found to be engorged with blood ; this practice is attended with no inconvenience, and is at least beneficial by preventing the patient's bed from being soiled with the blood that ordinarily escapes from the cord. After its entire separation, the after-birth constitutes a foreign body in the uterine cavity, which the organ endeavors to dislodge by contracting. These contractions, Avhich are recognizable by the hardness of the uterine globe, and which are usually perceptible to the patient, indicate the time for operating ; the accoucheur then takes hold of the umbilical cord, after having enveloped it with a cloth so as to prevent it from slipping, and winds its end around one or two fingers; he next makes a moderate trac- tion with a view of extracting it, but, as soon as any resistance is felt, he ought to slip up two or even three fingers of the other hand along the upper surface of the cord as far as the os uteri; the points of these fingers, which are intended to press the cord backwards, are brought together so as to receive the latter in the entering angle thereby formed, around which it plays like a pulley. To understand the advantage of this manoeuvre, it is Dnly necessary to bear in mind that the tractions made by one hand alone DELIVERY OF THE AFTER-BIRTH. 385 would correspond to the axis of the vagina, which forms an angle with that of the uterus; whence it happens that the placenta, instead of being drawn towards the centre of the orifice it has to traverse, would abut against its anterior border, and the corresponding parts of the cervix, upon which all the tractive efforts are spent. The patient should be directed to bear down while the tractions are made. As the placenta clears the orifice, and gets into the excavation, the operator changes the line of action, and gradually carries the cord forward, so as to make it always correspond with the axis of the pelvic canal. Under the joint influence of the tractions and the patient's bearing-down efforts, the placenta soon reaches the vulva, where it is seized by the thumb and fingers and twisted round several times, so as to complete the detachment of the membranes and form them into a solid cord, for the double purpose of preventing their laceration and of securing their entire removal. 1 It is impossible to state precisely the amount of force which may be used in these tractions upon the cord, and it must be left to the intelligence of the practitioner to discover what is proper to be done. When, however, the tractions have no effect, and the placenta seems to rise up and draw the cord after it, as soon as they have ceased, all efforts should be suspended for the time being. " When the placenta is partially engaged in the orifice by a portion of its periphery, this plan," says M. Guillemot, " ought to be somewhat modified ; for in this presentation, the root of the umbilical cord, instead of corre- sponding to the cervix, is higher up in the uterine cavity ; and hence, if the operator resorts to traction, the centre of the placenta will have a tendency 1 There certainly would be no very great danger in leaving a portion of the mem branes in the uterine cavity; although, in addition to the accidents that may aviso from the presence of a foreign body there, the following phenomenon might possibly occur. The membranes may inclose some coagula, and thus form a mass whose expul- sion is often difficult. In the course of a few days, the uterus, being irritated by the presence of this inconvenient, lodger, begins to contract, and the woman experiences some colicky pains, varying in intensity with the strength of the contractions; a little blood escapes from the vulva, and, after the pains have lasted for a longer or shorter period, the patient is finally delivered of the foreign body, or, according to her expres- sion, of a I iryc piece of flesh, the appearance of which causes great alarm. Placental Expression. Crede's Method. Of late years, delivery of the placenta by com- pression of the uterus has been practised by many under the name of Crede's method. The plan described by this author is to seize the uterus with the hand, the lingers grasping the posterior and the thumb the anterior BUrface of the fundus. Owing to contraction, firm compression is made, thus forcing the placenta and membranes out of the womb. (See page 1073.) Playfair recommends thai the fundus should be grasped in the hollow of the lefl hand, the ulnar edge being well pressed down behind, and when the uterus is felt to hardi n Strong and firm pressure Should be made downwards and backwards in the axis of the brim. The uterine surface of the placenta, by this method, is generally the lirsi expelled, the membranes remaining within the vagina. The precaution is given to receive the placental mass in the palm of the right hand. to avoid any strain upon the membranes which mighl otherwise happen, and thus leav< a portion within the uterus. One objection to the above method is the chance of part of the membrane- being torn off and left in utero. 25 336 LABOlt. to enter the orifice, and tluis add its bulk to the disk already engaged there. Such a disposition sometimes constitutes an obstacle to the further delivery of this mass; but it is surmounted by making some moderate tractions, not nil the cord itself, but rather upon the part previously engaged, by applying two fingers on its surfaces." We have had numerous opportunities of test- ing the practical utility of M. Guillemot's advice. '• This seems," says Merriman, "all that it is right, to do, for a full hour after the child is born ; but that time being elapsed, and there being no reason to expect that uterine contractions will spontaneously arise, the accoucheur is to consider whether it is prudent to wait longer, before he proceeds to extract the placenta, by introducing his hand into the uterus. "If no bad symptoms are present, there can be no danger in allowing more time to elapse before we proceed to this operation ; especially, if there be reason to think that the retention arises principally from the exhausted state of the patient; because it is possible that a little more delay will recruit her strength, and that afterwards sufficient power may be imparted to the uterus to expel the placenta. " Yet, generally speaking, we can have but little expectation that the placenta will be expelled by the natural powers, after it has been retained much more than an hour ; we may, therefore, consider ourselves justified in interfering to extract it, at the end of an hour or two after the child is born, "It appears, then, to be a question of prudence or discretion, which every accoucheur must judge of in the individual case he is attending, whether to proceed to delivery at the end of the hour, or to wait another hour or two before he undertakes this operation. But, of course, this only applies to cases where there is no apparent danger." (Synopsis, page 153.) " The time for interference of the accoucheur for the delivery of the placenta, should always be regulated by the condition of the uterus itself," says Dewees, " and that condition is whenever it is firmly contracted. Time, simply considered, can never form a safe rule for the delivery of the placenta ; the degree of contraction of the uterus alone can point out the proper moment to operate, or teach us when it would be improper to attempt it. This rule, I believe, will never deceive, or at least I have uniformly acted upon this principle; and, so far, I think I am safe in saying, I have not had cause to believe it wrong." (System of Midwifery, page 447.) As soon as the placenta is delivered, we must ascertain whether any por- tion of it, or of the membranes, has been left behind in the womb ; but this is easily done by carefully examining the secundines. Should it happen that the membranes or after-birth are not extracted entire, it would be proper to pass the hand into the uterus, for the purpose of removing the remnants. If a large quantity of the coagula that usually accompany the placenta remains in the womb, they may subsequently become a source of the after- pains yet to be described. Consequently, if there is reason to suspect the presence of large clots in the womb, the latter ought to be stimulated to contraction by repeated frictions over the hypogastrium. Some authors have even recommended the introduction of the hand into the uterine cavity, so as to rid it completely of all foreign bodies; the advice is good, but to be followed cautiously, because, on the one part, the uterus would DELIVERY QF THE AFTER-BIRTH. 387 be unnecessarily irritated, and on the other, it would not prevent the subse- quent formation of fresh coagula. We stated above, that usually in the course of fifteen, twenty, or twenty- five minutes after the birth of the child, the uterus, by contracting, notifies the accoucheur, as it were, of the proper moment for his intervention. It should always be remembered, however, that moderate tractions are all- sufficient for the delivery of the after-birth ; and, if much resistance is met with, it would be far better to wait, and not make any new attempts, until the contractions shall have partly or completely overcome the obstacle. Where there is the least reason to suspect the existence of a second child, after the birth of the first, the physician ought to satisfy himself on that point, both by an external and an internal exploration, before attempting to remove the placenta ; and should a twin pregnancy be recognized by the great size of the womb, and more particularly by the vaginal examination, a ligature is to be applied immediately on the placental extremity of the cord belonging to the first infant ; and the secundines are only to be extracted after the expulsion of both children. If, however, the placenta were detached, and presented at the orifice, he should attempt to extract it, more especially when it seems to obstruct the passage of the second foetus. Nevertheless, such tractions ought to be exceedingly reserved ; because, in compound pregnancies, there are frequent adhesions between the two placentas ; and, if this were the case, it is evident that any forcible traction might detach the after-birth of the second child long before its expulsion ; and this premature separation would render the mother liable to severe hemorrhage, and the child to fatal asphyxia. After the birth of both children, so far from pulling on the two cords simultaneously, and moderately twisting them into one, it is more prudent to bring down the placentas, one after the other, giving the priority to the one which offers the least resistance. The mass of these conjoined bodies is made to engage in this way by one extremity ; and it is thus enabled to clear the uterine orifice more readily. In most cases of compound pregnancy the womb is excessively distended, and this distention, aa we are all aware, is one of the circumstances that is most likely to enfeeble the contractility of its tissue ; therefore the removal of the after-birth, after the labor is over, should not be accelerated too much, and the womb must be allowed a longer time than usual for its retraction ; while moderate frictions are to be made over the fundus of the organ for the purpose of stimulating its action. As regards the removal of the secundines after a miscarriage, we have nothing t) add further than what will be stated in the article on Abortion. 388 LABOR. CHAPTER VII. OF THE NECESSARY ATTENTIONS TO THE WOMAN AND CHILD DURING LABOR. ARTICLE I. OF THE ATTENTIONS TO THE WOMAN DURING LABOR. When the accoucheur is summoned to a woman in labor, he shouH always provide himself with lancets, a female catheter, and the forceps; and, if in the country, he should have besides some ergot, either the wine or the fluid extract, arid one or two drachms of Sydenham's laudanum. His arrival ought always to be announced before entering the patient's chamber, for the emotion caused by a sudden entrance often proves sufficient to suspend the pains for a considerable time. Then, after having made the usual inquiries as to the time at which the pains began, their frequency, their duration and intensity, he might, if he supposes from this account the labor to be somewhat advanced, proceed at once to the vaginal exploration ; in the contrary case, he may wait a few minutes, as well to satisfy himself of the value of the communications made by the attendants, as to give the woman time to prepare for the examination. When he finally judges this is necessary, he is to proceed with all possible decency, and always during the interval between the pains. The object of this is to endeavor to ascer- tain: 1, whether the woman is pregnant; 2, if she is. in labor; 3, if she is at full term ; 4, whether the membranes are ruptured ; 5, whether the labor is far advanced; 6, what is the condition of the cervix, vagina, and perineum, and their degree of suppleness or resistance; 7, what is the conformation of the pelvis; 8, lastly, what part of the child presents. At first sight, it may seem a ridiculous precaution to attempt to verify the existence of the pregnancy in a woman who declares she is actually suffering from the pains of childbirth ; but, to say the least, this is not altogether useless, since it has unfortunately happened that some over-con- tident accoucheurs have been imposed upon by women who were themselves deceived as to the nature of the pains they felt; and we might quote many instances where, after having waited for the delivery to take place for several days, they have ultimately been constrained to acknowledge their mistake. Besides, this error is easily avoided by bearing in mind the diagnostic signs pointed out in the article on Pregnancy. After observing the progress of the pains for some instants, he should next endeavor to ascertain their cause and nature, in order to favor those which have a bearing on the labor, and to combat any that are foreign thereto. Women are not unfrequently tormented by pains during the latter stages of gestation, which are dependent on some sympathetic disorder of the intestines, or abdominal organs, and which even a physician might mis- take for the commencement of labor ; these have been denominated the false pains, by way of distinguishing them from those produced by the con- traction of the womb. The true and the false pains may be recognized by ATTENTIONS TO THE WOMAN AND CHILD. 389 trie following characters: the latter are ordinarily seated m the region occupied by the diseased organ, while those occasioned by the commence- ment of the travail usually begin about the umbilicus and loius, and die away at the perineum, the anus, or the sexual parts; the false are almost continuous, and their intensity is nearly uniform ; the others, on the con- trary, are intermittent. If the irregularity in the return and progression of the pains be such as to leave any doubt as to their character, he should interrogate the neighboring organs, and by a little attention he will suc- ceed in determining their seat and nature. There are, however, certain pains which have their seat in the uterus itself, affect a certain degree of regularity, and simulate a true labor, which are dependent on a plethoric condition of the organ, that may be calmed by rest, a restricted diet, and blood-letting. Further, the epoch at which they occur, and the absence of the other phenomena of labor, will serve to lessen the difficulties in deter- mining the diagnosis ; nevertheless, it is the touch alone that can dispel all doubts ; for the hardness that comes on in the uterine globe, the rigidity in the circumference of the os uteri, the tension and protrusion of the mem- branes during the pain itself, together with the retreat and relaxation of all these parts in proportion as it diminishes, characterize the pains of child- birth in an infallible manner. " By examining," says Wigand, " the course of the true contractions, it will be found that they commence at the cervix, and pass to the fibres of the fundus, which are then thrown into action ; and hence all contractions that begin in this latter part of the womb are anomalous, and result either from some disorder having occurred in the uterine forces, or else they are pro- duced by an inflammation, or a disturbance in the functions of a neighbor- ing organ." When the true pain is manifested, the head, which reposed during the interval on the cervix, sometimes mounts up even beyond the reach of the finger, but the membranes engage more or less in the orifice. In the course of a few seconds, the contraction extends all over the uterus, and more particularly to the fibres of the fundus; and the head, which was at first elevated, is forcibly pressed down on the neck, thus assuming the office of a wedge for hastening its dilatation; and, as a general rule, it is only when the fundus contracts in this manner, that the woman complains of pain. We may, therefore, consider the true pain as constituted of a series of phenomena, which succeed each other in the following order: first, the periphery of the cervix becomes tense ; then, the presenting part ascends, and the membranes bulge out; next, the remainder of the uterus, the fundus especially, becomes hard, during which the patient complains of a sharp pain ; and, lastly, the part that presented endeavors anew to engage. It is unnecessary to add, that the rapidity with which these phenomena succeed each other necessarily varies according to the individual, to the irregulari- ties to which the process is subject, and according to the stage of the labor. Other things being equal, the contractions will effeel the dilatation so much the soouer, in proportion as the cervix shall correspond more directly to the fundus of the organ, and the uterine axis shall he the more parallel to that of the pelvis. After having learned the true character of the pains, the accoucheur ncx' 390 LABOR. endeavors to ascertain whether the woman is really at term, so as not to encourage a premature labor, which might often be prevented if he knew its cause. He ought, therefore, to recall the various signs, by means oi which we have attempted to characterize the different periods of pregnancy. Thus, should he find that the cervix is not yet entirely effaced, that it still retains a certain degree of length, that it is hard and resistant even during the interval of the contractions ; that the hitter are much less regular in their course, duration, and return, than in parturition at full term ; and the belly not yet sunk down; he may justly conclude that the patient has not yet reached the end of the ninth month ; also, that such a premature labor is owing either to some acute moral emotion, or some antecedent external violence. In all cases, he ought to attempt the arrest of this premature or false labor, by rest, both of body and mind, by venesection, if the woman's general condition will admit of it, and, more especially, by the administration of laudanum in full doses, taking care to empty the bladder when necessary, and to keep the bowels free by mild laxatives. The use of means to stop the premature labor ought not to be given up, even though the cervix be entirely effaced, the orifice somewhat dilated, and a certain amount of water discharged ; inasmuch as the escaped fluid might proceed from a hydrorrhoea and not from within the amnios, whilst prema- ture pains can sometimes be calmed and the pregnancy enabled to proceed to full term. Very conclusive observations on this point were published in 1857 by Dr. Charrier: he cited cases in which the dilatation equalled a quarter of a dollar in size, and in which the pains were suspended notwithstanding the membranes were engaged in and projecting from the orifice. The cervix afterwards closed in such a way as to reproduce its external orifice, and to present the conical shape which it has in the eighth month of gestation. This phenomenon, styled by M. Charrier, retrocession of labor, though doubtless rare, need only be possible in order to encourage the practitioner to suspend the labor whenever he is sure the membranes are intact, the child alive, and the woman not at term. However, there is one phenomenon, sometimes manifested in the latter weeks of gestation, which may place the most skilfui practitioner at fault. 1 allude to what has been designated as the false labor, in which certain women, after having nearly reached their full term, experience the true contractions ; the pains are regular, the membranes bulge out, and the os uteri dilates ; at times, these pains last from four to six hours, but then they disappear all at once, and everything goes on as usual. In others, the false labor is kept up at first during several hours, and then it passes off, return- ing in this manner every day, particularly towards the evening, and lasting one or two weeks. (See Uterine Rheumatism.) When the accoucheur is very sure that the woman is really in labor, his attention must be directed to the frequency and the intensity of the pains, and to the dilatation, the hardness, and thinness of the cervix, in order to judge of its probable duration. During the same exploration, he should ascertain the conformation of the pelvis, particularly if the woman happens to be in her first confinement, and it' any apparent deformities exist; he ATTENTIONS TO THE WOMAN AND CHILD. 891 should also learn the situation of the orifice, the obliquity of the body and neck 4)f the womb, and the child's presenting part. (See Mechanism of Labor.) If this latter is so high up as to render the diagnosis of the pre- sentation difficult, its examination should be deferred until a more advanced period of the labor; but the bag of waters is never to be ruptured, in any case, for the mere purpose of rendering this examination more easy, before the entire dilatation of the neck ; for such an untimely rupture of the mem- branes would be attended by very great inconveniences, if the position were at all defective ; for, all the waters escaping, the foetus might suffer from the pressure exercised directly upon it by the uterine walls; the umbilical cord would be compressed ; and the womb, irritated by the prolonged con- tact of the foetal inequalities, might be affected with spasmodic contrac- tions ; and, finally, the intervention of art becoming necessary, long alter the evacuation of the waters, the necessary manipulations would be attended with much greater difficulties. But it is not always so easy a matter as one might imagine to ascertain whether the membranes are ruptured or are still intact; for instance, where the vaginal examination is resorted to between the pains, in a vertex pre- sentation, they are often applied so directly to the scalp that it is impossible to distinguish them. A pain should then be waited for, because, as soon as the uterus contracts, it drives the waters towards the lower parts, and the finger is observed to be raised up by a small quantity of this fluid that in- sinuates itself between the head and the amniotic sac, the integrity of which latter is thereby easily verified ; but where the head is more deeply engaged, this afflux of liquid is very inconsiderable, and the tension of the mem- branes can scarcely be distinguished. Consequently, attention should be given to the state of the tumor both during and after the contraction. Where the waters have escaped, and the finger comes directly upon the child's cranium, it will detect the hairy scalp puckering up while the pain lasts, and becoming smooth and even as soon as it shall have ceased ; though the contrary will take place when the membranes are intact, for they are never more smooth or more tense than during the contraction itself. It is difficult at times to reach the cervix uteri in the commencement of the iabor, because it is then carried so far backwards that the plane of its orifice actually looks towards the anterior face of the sacrum. I have often seen young practitioners who were unable to get at it at all, and others, who, not finding the os uteri, and distinctly feeling the child's head through the anterior inferior part of the womb, which is then rendered very thin by the distention it has undergone, have imagined that the dilatation was al- ready completed, whereas it had hardly commenced; the disastrous conse- quences to which such an error might Lead, can be readily imagined. In fact, it is very often necessary to pass the finger around the convex tumor which fills the excavation, in oi'der to get the index far enough upwards and backwards, where the uterine orifice is to be found. All these questions being determined, the accoucheur's attention should be directed early in the progress of the confinement to having the woman moved into the most suitable place. The chamber intended for her lying-in should be spacious, airy, well lighted, and retired ; the air she respires ought 392 LABOR. to be pure and of a moderate temperature, and all strong odors, whethei good or bad, should be excluded. A temperature too elevated will predis pose her to nervous agitation, and to hemorrhagic accidents; and, on the other hand, the impression ol* culd is a very frequent cause of acute inflam- mation, or of chronic engorgements, such as those that often come on aftei delivery, which have for so long a time been attributed to lacteal metas- tasis. But few persons are to be admitted in the chamber, and all those, especially, whose presence is at all unpleasant to her, ought to be rigidly excluded. This latter point demands the greatest care on the part of the physician, for it is he alone who has authority thus to dismiss such as ho may think useless or injurious, and he must judge, from the reception given to each, of the pleasure or otherwise the patient experiences from their pre- sence. Some women are almost ashamed of being delivered in the presence of the husband ; with others, on the contrary, it is one of the greatest con- solations to have him near them, and the accoucheur must endeavor to dis- cover all the little shades of delicacy and feeling, to sound, by discreet and artful questions, a wish that the woman herself at times fears to express, and, alter having once learned it, he should religiously comply with it. As a general rule, the mother and sister, or two intimate friends of the patient, besides the nurse, are the only ones that are to be allowed to stay in the room. With regard to dress, her garments should be full, sufficiently so, as neither to incommode her movements nor her respiration. If some time has elapsed since she has had a passage from the bowels, a simple injection must be given ; and where this does not prove sufficient to procure a stool, a second is to be immediately administered with the addi- tion of one or two ounces of the miel mercuriale. 1 The evacuation of the matters contained in the rectum is the more necessary, as its distention might subsequently retard the escape of the head, and likewise prevent that of the intestinal gases, whose accumulation might bring on colic and grip- ings; besides, this precaution has the advantage of sparing the woman the shame and disgust which an involuntary expulsion of the faeces during the last moments of labor would necessarily cause, as also of preventing the accoucheur's hand from being soiled, while it supports the perineum. The accumulation of urine in the bladder ought likewise to be prevented, by persuading the patient to urinate in the very commencement of her par- turition ; for, where she has not observed this precaution, or the physician arrives too late to insist upon it, the emission of water becomes more and more difficult, and sometimes quite impossible, owing to the compression which the head, engaged at the superior strait, makes on the neck of the bladder. In such cases, he should endeavor to push the head up somewhat bv two fingers, so that she can urinate ; and if this does not succeed, the catheter must be resorted to. We have elsewhere stated that it was advis- able, under such circumstances, to use a male catheter, the curvature of which is greater; though, even by taking this precaution, a considerable resistance is occasionally experienced to its introduction. This condition i This preparation is only used as an injection ; it is prepared by taking equal parts of clarified honey and the juice of the mercurialia annua, a plant belonging to the tribf of the Euphorbiaceae, an 1 reducing hem to the consistency of a syrup. — Translato" ATTENTION'S TO THE WOMAN AND CHILD. 393 requires the most careful manipulation; the woman must lie flat on her back, and then, with one hand the womb is pressed backwards from the strait, or what is preferable, while the head, which by its presence in the lesser pelvis compresses the urethra, is raised by two fingers in the vagina, the other introduces the instrument into the urethra. The accumulation of urine is attended with such grave consequences as to warrant a persevering effort to introduce the catheter. The least of all the accidents which may result therefrom, is a relaxation, or even the total cessation of the pains ; for the distressing sensation caused by a distention of this organ, which is increased when the abdominal muscles contract, induces the woman to suspend the contractions as much as possible; besides which, the pain itself is sometimes so acute as to paralyze, as it were, the action of these muscles ; and again, as they are separated from the uterine walls by the mass of urine shut up in the bladder, their action is trans- mitted to the womb in but a very feeble manner. The paralysis of the bladder, so often met with after labor, is a common consequence of pro- longed retention of the urine; and finally, the Avails of this reservoir are occasionally ruptured just at the moment when the woman gives way to the most violent bearing-down. Doubtless this last accident is rare, but still it is not without example, since Ramsbotham, Sen., has observed two cases of the kind. ( Obs. Pract., cases 89, 90.) l The tumor thus formed by the over- distended organ may easily be recognized, more particularly after the rup- ture of the membranes, by the soft, fluctuating tumefaction detected imme diately above the pubis, extending at times nearly as high as the umbilicus, at the side of, and behind which, the hard resistant mass constituted by the uterus can be distinguished, whose consistence varies according to whether the examination is made during or after pain. He should also attend early to having everything prepared that may be wanted somewhat later ; thus, the thread intended for the ligature of the cord is to be laid out, and the band and linen for covering the child's navel are to be cut; for the mother, he ought to procure some cold iced water, vinegars, and smelling-salts, agents that will probably be unnecessary, but which, notwithstanding, he ought always to have at hand ; and, lastly, he must direct the preparation of the bed upon which the woman is to be delivered. This bed (called the lying-in bed, the bed of misery, or the little bed) is arranged in the following manner: one with a sacking-bottom is procured, of a moderate height, and about two feet to two and a half in width, and one end of it is placed against the wall, being careful to keep it clear on both sides, so that one can pass freely all around it. A first mat- tress is placed on the bottom, and upon this a second, which covers its upper part, and is folded double towards its superior third, in such a way as to leave the first one uncovered about the foot. An oil-cloth, then a sheet, 1 The symptoms of this accident are very similar to those of a rupture of the womb, excepting that the child remains in situ. There is, besides, a sudden and sharp pain in the vesical region, and the patient complains of the sensation caused by the effusion of the liquid into the abdominal cavity, syncope, &c. The signs peculiar to the vesical rupture are the collapse and disappearance of the tumor previously formed by the bladder (nhich could be felt above the pubis), and an obscure fluctuation in the belly 394 LABOR. some pillow?, and a coverlet, complete the furniture of the bed. A s did bar is placed transversely across the foot of the bed, so as to give the woman's feet a solid point of resistance in the last moments of her labor. In France, the patient is so placed that the upper part of her back rests on the inclined plane formed by the second mattress, and her breech at the margin of the same mattress ; the inferior extremities are slightly flexed, and the feet press against the transverse bar placed at the foot of the bed. In England, women are delivered on the edge of their beds ; they lie on the left side, having their legs and thighs flexed, and their knees separated by pillows. In Germany, the lying-in chair of the ancients is used ; the patient is placed on an inclined plane, which can be modified at will, by lowering or raising the back, by means of a rack ; the woman then draws on the arms of the chair, and presses her feet against the rounds with which it is sup- plied, and, as she gives way to the throes of labor, the sexual parts are uncovered, and correspond to the opening made in the edge of the seat. But, on the whole, the bed, furnished as we have described, appears prefer- able, the more so, because it is always at hand ; and, as suggested bv Desor- meaux, it is particularly suitable where the woman must remain recumbent during the whole progress of labor, as is necessary whenever she is affected with hernia, or is threatened with hemorrhage, prolapsus, or a displacement of the womb. In case of necessity, its place might be supplied by a table and a few chairs placed against the wall. It would be much better, say Desormeaux and M. P. Dubois, where the family are in easy circumstances, to make use of an ordinary bed, taking care, however, to supply it with a rather hard mattress, and a hard cushion near the buttocks, to prevent the pelvic region from sinking down into the substance of the mattress, and the borders of the hole thereby produced, from forming an obstacle to the extension of the coccyx, or the escape of the child's head. On this bed, the woman is more at ease ; she can lie on her side, or take the most convenient attitudes, and even sleep during the intervals of the pains ; and then, after the delivery, she may remain there some tiim before being transported to another. Ought the accoucheur to remain constantly with the patient? This is a (piestion whose solution varies according to the character of the female her- self, and the greater or less intimacy existing between her and her physician, lor there are some timid women who desire to have him always close at hand, and others again, who are impatient and annoyed by his continual presence. But in all cases, he should bear in mind that, during parturition, the patient very often wishes to urinate or to empty her bowels, and lie ought, therefore, to go from time to time into an adjoining chamber, in order to give her the desired opportunity. Again, during the labor, a wife is fre- quently cheered up by the caresses and consolations bestowed by her husband; the physician will understand that his presence at such times must act as a restraint, and lie should discreetly withdraw, or, at least, not observe what is going on. Further, he may absent himself more frequently during the period of the dilatation; for instance, after having made the examination, and ascertained that the child's presentation and position are both favor nble, he might, if the cervix was just beginning to dilate, attend to his othei ATTENTIONS TO THE WOMAN AND CHILD. 395 occupations, and return again in the course of a couple of hours; but if the diagnosis of the position had been impossible, or if the latter had proved to he an unfavorable one, he must not quit her under any pretext, in order to be always ready to ward off any accidents which might subsequently demand his intervention. When the stage of expulsion commences, the accoucheur places himself at the right of the bed, on a chair of a suitable height. The part he has to perform consists, in a natural labor, in ascertaining its pro- gress, from time to time, by the touch, in directing properly the bearing down efforts of the patient, and in sustaining the perineum with his hand while the child's head is passing through the vulva. During the first stage, the woman may lie down, sit down, or walk about, at her pleasure ; indeed, this frequent change of position renders the slow- ness and fatigues of childbirth more supportable ; but, at the end of this stage, when the dilatation is completed, and the amniotic sac projects strongly, and is on the point of yielding, she must then resume her bed ; and this precaution is particularly indispensable in those who have already borne several children ; because, in them, the expulsion of the foetus some- times follows so promptly after the rupture of the membranes, that the patient has not always the time to regain her bed, and is liable to be deliv- ered standing. But when, after the rupture, the progress of the labor is slow, and the head is more or less engaged in the excavation, or has already descended as low as the perineum, but does not advance, and the pains seem to become more and more feeble and distant, it is advisable to recommend her to get up and walk about, having her supported by assistants, if her own strength does not permit her to walk alone, for it is found by experience that bodily motion seems to give more activity to the uterine contractions. In the contrary case, she must not leave the bed without some special indica- tion. Where the patient is tormented by pains in the loins, we may relieve them by stretching a folded napkin under the small of the back, and direct- ing two persons, placed at the opposite sides of the bed, to pull on the ex- tremities of the towel during the pain. Attempts should be also made to assuage the cramps, so often experienced in the thighs and calves of the legs, by voluntary contraction of the antagonist muscles of the suffering ones, which will be far more effectual than frictions over the suffering parts. Some nervous women are troubled with tremblings and chills, in the very commencement of their labor, which are at times sufficiently marked to cause much disquietude. Dewees observed that they often coincide with an unusual rapidity in the dilatation of the cervix, and he says: " A lady, who every moment expected her labor to commence, was awakened suddenly in the night by a violent chill. The nurse became alarmed, and I was imme- diately sent for. When I arrived, I found her still trembling very severely, but she had not experienced any symptoms of labor; she assured me that nothing was the matter with her except what I was witnessing, namely, an agitation of the whole body, which she could not, by any effort, control. In about five minutes, she cried out she believed her labor was coming on ; and this really was the case, and so rapidly as not to give me time to place her in a proper situation for delivery; she was delivered in less than live mir.utes from the time she first called my attention to her. These shiver 396 LABOR. ings are sometimes renewed during or immediately after the labor, oui. hi no ease do they merit a serious attention." Patients are often frightened at the time the bag of waters is torn, and it is therefore a good plan to advise them of it beforehand; and the precau- tion should also be taken of placing a sponge or some old linen near the genital parts, so as to receive the liquids as they escape. Immediately after the discharge of the waters, it is advisable for the practitioner to assure himself anew of the presentation and position, lest he might have been deceived in the first examination. The rupture of the membranes generally takes place spontaneously, but this is not always the case, and the accoucheur must sometimes interfere. It is very certain that when the uterine orifice is entirely dilated, when the membranes are forced into the vagina by a large quantity of fluid, and the head is movable, but still the contractions do not produce a spontaneous rupture of the membranes, — it is evident, we repeat, that they, by their resistance, prolong the labor. Although this obstacle is never insurmount- able, by the efforts of nature alone, yet the delay in the delivery and the dragging on the membranes may be attended with some inconveniences, and it is therefore better to lacerate them. This is done by taking advan- tage of a strong contraction, and, while, they are greatly distended, forcibly pressing the index finger against the centre of the tumor. When this rough pressure is not sufficient, we scratch the membranes with the finger-nail ; and by gradually weakening the three tunics, succeed in rupturing them. Sometimes, however, they still resist, and then some instrument, such as a blunt probe, or, still better, the end of a quill cut down, is directed up to them along the finger. M. Dubois made for the same purpose a very convenient instrument, consisting merely of a piece of whalebone sharpened at one end. Where the waters breflat, that is, when but little liquid intervenes between the membranes and the head, some care is requisite, in using the little instrument, to direct it obliquely, so as not to wound the foetus with its point. Rupturing the membranes is, therefore, a trilling operation ; still, excepting in some rather rare cases to be spoken of hereafter, it ought not to be performed until after the orifice is thoroughly dilated. Whatever the presenting part may be, there is always an ad- vantage in retaining a large amount of fluid in the uterus. Some peculiar circumstances may, however, demand the artificial rupture before the dilatation is completely effected. In a ease reported by Baudelocque, the child was so movable, that it suc- cessively presented every part of the surface of its body at the os uteri. In a woman whose belly was distended by a great quantity of water, M. Martin, of Lyons, had recognized the feet and one hand through the membranes. '•I then felt disposed," says he, "to terminate the labor, when, at the request of her husband, I called a friend in consultation; but on touching her again, before his arrival, I detected the head where I had previously found the feet and hand, when I immediately punctured the membranes, whereby the head was fixed at the superior strait and the delivery rendered natural." I Cmnj,!.* Rendus, p. 155.) Should a case of this nature be met with, the rule we have just given might be laid aside, and the membrane? ATTENTIONS TO THE WOMAN AND CHILD. 397 be ruptared, however inconsiderable the dilatation. It is scarcely necessary to add that an artificial rupture is only to be resorted to when the foetus shall be detected presenting by its cephalic extremity ; for then the dis- charge of a certain quantity of the amniotic liquid, and the retraction of the uterus, will irrevocably fix this part at the upper strait. Again, according to the majority of writers, the membranes maybe lacer- ated before the entire dilatation of the cervix, where there is reason to suppose that the waters, from their too great abundance, distend beyond measure, and thus Aveaken the contraction of the uterine walls ; but, even here, Gardien recommends the greatest circumspection, and advises the previous employment of all the measures calculated to stimulate the con- traction of the womb. Finally, we shall learn hereafter that the puncture of the ovum at an early period of labor, is one of the most effectual means of arresting certain dangerous hemorrhages which may supervene during its progress. The finger ought to be introduced into the vagina several times in the course of the last stage of labor, both during the pains and in the interval between them, to ascertain the progress of the head in the excavation. Nevertheless, this exploration is to be resorted to as rarely as possible, and only when the interest of the mother seems to demand it. Most women, supposing that they can materially hasten the termination of the labor by making the most of their pains, contract their muscles, bear down violently, and make extraordinary efforts at the beginning ; but these uselessly exhaust their strength ; for, so long as the neck is ineffaced, and the bag of waters unbroken, all bearing-down effort is fruitless. But in the second stage, where the head descends into the excavation and rests on the perineum, she should be encouraged to aid the uterine forces by a volun- tary contraction of the muscles of the trunk and limbs; though, as soon as the pain has passed off, all the auxiliary efforts should be at once suspended. Again, in the latter moments of the travail, just when the head is about to clear the vulva, the pains are so sharp that the woman naturally gives Avay to incredible exertions, which may possibly occasion serious accidents ; hence all the powers of persuasion should then be employed to induce her to moderate her strainings. During the last moments of childbirth, the pressure of the head on the lower part of the rectum creates an urgent desire of emptying the bowels ; and many women, yielding to a misunderstood modesty, then wish to rise and retire to the closet; but it would be exceedingly imprudent to comply with their demand, and they must not leave the bed under any pretext whatever. In the first place, this desire is often illusory, more especially where the precaution has been taken to empty the intestine at the com- mencement of labor; and then it may happen, as I once witnessed, that the patient, surprised by a violent pain, is delivered on the close stool, without the physician being able in any way to render her the necessary attentions. It is in these last moments that the accoucheur must give all his attention to supporting the perineum, which is done by pressing the whole perineal surface equally, and with a moderate degree of force, by the palmar face of the hand. The latter is applied in such a way as lo make the radial 398 LABOR. border of the index finger cover the anterior margin of the perineum, the ends of the fingers corresponding to the left side, and the thenar eminence of the palm to the right side of this partition, while the thumb is held to the right of the labia externa. The pressure should be somewhat greater near the anus, so as to give the foetal head a forward direction, and facili- tate its movement of extension. (See article, page 680.) Finally, whatever may be the child's position, we should, contrary to the jpinion of certain authors, abstain from introducing the fingers into the lower part of the vagina, or making pressure on the perineum and coccyx; in a word, from performing what they call their little labor. There are, however, a few measures which may be useful ; for instance, when the geni- tal parts exhibit great rigidity, heat, and dryness, the emollient injections, or frictions with mild ointments, such as cerate, or cucumber ointment, emollient fumigations, or bathing in lukewarm water, may be very advan- tageous. This last remedy, especially, is of marked utility where the abdo- men is tender and painful, and the cervix uteri is rigid and resistant. Within a few years, Professor Simpson has introduced into obstetric prac- tice the use of those anaesthetic agents, which are daily productive of such wonderful results in surgery. The Edinburgh accoucheur does not, how- ever, reserve ether or chloroform for difficult cases, but advises their use in the most natural labors. The importance of the subject demands of us a detailed examination ; and a long article will be found appended, in which, alter having stated the known results, we shall give frankly our own opinions. Regimen of Women in Labor. — Those women whose labors are unusually short, need not, as a general rule, take any nourishment whatever ; but when the travail drags along, it is necessary to sustain their strength by articles of easy digestion ; thus, as many are in the habit of taking coffee with milk every morning, this may be allowed them without danger ; and then, during the day, a few cupfuls of some broth may be given, though always in small quantities at a time. Where the stomach is disordered and vomiting takes place, as very frequently happens, even these liquid aliments will have to be restricted. This plan, however, is not applicable in all cases, since some must be allowed what we should refuse to others ; for example, there is no necessity for subjecting robust country-women to the same severity of regimen as the delicate ladies of large cities. The choice of drinks is also a matter of some importance, and we may recom- mend some pure or sugared water, or a weak infusion of lime, or orange- leaves, of mallows, violets, &c. Lemonade, or wine diluted with water, will be very agreeable to most women at first ; but, in general, they soon produce a sour stomach and eructations; all hot cordials and fermented liquors should be positively prohibited. In the country districts, there is often much difficulty in overcoming the vulgar prejudices on this subject; but the physician must insist upon it, for he ought never to lose sight of the distress and agitation that follow the administration of spirituous beverages, and which expose the patient to inflammations and active hemorrhages. Should it happen that her feeble condition requires any restoratives, then some good broth, or a little old wine, or a few spoonfuls < f sherry-wine, arf the only and the best means that can be employed. ATTENTIONS TO THE WOMAN AND CHILD. 399 ARTICLE II. OF THE ATTENTIONS TO THE CHILD DURING LABOR. Having determined the presentation and position, the accoucheur should next ascertain whether the child is living or dead, as it is highly important to determine this point, in order to diminish his own responsibility, by advising the family of the fact. Before the membranes are ruptured, the diagnosis may be easily made out by ascertaining through auscultation the existence or absence of the pulsations of the foetal heart, as also the continuance or complete cessation of the active movements, in regard to which the woman can always give sufficiently accurate information. After the rupture of the membranes, tLe active movements are feeble, and sometimes entirely absent ; in which case, however, the pulsations are still detected by auscultation. The touch also reveals certain signs which may shed still further light upon the question. Thus, when the child is alive and the head presenting, it often becomes affected with a sanguineous swelling, the size of which depends upon the length of time which has elapsed since the discharge of the waters. This tumor does not form when the child has ceased to live ; and if its death dates back for several days, the resisting tumor foi'med by the sero-sanguineous infiltration will be replaced by a soft, flaccid, and wrinkled condition of the hairy scalp. Besides this, the bones of the cranium will be more movable, and the overriding of their edges greater than usual ; a sort of crepitation is also produced by their rubbing against each other. A more embarrassing case is that in which the child dies some time after the rupture of the membranes, but not before the sanguineous tumor has had time to be developed. Even here the uncertainty will be of short duration, for, provided the labor should continue beyond three or four hours, the tumor will lose its consistency, and its softness and flaccidity render a mistake a matter of difficulty. Finally, when the pelvis is rather contracted, the wrinkling of the scalp may simulate a swelling, whose diagnostic importance it is well to appre- ciate. In this case, says Merriman, the best means of judging of the life or death of the child by the tumor of the scalp is as follows : when living, it is observed that, at the moment when the head is strongly urged down by the contraction of the womb, the bones overlap each other, and, as a consequence, the scalp becomes folded, and thus constitutes a temporary tumor; but immediately after the pain is over, the head regains its primi- tive form, by the expansion of the cranial bones, and the folds and tume- faction previously exhibited by the skin disappear, or, at least, considerably diminish. On the contrary, however, if it be dead, the expansibility of the bones is destroyed, and the head does not reassume its primitive form and volume after the contraction has passed off; wherefore the tumor formed by the doubling of the hairy scalp still persists, in a great measure. Now, in this condition of affairs, the swelling is sometimes greatly augmented by the liquids forced in by the pressure from above, ami whenever, in such cases, a perforation of the cranium has to be resorted to, practitioners well know there is half an inch at least of soft parts to be traversed before reaching the bone. (Merriman's Synopsis.) 400 LABOR. If the face should present, the softness of the lips, and the flaccidity ano immobility of the tongue, should had us to suspect that the child is dead ; since, when living, the firmness of all its parts, and the motion of the tongue, are often felt with ease. In breech presentations, the introduction of the finger into the anus will detect a resistance and contractile power on the part of the sphincter if the child be living, which will be absent if the child be dead. Lastly, in shoulder and arm presentations, the swelling of the member, and its violet hue, will afford an indication in favor of its life. Should the cord hang in the vagina, its softness, withered condition, and the absence of pulsation in the umbilical arteries, would justify a belief that the child was dead. A thick and fetid condition of the amniotic fluid, and a discharge of meconium, have been regarded as indicating the death of the child. The altered condition of the waters is of no great importance, since it has some- times been found to coincide with perfect integrity of the foetal life, but the discharge of meconium is of greater significance. It is not ac all uncommon to find the meconium escaping in greater or less quantity during parturition ; and, as previously stated, this peculiarity most frequently occurs in the positions of the pelvic extremity, and is then of little consequence ; but this does not hold good in any other presentation ; for then its discharge is always an unfavorable sign, one calculated to arouse the anxious solicitude of the medical attendant, as it usually indi- cates a state of suffering on the part of the child, which is almost always due to a compression of the cord. It must be apparent, on the least reflec- tion upon the part performed by the placenta during the intra-uterine life, that an interruption of the foeto-placental circulation produces asphyxia, which latter determines a cerebral congestion, and sometimes even an apoplectic effusion, whence a paralysis of the sphincter ani results. Now, if to this palsy of the sphincters, we add the instinctive acts of respiration 1 made by the foetus, which are the more violent as they are the more ineffec- tual, we can understand without difficulty how an escape of the meconium may result from a compression of the cord. As regards the prognosis, it is important to observe the precise moment at which this discharge takes place, as it is always serious when it does not occur till some time after the rupture of the membranes ; though the waters, when they escape, are often colored yellow, and the presence of the meco- nium then is not necessarily an alarming symptom. In some cases, it may indeed indicate an actual compression of the cord ; but it may also result from a compression that had existed some time before birth, which may have compromised the child's life for a few moments, and then have sud- denly disappeared in consequence of some brisk movement of the infant. It is not difficult to conceive that the cord might undergo a momentary compression during the last months of gestation, as also that it might be displaced by a sudden motion of the child, and the fceto-placental circula- tion be re-established in consequence. Now, this compression may have 1 Mayer has observed respiratory movements in embryos, even within the ovum, as soon as he compressed the cord. ATTENTIONS TO THE WOMAN AND CHILD. 401 lasted so long as to threaten asphyxia, and consequently to prod ice a dis- charge of meconium. Endeavors have been made to determine by the physical characters of the meconium, whether its discharge was occasioned by a presentation of the breech, or by the sufferings of the foetus. It has been said that, in the latter case, the meconium is very fetid, thinner, and more diluted, than when the breech is above the uterine orifice. Such signs, however, are very inconclusive. On the whole, therefore, a discharge of meconium in breech presentations is of little consequence; but, in the other presentations, and where occur- ring some time after the rupture of the membranes, it is always an unfavor- able sign ; though, to judge of its value at the time of the rupture itself, recourse must be had to auscultation. Of all these signs, the best undoubtedly is that supplied by auscultation of the heart, whose pulsations are always perceptible if the child be living. It is quite possible for the pulsations of the cord to escape detection even though the foetus be living, inasmuch as they sometimes stop during the pain and begin again when it is over. Therefore, certainty of diagnosis would require that the pulsations should have ceased for a considerable time, ten or fifteen minutes at the least. In vertex presentations, as soon as the head is expelled its disengagement is effected. Immediately after its expulsion, the disengagement of the head is com- pleted, either by carrying it more and more towards the pubis, or by insinu- ating the index upon one side of the lower jaw ; this being accomplished, we must next ascertain whether the cord does not make one or more turns around the neck, and if so, gentle tractions must be made on its placental extremity, to avoid its being dragged upon, and to prevent strangulation of the foetus, &c. ; and when a sufficient extent of it cannot be brought out, to render the prevention of such accidents certain, we have to cut it, and terminate the labor as promptly as possible, by hooking one or the other shoulder with the forefinger.' After the head is born, the womb, exhausted by its last efforts, remains passive for some instants, and it frequently hap- pens that the child begins to respire and cry, even before the delivery of the chest. We may, therefore, wait patiently until the contraction is re- newed, simply supporting the head, lest the mouth and nose be choked up by the cloths or blood found between the woman's thighs; but if the atony is prolonged, and more especially if the face of the new-born infant is ob- served to be red and tumefied, as sometimes happens after painful labors, the remainder of the travail ought not to be left entirely to nature, but new pains should be at once solicited by frictions over the abdominal walls, and the patient be encouraged to bear down. The disengagement can al- most always be accomplished by moderate tractions upon the head grasped 1 These folds may occasionally be drawn so tightly as to strangle and kill the infant, as occurred in the following case : "Upon approaching a woman who had just been delivered, I found the child dead, and still lying near the genital parts; the cord made three turns around its neck, and they were so firmly tightened th.it a deep eccliymosifl was seen on this part." (Guillemot. ) 26 4:02 LABOR. by both hands ; and if these measures prove insufficient, tne index finger, curved like a hook, is to be placed in one of the armpits, and the disengage- ment of the anterior shoulder thereby first effected. After the shoulders are disengaged, the spontaneous expulsion of the breech and lower extremities may also be delayed in consequence of inac- tivity of the womb. Here again, it is especially proper to endeavor to ex- cite the contractions by frictions upon the abdomen ; but should the life of the foetus appear to be in danger, the extraction should be effected imme- diately. The artificial extraction of the shoulders or of the lower part of the trunk, we see, ought not to be resorted to until expectation might become dangerous to the foetus. When the expulsion is left entirely to nature, the womb contracts in proportion as it is emptied, and there is less cause to fear the consecutive inertia which is sometimes produced by too rapid an ex- traction. In those rare cases, where the occiput remains posteriorly until the end of labor, most accoucheurs have recommended that an attempt should be made to bring it round to the front, but we doubt whether this will often prove successful, although we have never seen it tried, nor ever attempted it ourselves ; for we believe that where the process of rotation does not take place spontaneously, all efforts to produce it artificially would be useless, not to say injurious. Nevertheless, most authors advise, when the head has descended into the excavation, immediately after the discharge of the waters, to make it deviate either towards the right or the left in the interval between the contractions (Velpeau), by slipping two or three fingers either along the sacrum, to press the occiput forward, or else upon the side of the forehead, behind the pubis, to carry it backward. If we should ever entertain the thought of attempting this manoeuvre, we would much prefer acting during ■;he contraction, for then we should only aid, without absolutely supplanting lature ; we would prefer, whilst acting upon the occiput, as indicated by Velpeau, applying, at the same time, two fingers on the temples, and acting thereupon in such a way as to turn the forehead posteriorly. But, we repeat, this appears unnecessary in the great majority of cases, because it only hastens the process of rotation, which would have subsequently taken place without it ; and even hurtful in others, for the efforts used to bring it about might exert a pernicious influence both on the mother and her child. In fact, in ordinary cases, where the rotation is produced by the natural powers, the trunk follows the movements of the head ; but where the latter lias been turned by the fingers, the body remains immovable, and hence the process of forced rotation may dislocate the atloido-axoid articulation and kill the child. The oiler accoucheurs thought that a spontaneous delivery, in face pre- sentations, was altogether impossible, and consequently they advised an endeavor to be made, in the very outset of labor, to convert them into ver- tex positions; but we of the present day understand better the value of such opinions. However, the rotation by which the chin is brought under the symphysis pubis, whatever might have been its primitive relation to the superior strait (see Mechanism of Delivery by the Face), is difficult, painful, ATTENTIONS TO THE WOMAN AND CHILD. 403 and sometimes, in the mentoposterior positions, does not take place at all. It will be seen, further on, that the non-accomplishment of this movement forms one of the most serious complications met with in practice, and that craniotomy often becomes necessary in consequence. When the face is engaged at the inferior strait, and the chin is found under the pubic arch, the movement of flexion begins, and then, as has been shown, the pressure to which the vessels of the neck are subjected, during the fourth stage, may retard the circulation enough to determine death by cerebral congestion. Hence, we learn what great precaution is necessary in supporting the peri- neum, since it must be evident that too great a pressure made upon this part would necessarily augment the compression of the child's neck. The delivery by the pelvic extremity ought to be abandoned entirely to nature, unless there are some unfortunate complications. We have already insisted upon this point in the note at page 354 ; but do not hesitate to repeat again the advice, not to resort to any traction in a natural labor by the breech, because, as there stated, a stretching out of the arms, and some- times even an extension of the head, result from such imprudent tractions, whilst these complications are scarcely ever met with where the expulsion is left to the uterine contractions entirely. Now, there is no difficulty in comprehending these different results, for when the womb is the sole agent of the delivery of the child, the latter is forcibly urged on by the circular fibres at the superior part of the organ, and at the same time is strongly pressed on its sides by the longitudinal fibres. The upper extremities are therefore maintained against the lateral and anterior parts of the chest, the head is kept flexed on the thorax, and all these parts descend together ; but, on the contrary, if any tractions are made, they only act on the trunk[ which then descends alone, while the arms, being arrested by the margins of the cervix uteri, or by the periphery of the straits, do not participate in the descent, and are ultimately found placed against the sides of the head ; hence, the accoucheur's exclusive duty consists in receiving and supporting the lower parts of the child as they become disengaged ; taking care, as soon as the breech has cleared the vulva, to ascertain the condition of the cord. For that purpose, the forefinger is slipped up as far as the navel, when, if the cord is found to be tightened at its umbilical insertion, he joins the thumb to the index so as to produce some traction on its placental ex- tremity only, with the view of preventing both its being dragged upon, and ts possible laceration. The cord sometimes gets between the infant's thighs; ind, in such cases also, the loop thereby formed must be enlarged by pull- ing on the placental extremity, and then by disengaging it from the poste- rior limb, bring it into contact with the perineum, that is, with soft parts whose compression will be less severe, and consequently less dangerous to dhe circulation than what it would sutler from the symphysis pubis; but if it is too short to be brought to the exterior, it must be cut, and have a liga- ture applied on its umbilical extremity, and the labor be terminated^ rapidly as possible. But, whatever may have been the cause, the death of the foetus always results from the slowness with which the shoulders and hea 1 are expelled for it is only during this last part of the travail that the cord is compressed, 404 LABOR. jr that a separation of the placenta takes place; hence, although we have condemned all traction in general, it must be otherwise under such circum- stauces. But how is it possible to determine the period beyond which it would be imprudent to wait? AVe answer, that as soon as asphyxia comes on, the suffering condition of the child may easily be detected by examin- ing the portion of the cord which has been delivered; and if the pulsations si ill maintain their intensity, their frequency and habitual regularity, the rest of the process may be abandoned without danger to the powers of nature ; but, on the contrary, if they are found to relax, or even to become more rapid, though at the same time more feeble, threaddike, and especially if intermittent or irregular, every effort must be used to remove the foetus from the danger which threatens it. The signs furnished by the irregularity of the pulsations of the umbilical arteries, and to which great importance has been attributed by some authors, only become sensible after the asphyxia has lasted for so long a time that it is not always possible to overcome it ; therefore we regard as much more available the phenomena next to be mentioned. When the head alone remains behind in the pelvic excavation, the child is very often observed to dilate its chest actively, and make a violent inspi- ratory effort, which may be referred to a rapid convulsive contraction of the diaphragm and abdominal muscles, repeated at irregular intervals; now such acts never take place while the feeto-placental circulation remains intact, since the pulmonary respiration is unnecessary so long as the pla- cental one is going on, and therefore these struggles constantly announce a state of suffering, or of imminent asphyxia, from which the infant must speedily be relieved. Where the head alone is undelivered, the patient must be encouraged to bear down strongly, so as to hasten the termination of her labor, and avoid a prolonged compression of the cord ; and the accoucheur might facilitate the flexion of the head by gently carrying the trunk up in front of the symphysis, or when the flexion appears difficult, he may, by insinuating two fingers under the symphysis, press slightly on the occiput ; for a comparatively light force exercised on the posterior part of the head is often sufficient to reverse the great occipito-mental diameter, and terminate the delivery. Should the head resist these efforts, other measures become necessary ; but they belong to instrumental delivery, and we shall treat of them in the article on Version. Finally, should it be impossible to extract the head immediately, Ave may endeavor to introduce the fore and middle fingers into the mouth of the child, and then separate them slightly, so as to leave an open space through which air might find its way to the mouth. The same object would be effected with still greater certainty, by introducing a large catheter into the mouth. ATTENTIONS TO THE WOMA2J AND CHILD. 405 CHAPTER VIII. OF THE ATTENTIONS TO THE WOMAN AND CHILD IMMEDIATELY AFTER DELIVERY. ARTICLE I. OK THE ATTENTIONS TO THE WOMAN IMMEDIATELY AFTER DELIVERY. As soon as the child has been expelled, the accoucheur should place "his hand upon the mother's abdomen in order to ascertain -whether there is another child, as also to learn whether the uterus contracts well, inasmuch as inertia of the organ should lead to the anticipation of hemorrhage. It would also be right to determine whether there be too free a discharge of blood from the external parts. The expulsion of the placenta and its annexes, whether spontaneous or assisted by the accoucheur, generally follows very shortly after the exit of the foetus. In order to avoid separating the study of this natural delivery of the after-birth from that of the difficulties and dangers which may attend it, we shall treat of them separately. (See Delivery of the After-birth.) After the delivery, the accoucheur should ascertain, both by the external examination and the vaginal touch, whether the placenta has drawn down or inverted the fundus of the womb, for the purpose of rectifying it at once if such an accident has occurred. If everything proves to be in its natural condition, frictions with the hand are to be made over the hypogastric region from time to time, in order to excite the retraction of the uterus, and thus favor its disengorgement, and the expulsion of the coagula which may be still contained there. The patient is allowed to remain for some minutes on the bed where she was delivered, so as to give her a little repose, as well as time to the uterus and vagina to clear themselves of the blood, which flows at first in abundance, and would soil the linen in which she is about to be enveloped. Besides, a few r minutes are ordinarily devoted to paying those necessary attentions to the infant, hereafter pointed out. In fact, she might remain upon the same bed a still longer period, when the delivery has either been preceded or followed by syncope, hemorrhage, or any other accident, or even where there is reason to fear something of this nature, taking care, however, to substitute dry things for those that have been soiled. She ought to lie perfectly flat, the thighs stretched out alongside of each other, lightly covered, and be left in silence, and the most absolute rest of both body and mind. In about half an hour, the patient will again require special attention ; the genital organs, and upper part of the thighs, are to be first washed carefully and gently with lukewarm water, pure or mixed with a little wine; then they are to be wiped with warm and well- dried towels, and all the garments worn (luring parturition that have been eoiled by the perspiration, discharges, and fecal matters, are removed, and replaced by others, previously well dried and wanned ; their shape is unim- portant, the only point requisite is to have them large enough not to incommode the woman in any way, and to admit of being changed easily 406 LABOR. and promptly. The greatest celerity is to be used in this toiht, lest she should be long exposed to the air ; the arms and breast particularly ought to be well clothed, so that the patient may, .luring the day at least, keep them out of bed without danger of taking cold. All these preparations being completed, she is next to be transferred to the bed intended for her reception during the lying-in. Many females, finding themselves well enough, want to walk across to the permanent bed ; but against such an imprudence the physician must interpose the whole weight of his authority. The one to which she is to be transported must be previously warmed, and provided with a sufficient amount of covering that .an easily be changed ; though the coverlets should not be thicker or more numerous than those used before pregnancy. There is a custom much in vogue of surrounding the belly with a moder- ately tightened bandage; and the women, for the most part, attach the highest importance to this measure as a preservative against the wrinkles and folds that are found after labor on the skin of the abdomen, as also to prevent the latter from remaining too voluminous. Their desires may be yielded to the more willingly, as such a bandage, when moderately drawn, supplies the pressure no longer afforded by the abdominal walls, and thereby prevents the afflux and stasis of the fluids, the engorgement of the uterine walls, and the dilatation of the cavity of this viscus; and it has the further advantage of obviating the tendency to syncope, and of diminishing the after-pains. But, in order to obtain all these benefits, it should be large enough to compress the whole sub-umbilical region equally. Care should be taken to prevent its becoming doubled up, whereby a circular cord is formed, which, from opposing the ready return of the fluids, would then prove a cause of hemorrhage. The body bandage may he substituted with advantage by a folded cloth applied fiat upon the abdomen which it compresses gently by its weight, which is sufficient for the purpose. Smuic women, influenced by a feeling of coquetry, also desire to (ompress their mammae by means of a bandage, with a view of preventing their en- largement, and their consequent softness and flaccidity, and some even go so far as to apply topical astringents for the purpose of obviating an over- abundant secretion of milk ; but such measures should be proscribed in the most absolute manner, since they might prove very dangerous. These organs only require a sufficient amount of covering to protect them from the contact of the external air, and to maintain a proper degree of heat. ARTICLE II. OF THE ATTENTIONS TO THE CHILD IMMEDIATELY AFTER ITS BIRTH. The management of the new-born infant necessarily varies according to whether it is strong, vigorous, and healthy; or whether, on the other hand, it is born in a state of debility or disease. § 1. Of the Child in a Healthy State. When the child escapes from its mother's womb living, and in a healthy utate, the circulati existing between it and the placenta is observed to ATTENTIONS TO THE WOMAN AND CHILD. 407 continue for some time, where the delivery is abandoned entirely to the powers of nature; the after-birth is soon detached and expelled, and then it as well as the cord loses its vitality, the circulation becomes weaker and weaker, and the pulsations in the arteries gradually cease, commencing at their placental extremity; and some authors have advised this event to be waited for before cutting the cord; but as this spontaneous delivery most generally requires a long time, it is customary to make the section irame diately after its birth, and then the following attentions to the new beirg become necessary, namely : where the infant is entirely clear of the mothei 's parts, the cord is disengaged if it had been twisted around its neck or body. and the child is placed on the side, having its face turned away from the vulva, so that it may breathe freely without running the risk of being suffocated by the liquids that escape from the vagina. The umbilical cord is next cut at about five or six fingers' breadth from the abdomen, generally using the scissors for this operation, though it may be done with any cutting instrument whatever. As soon as the section is effected, the cut extremity is slightly pinched between the thumb and forefinger, while the remaining three fingers grasp the breech, and the other hand is placed under the shoulders and neck of the child, which is thus lifted out of the bed, and placed on the nurse's knees prepared for its reception. It may then be examined more at leisure, to ascertain that no loop of intestine exists at the base of the cord, and to permit the latter to bleed if judged advisable, before applying the ligature. A ribbon, eight or ten inches long, may be used for this latter purpose, or a cord consisting of a skein of coarse thread ; but, before applying it, the gut is to be reduced if there is an umbilical hernia, and then it ought to be tied at about two, three, or four inches from the surface of the abdomen; the only precaution requisite is to avoid placing it around the skin, which is prolonged more or less upon the cord ; for pain, inflammation, and ulceration would thereby result, the subsequent cure of which might be attended with some difficulty. As a general rule, it is best to leave sufficient space between the ligature and the fold of the skin, to allow of the application of a second, should the first prove insufficient. The ligature must be drawn tight enough to obliterate the arteries completely and permanently, without cutting their coats. If the cord happens to be thick and infiltrated, the ligature will strangle its vessels but very imperfectly : and when it afterwards becomes diminished by the escape or evaporation of the fluid parts, the vessels being no longer compressed, will obviously permit a free discharge of blood from the cut end. Besides, the putrefying of the lymph will soon produce a very fetid smell, and irritate the skin wherever it comes in contact; and it is therefore, to prevent such accidents, that authors very properly recommend the expression of this viscid fluid by pressing and slipping the cord between the fingers, and even by pricking its enveloping membrane, taking care, however, to avoid wounding its vessel-; and lastly, if the cord were unusually huge, it might, for greater security, be bent backward after the first knot was tied, and be included in a second one. Where there is reason to suspect a twin pregnancy, it is necessary after cutting the cord of the first-born to apply a ligature around its placental extremity also. Though the application of the second ligature i>, in most eases, a use- 408 LABOR. less precaution, yet the feet that in some very exceptional cases in which a communication exists between the vascular ramifications of 'die two placentas, it might prevent a hemorrhage which would quickly prove J atal to the second child, is sufficient reason for never dispensing with it. Numerous discussions have sprung up as to whether the ligature of the umbilical cord was absolutely indispensable, and. if so, whether it should he applied prior to the section, or whether the cord might he cut before it is tied. Now, although it is highly probable that the circulation in the umbilical vessels would be arrested spontaneously, after the regular estab- lishment of the respiration ; as, also, that the ligature is almost or entirely 3S in the great majority of cases, yet, if it is certain that a hemorrhage has taken place in some few, even though they be exceptional instances, from the cord having been imperfectly tied, or else not ligated at all ; this, of itself, is a sufficient reason for not neglecting so simple a precaution ; and as to the second question, the course just pointed out is, in our opinion, de- cidedly preferable. The surface of the child's body is next to be cleansed of the ceruminous Bubstance that covers it, and from the blood and other matters which be- come attached at the moment of delivery ; but as this can scarcely be re- moved by a simple rubbing with dry towels, it should first be diluted with a little oil, or fresh butter, and then be gently wiped off; the yolk of an egg would produce the same effect, and besides, would render this matter more miscible with water. To get rid of the blood and other impurities, water mingled with wine, or else a simple bath, into which the child is plunged, is most generally employed ; the temperature of the bath should he about twenty-five degrees (77° Fahr.). The infant being well washed, sponged, and wiped, is next to be dressed ; hut, hefore doing so, the physician himself should first envelop the cord in a compress intended for that purpose; which compress is merely a piece of fine linen, of a square shape, and having an opening at its centre large enough to allow the cord to pass through it easily, and then, after having ripped one of its sides from the free margin lown to this hole, the root of the cord is lodged at the bottom of the resulting fissure; then the uncut pari of this little compress remains below, and the two halves of the divided portion are turned over and crossed in front of the cord, the whole being placed at the upper and left side of the abdomen. A second soft and square compress covers the first, and a band three or four fingers' breadth wide, and Ion-- enough to go twice round the body, supports the whole of the little apparatus in this position. Before enveloping the cord, the dressing of the child had already com- menced, it- head, arms, and chest being then covered. The rest of its clothing should he warm, .-oft, and modeiately tight. In France, it consists of a camisole, or little woollen jacket, furnished with a soft chemisette that h fastened behind by pins, then one of linen, and another of wool or cotton. The English envelop their children in a long, loose robe, or something like a flannel sack. Befom dressing the child, the physician should ascertain whether it is Affected with any malformation ; and during the three or four days following ATTENTIONS TO THE WOMAN AND CHILD. 409 its birth, he ought carefully to watch over the excretion of urine and of meconium (for the expulsion of the latter is sometimes delayed for that length of time), and to facilitate it by plunging it into a tepid bath, when he is certain the infant is well formed. The prolonged retention of the meconium is also an indication for the employment of some mild laxative, such as whey, the syrup of violets, the oil of sweet almonds, or manna ; the compound syrup of succory is also very generally used, or the compound syrup of rhubarb, either alone or mixed with sweet almond-oil, in the quan- tity of two drachms or half an ounce in the course of the day. Some per- sons administer these gentle remedies to all children without distinction, more especially to those that are wet-nursed, for the purpose of supplying, they say, the place of the colostrum, or first maternal milk, whose slightly purgative action clears out the intestinal canal ; but the warm water and sugar ordinarily given to the child as nourishment on the first day, is usually quite sufficient to facilitate the expulsion of the meconium, and the viscid fluids that sometimes obstruct the fauces and stomach. § 2. Of the Child in a Feeble or Diseased State. The ordinary attentions to the child, when born in a healthy condition, have just been described ; but it not unfrequently happens that the infant, at the moment of its birth, is in a state of great debility, or even of apparent death, which would soon be followed by a real one, if adequate measures were not resorted to at once to prevent it. This apparent death shows itself under two widely different aspects, which have been described by most authors as the apoplexy and the asphyxia of new-born children. Many English and German accoucheurs have for a long time rejected these deno- minations, as characterizing but imperfectly the pathological conditions to which they were applied ; and M. P. Dubois, in a more recent article, after having remarked that the most constant anatomical character of apoplexy in the adult is wanting in what has been called the apoplexy of the child, and that wide differences also exist between the symptoms of asphyxia in grown persons, and those of the asphyxiated state of the new-horn infant, likewise concludes that the same name has been improperly applied to such dissimilar conditions ; and consequently he, like M. Nsegele, designates that state of the child in which no sign of life is observed, and none of those of death is recognized, under the title of apparent death. Both terms of this definition are evidently contradictory, since death is characterized by an.entire absence of the signs of life. For our own part, we regard apparent death as a state in which, notwithstanding the abolition of the actions of animal life, some at least of the functions of organic life continue, and, of necessity, the pulsations of the hear!. Now, in carefully examining the symptoms of the child's apparent death, it is found that it is sometimes characterized by a vivid redness of the face and upper part of the body, by a prominence and injection of the eyeball, and a swelling of the countenance, the skin of which is dotted here and there with bluish spots; while at others, we are struck with the discoloration 410 LABOR. in the skin, and the flabbiness of the flesh. In the foiraer case, the head is swollen and very warm, the lips are tumefied and of a deep-blue color; tne eyes start from the head, and the tongue adheres to the roof of the mouth; the head is often elongated, hard, and the features slightly swollen; the pul- sations of the heart, though sometimes quite strong and distinct, are at other? obscure and feeble; occasionally the umbilical cord is distended with blood. In the second, the child exhibits a mortal pallor; its limbs are pendent and flabby ; the akin is discolored, and is often soiled by the meconium ; the lips are pale; the lower jaw hangs down, and the umbilical cord and heart either do not palpitate at all, or but very feebly. An infant, in this condi- tion, often moves at the moment of birth and cries, but soon falls back again in a state of apparent death. These diversities in the physical characters of children born in a state of apparent death, may be occasioned, doubtless, by various causes, though they are also often due, simply, to a greater or less advanced condition of the same pathological state ; hence it is wrong to regard them as the charac- teristic signs of quite dissimilar lesions. Therefore, although I am convinced that they sometimes furnish indications for very different kinds of treatment, and thai under this point of view it is important to observe them carefully, I cannol regard them as affording a basis for nosological distinctions which it is impossible to justify. As the expression apparent death presupposes nothing in regard to the nature and cause of that state, it deserves on that very account to be retained. That what we are about to state respecting the apparent death of new- born children may be the better understood, we shall give, first, a brief ex- position of the mechanism by which respiration is established immediately after birth. All physiologists admit, that the medulla oblongata is the centre and regulator of the respiratory movements of the adult. From it also is sent forth the motor impulse which gives rise to the first act of inspiration. Marshall Hall has endeavored to prove, experimentally, that the first in- spiration is the result of a reflex action, 1 produced by the excitement of the nerves of the surface of the body, especially of the trifacial, by the contact of the external air, and that the respiration, when once established, is sus- tained through the influence of the reflex action due to the irritation of the pneumogastric nerves by the contact of the air introduced into the lungs. 1 An impression made upon our organs may give rise to movements of different char- acters, by pursuing different routes to the cerebro-spinal axis. Thus, sometimes, when transmitted directly to the encephalon by the sensitive nerves of the cranium, or indirectly through the nerves of the spinal marrow, it is transformed into a sensa- tion in th.it pari of the encephalon in which the sensorium commune is situated, and consequently reaches the consciousness of the animal, who is then capable of reacting by voluntary movements. Sometimes, also, it is transmitted bythe nerves of sensation cither to the encephalon or to the spinal marrow, which impression, without neces- sarily being transformed into a sensation, may produce an excitement which is imme- diately reflected upon the motor nerves, and gives rise to the so-called reflex move- ments, in the production of which the will has no part whatever. The power which tint-- gives rise to movements without the participation of the will, has been regarded as a special endowment of the cerebro-spinal axis, and has been designated as the r,jL\c poi*t r , faculty, or propria. ATTENTIONS TO THE WOMAN AND CHILD. 411 The same physiologist also holds that the respiratory movements may take place under the influence of other causes; such, for example, as the impres- sion produced upon the medulla oblongata by a great loss of blood, as also the excitement which it undergoes from the contact of venous blood. Intc the latter category enter all the respiratory movements of incomplete as- phyxia. In normal cases, the foetus, having in no wise suffered during the labor, retains its cutaneous sensibility intact, and the irritation produced by tin. contact of the air with the cutaneous nerves is transmitted to the medulla oblongata, which, acting in its turn upon the respiratory nerves, produces the movements of respiration. But should it happen that the foetus from the moment of birth has been deprived for a certain time of those means of respiration which it finds in the placenta, or that, the latter being separated immediately after the child is expelled, any obstacle should arise to the introduction of air into the bronchia, there would be, in both cases, a commencement of asphyxia. The contact of the non-oxygenated blood would irritate the medulla oblongata, and this irritation being transmitted to the inspiratory nerves, may also give rise to respiratory movements of the muscles of the face, breast, and abdo- men, and produce, in short, the first inspiration. 1 The central motor im- pulse would soon be substituted by the reflex action of the ramifications of the pneumogastric nerves, which are irritated by the air introduced into the lungs, and the respiration would continue under its influence. When the foetus is threatened with asphyxia in the latter stages of preg nancy or during labor, in consequence of compression of the cord or separa- tion of the placenta, its death is preceded by convulsive movements and efforts to breathe ; then the mothers tell us, that the child, after having moved actively, suddenly became quiet ; and Beclard saw a foetus inclosed in the unruptured membranes make inspiratory movements, and breathe water instead of air. It is for this reason, also, that in certain positions of the face the child has been enabled to respire, although still inclosed in its mother's womb ; and the uterine vagitus, which always supposes a previous inspiration, can be explained in no other manner. In all these cases, in fact, the non-oxygenated blood acts as an irritant to the medulla oblongata, which transmits the irritation in its turn to the nerves of inspiration. Nothing can be claimed here for reflex action. We must be careful, however, not to confound these two excitors of the inspiratory act. The first is the natural excitant, whilst the other is always pathological, and only intended to replace the normal stimulus. Now, every 1 Marshall Hall removed the brain of a kitten, cut the pneu gastric nerves, and opened the trachea. He found the respiration to become slower, though it continued with regularity. When he Btopped the opening in the trachea, the Bcene changed im- mediately; the animal opened its mouth widely, made violent inspiratory efforts, and was affected with some movements of a convulsive character. When the trachea was reopened, the respiration became as regular as before, and when closed again, the symptoms of asphyxia reappeared; in both these cases, the central organ, or the me- dulla oblongata, was evidently the source of the respiratory impulse: since the .lest ruc- tion of the brain and the section of the pneumogastric nerves rendered all reflex action impossible. 412 LABOR. pathological act is but an effort to accomplish some physiological pi.ieess, ivhich has become difficult or imjiossible ; and though it may in some cases restore life to a child, it is likely, in many others, to prove insufficient. it very often happens that a child born in a semi-asphyxiated condition, in consequence of a difficult labor, makes a few sudden and violent inspiratory movements, but would nevertheless succumb rapidly, were not the reflex action called into play, and did it not soon replace completely the patholo- gical excitant, which, just before, had acted alone upon the spinal marrow. As the skin, in this state of diminished sensibility, is no longer stimulated sufficiently by the external air, special means should be resorted to whilst there is yet time to arouse the excito-motor action of the cutaneous nerves, and provided the asphyxia has not gone too far, they will often be crowned with success. But if the child is small and feeble, or if the causes of the asphyxia have acted for too long a time, the contractions of the inspiratory muscles are feeble and distant, and soon cease entirely; the heart, too, ceases to beat, and the child dies. Though, whilst the heart is still beating, we may succeed in exciting the reflex action of the muscles of inspiration, to the extent of producing a sudden inspiratory movement after every excitation, the symptoms of asphyxia remaining, however, unchanged, the child will die in spite of all that can be done. If it be true that the impression produced by the external cold upon the skin of the body and face, is the first and only cause of the reflex action of the medulla oblongata upon the nerves of inspiration, and thus produces the first inspiratory art, we can readily understand that everything calculated to diminish notably or to destroy the cutaneous sensibility, will retard, or even render impossible, the first inspiratory effort, and reduce the foetus to a state of apparent death. The causes of the latter are, therefore, such as paralyze to a greater or less extent the nervous centres, whose influence, though completely foreign to the maintenance of foetal life, becomes indis- pensable to the establishment and continuance of extra-uterine existence. Now, these causes are quite numerous; and, with the exception of a few, exert their destructive influence during the latter periods of labor. They may be divided into: 1, lesions of respiration; 2, lesions of circulation; 3, lesions of the nervous centres. The first are capable of producing various degrees of asphyxia; the second may give rise to a fatal hemorrhage as regards the child ; the third affect the nervous centres directly, and render them incapable of performing the functions to which they are destined immediately after birth. 1. Lesion* of tin Respiration. — These are occasioned by everything which obstructs the respiration. Thus, there have been pointed out as occurring during labor, the compression of the umbilical cord between the sides of the pelvis and the head or body of the child ; the winding of the cord so tightly around the neck or some other part, as to obstruct simultaneously the venous circulation in the brain, and that of the blood in the umbilical vessels; the premature separation of the placenta, whether it be inserted upon the neck or not, for since the separation necessarily produces the rupture of the utero- placental vessels, it renders the fetal hsematosis as impossible as does the compression of the cord: the great retraction of the uterus, when in delivery ATTENTIONS TO THE WOMAN AND CHILD. 413 by the breech the head only remains in the excavation, and the child is unable to respire ; for this retraction renders the vessels of the uterus almost impermeable to blood. In all these cases, the asphyxia results evidently from a suspension of the placental respiration, and it is the contact of black blood with, the brain, which paralyzes its action in the fetus as well as in the adult. Finally, it is plain that after the child is born, the accumulation of mucus in the nose, mouth, and air-passages, may also produce asphyxia by prevent- ing the introduction of air into the bronchia? ; here, however, the mode of operation is precisely the same as in the adult, since it results from a me- chanical obstacle to the introduction of the external air into the pulmonary vesicles. In consequence of the action of some one of these causes, the foetus may be born in a state of apparent death, and exhibit the very different symptoms which we have already mentioned ; thus, in most cases, the surface of the body has a swollen appearance, and is of a violet, or rather of a blackish- blue color, the discoloration being more marked at the upper parts of the trunk, and more particularly on the face than elsewhere. The muscles are motionless ; the limbs preserve their flexibility, and the body its heat ; the pulsations of the cord, of the radial artery, and even those of the heart, are obscure or insensible. Where a post-mortem examination is made, the vessels of the encephalon are found engorged with blood ; at times, this fluid is even effused on the surface of the membranes, or into the substance of the brain itself, though most generally, says M. Cruveilhier, the effusion is limited to the surface of the cerebellum ; sometimes it covers the posterior lobes of the cerebrum, but it is rarely found in the ventricles of the brain ; and, in all the cases examined by him, there was blood enough in the cavity of the vertebral arachnoid membrane to distend the dura mater. Again, those congestions of the liver that are so common in infants, are then particularly apt to be met with ; but, says Billard, they vary considerably as regards the quantity of blood accumulated in the tissues of the organ ; for, in some instances, it is found there in such great abundance as to give rise to a sanguineous exudation on the exterior of the organ, the convex surface of which is discolored and moistened by a layer of effused blood, and I have even known an extrava- sation of tins fluid into the abdomen to result from this turgescence. The lungs are also gorged with blood. The external condition of the asphyxiated foetus is not always such as we have just described, for, as M. Jacquemier has observed, nothing is more common than to find the fetus born without any anomalous coloration of the skin, and even with a remarkable degree of pallor and flaccidity of the limbs ; and this, notwithstanding the apparent death has been produced by compression of the cord. Can this difference be due, as M. Jacquemier supposes in the latter case, to a sudden suspension of the placental respira- tion, whilst in the former the cessation was slow and gradual ? This expla- nation is probable, inasmuch as the same diilerenees are observed in the asphyxia of adults, and as, according to M. Devergie, those persons who are killed by the falling in upon them of earth, present the same discoloia- 414 LABOR. tion of tlie integuments. The suddenness of the real death may explain the peculiarity under these circumstances ; but it must Dot be forgotten that this external pallor is also the consequence of a slow but prolonged asphyxia, and that it often succeeds to the violet hue of the tissues; that we everyday witness this succession going on before our eyes when the asphyxia has lasted too Ion--, and that a child horn with a very deep color, becomes rapidly pale and flaccid, if the means employed fail to excite respiration. In the latter case, the discoloration of the tissues is the symptomatic ex- pression of a more advanced stage: the pulsations of the heart, which before were sufficiently strong and rapid, become less frequent and feebler, return only at long intervals, and real death soon succeeds to the apparent one. Now these phenomena, which we observe occasionally, take place in the same manner whilst the foetus is still contained in the womb, but is deprived of the placental respiration. When, at the moment of birth, the asphyxia has lasted but a short time, the child will exhibit turgescence of the face, the violet hue of the skin, firm- ness of flesh, and frequent and regular pulsations of the heart; if a longer period has elapsed since the interruption of the fosto-maternal circulation, the child will he pale and discolored, and the pulsations of the heart and cord feeble and intermitting; finally, if the asphyxia has lasted longer than is compatible with the life of the heart, the child will be really dead at the time of its expulsion. These two conditions, which are apparently so different, are due to the same cause, and are simply two decrees of asphyxia. Though in an etio- logical sense, no distinction can be made between them, they are important as regards the prognosis, for one is much more serious than the other, and, as regards treatment, the same means are not applicable to both. M. Pajot informs me that he has found these observations to hold true as regards the adult. 2. Lesions of the Fecial Circulation. — Ruptures of the cord or of the pla- centa may, of themselves, give rise to such a degree of hemorrhage as to en- i langer the life of the foetus ; fortunately, however, they are quite rare. When the hemorrh;iire is profuse, the child dies before the labor is over; but should anything happen to arrest the discharge of blood, the child may be born alive, but in a state of apparent death resembling syncope. The deficiency of nervous influence is here manifestly due to the fact that the medulla oblongata and the brain no longer receive a sufficient amount of blood to enable them to react upon the nerves of inspiration. The condition is a most dangerous one. The child is pallid, and its muscles are completely relaxed; sometimes, however, it makes a few short inspirations, and utters some very feeble cries; but if the hemorrhage has been at all profuse, it succumbs in a very short time. 3. Lesions of the Nervous Centres. — The cerebro-spinal system presides over none of those functions whose integrity is necessary to the maintenance id' foetal life; the respiration, circulation, and nutrition being subject ex- ■lusivelv to the nerves of organic life. These ganglions and their nerves derive from the arterial blood that principle of organic sensibility and motility which is uecessary to the production of involuntary or automatic ATTENTIONS TO THE WOMAN AND CHILD. 415 movements, as also to the maintenance of the irritability and vitality of the organs. Although the foetus possesses organs of animal life, its vitality is purely vegetative or organic. This fact serves to explain the life and development of acephalse, for where the organs are absent, the functions are also wanting; yet these monsters are endowed with irritability, are capable of motion, and their life is preserved intact, until the termination of pregnancy. Since the brain and spinal marrow have nothing to do with the perform- ance of the fatal functions, we readily foresee that any lesions which may affect them during pregnancy or labor, cannot disturb the harmony of those functions, or have any influence whatever upon the intra-uterine vitality. Therefore it is only after birth that the cerebro-spinal alteration or paralysis prevents the establishment of animal life, even though the organic life is still manifested by the integrity of the circulation, and even of the placental respiration. The first respiratory act is, as we have said before, the conse- quence of an excitement of the medulla oblongata, produced by the impres- sion of the temperature of the surrounding air upon the skin of the new-born child. For this impression to be effectual, however, it is necessary that the sensation should be perceived by the central organ, which is rendered in- capable of perceiving it by serious lesions of the cerebro-spinal axis. This important distinction should therefore be made between the various circum- stances capable of reducing the foetus to the state of apparent death, namely, that the foetus may be destroyed in the womb by asphyxia and hemorrhage, whilst lesions of the nervous centres always cause it to be born in a state of apparent death. We should also interpret in this way the effect which may be produced by the violent compression which the brain undergoes in certain cases of con- tracted pelvis; that which may result from the application of the forceps or lever under circumstances of difficulty; that which results from vascular congestion due to an obstruction to the return of venous blood in certain deliveries by the face; in cases where the cord is wound tightly several times round the neck, as also where it is strongly grasped by a spasmodic con- traction of the neck of the uterus; and finally, to the compression sometimes produced by effusions of blood, either upon the surface, or into the substance of the orain itself. So, also, is to be explained the mode of action of lesions of the medulla oblongata, such lesions as we know are easily produced by extreme rotation of the head, by tractions upon the head, or the pelvis when the head is arrested in an elevated position, and finally, by effusions at the base of the brain and upper part of the vertebral canal. As lesions of the brain are not absolutely incompatible with the establish- ment of respiration, they are not so dangerous as those of the medulla oblon- gata. The destr iction of a large portion of the encephalon bus not always prevented the child from breathing and crying after its birth, and even from living for several days. A similar fact is presented by anencephalous foetuses. By this we are advised that, in difficult labors, the temporary compression of the head may also suspend momentarily the action of the brain, but that as this suspension does not absolutely preclude respiration, the Bpecies of 416 LABOR. shock or concussion which the brain experiences may pass away so soon a not to interfere with the continuance of life. It is different, however, with lesions of the medulla oblongata, which is the only motor of the respiratory movements: it cannot be seriously affected without rendering extra-uterine life impossible. This explains the frequent death of children in pelvic presentations, when tractions have been made upon the trunk with Lie object of disengaging the head. Treatment. — Since apparent death, however produced, may present the very different symptoms already mentioned, it is evident that mere inspec- tion of the child can afford no information as to the cause of its condition. Although we regard the discoloration of the skin and relaxation of the ex- tremities as signs of very grave import, it is impossible to determine the extent of the cerebral disorders, and consequently to foresee the result of measures calculated to restore the child. In this state of uncertainty, all cases should be treated as though they afforded a chance of success. The lapse of half an hour, an hour, or even more, from the time of delivery, is not sufficient cause for despair, since a number of facts may be mentioned going to prove that children have been in an asphyxiated condition for an hour, and were afterwards restored to life. Long continued silence of the heart, the entire absence of pulsations at the precordial region, frequently determined at intervals, is the only sign which can be regarded as destructive of all hope. The heart is the ultimum moriens, and I do not believe that efforts to restore its pulsations, when once completely extinguished, have ever been crowned with success. But the softness and flaccidity of the tissues, and coldness of the body and face, 1 are no reason for abandoning the child, j>rovided the heart still beats, however feebly, slowly, or irregularly. When the child is born with a general injection of the capillaries of the face and trunk, when, in short, it presents the characters of the state formerly termed apopleasy, it is evident that the first indication is to relieve the engorge- ment of the head and lungs, which is done by promptly cutting the um- bilical cord, and allowing a few spoonfuls of blood to escape, when the respiration is most usually established soon after, if there are no mechanical obstacles, such as mucus in the fauces, to the introduction of air into the lungs ; and where these do exist, they may be removed by the extremity of the little finger, or with the feathered end of a quill ; the blue and violet color of the surface will then be found to gradually disappear, and give place to a rosy hue, at first on the lips, then on the cheeks, and afterwards over the rest of the body. However, in practice, we sometimes find the circula- tion so enfeebled or benumbed, as it were, that the blood will not run from the umbilical arteries; its effusion may then be encouraged by plunging the child into a warm bath, or by squeezing the cord several times from ics insertion towards the cut extremity ; and where this does not prove success- ful in obtaining blood, some advise the application of a leech behind each ear. But as this application would occasion the loss of precious time, it is better to have recourse at once to other measures. 1 The experiments of M. Brown-S6qnard on warm-blooded animals, prove that the time for which they are capable of resisting asphyxia is greater in proportion as they are subjected to a lower temperature. . ATTENTIONS TO THE WOMAN AND CHILD. 417 The small bleeding being practised or not, every effort should be made, by the use of various stimulants, to excite the sensibility of the skiu, and the rellex action of the cutaneous nerves. According to Marshall Hall, the best plan is to sprinkle the face and body of the child vigorously with cold water; immediately after which, it should be immersed in a warm bath, and then wrapped in warm flannels. The efficiency of this plan of treatment, which may be repeated several times, depends especially upon the rapidity with which it is executed. The im- pression of both the cold and heat should be sudden. Afterwards, the skin may be stimulated by frictions with the hand, or a brush, by dry flannel, or with any irritating liquors, such as vinegar or brandy; M. Moreau strongly recommends, and with reason, slight blows to be made with the palmar sur- face of the fingers upon the shoulders and thighs. In grave cases, I prefer flagellating the thorax and loins vigorously with a piece of wet linen. It, is also often very useful to irritate the mucous surfaces. A little brandy or vinegar may be placed in the mouth, or the fumes of burnt paper blown into the anus. A feather may be dipped into vinegar and then introduced into the nose or fauces ; this may be used at the same time to clear away the mucous secretions of the latter, which prevent the inhalation of air ; and where there is reason to suppose that such secretions have accumulated to a considerable extent in the air-passages, the advice of Dew r ees should be fol- lowed, by placing the child on its belly, taking care to elevate the feet higher than the head, and at the same time gently shaking it, so as to clear out the trachea, and thus facilitate the introduction of air ; " for," says the American author, " this is a measure of great utility, by which I am every way per- suaded that I have preserved the lives of many children." After a few moments, the child should be again plunged into a warm bath, rubbed with warm flannels, and then immediately subjected to cold aspersions. All these measures should be continued for a long time after respira- tion has been restored and become regular, in order to prevent secondary asphyxia. The child's body may be exposed with advantage to a current of cold air, giving it at the same time a swinging motion, and even after it has been restored and dressed, its face may be exposed to the fresh air, or, what is better, fanned, for a short time. It has been advised to make use of strong suction on the breasts, for the purpose of dilating the thorax mechanically, " which," says Desormeaux, "although without effect for the proposed object, appears to me admirably calculated to stimulate the muscles that move the ribs." But a more power- ful remedy, highly extolled by the same author, is a sort of douche made by the mouth directly on the parietes of the thorax ; this douche is performed by taking a mouthful of brandy and blowing it forcibly against the breast; and it is rarely necessary, he remarks, to repeat it many times, for it is found to produce a convulsive contraction of the inspiratory muscles almost immediately ; the blood and air penetrate the lungs, and the respiration is irregularly established, being at first feeble and spasmodic, but soon becom- ing stronger and more regular. I have often used successfully with tin 27 418 LABOR. same object, a cold douche, produced by pouring. :i stream of cold water upon the precordial region, from an elevation of about a yard. If the excitation of the spinal and facial nerves is insufficient, the branches of the pneumogastric uerve should be acted on by insufflation. This measure can now boast of such a degree of success, as to make it proper to have recourse to it whenever the means just mentioned have failed. M. Depaul has, in an excellent memoir upon the subject, completely refuted the objections urged against it, and confirmed by his experiments the pre- vious results of Dumeril and Magendie. Like them, he found that a false idea has been entertained of the powers of resistance of the pulmonary vesicles, and that it is necessary to blow much more strongly than is required to produce a simple dilatation, in order to effect their rupture. He has proved by instances, that children have been restored to life, whom the failure of the mean- commonly advised seemed to devote to certain death ; also, that in eases where it was unsuccessful, because the lesions occasioning the apparent death were beyond the resources of art, it had the effect, when the pulsations of the heart had not ceased entirely, to render them stronger and more frequent, and sometimes even to determine a spontaneous though imperfect inspiration. I would add, that long continued insufflation seemed to me, in three cases, to be more effectual than is claimed in the above paragraph, for not only did it excite spontaneous inspirations, but the respiration became gradually regu- lar, and existence was prolonged for ten, twelve, and in one case for twenty- two hoitis, in spite of mortal lesions of the brain. Now it will readily be understood that, in very many cases, the family might attach great impor- tance to twenty-four hours of life in a new-born child. M. Depaul, who has rendered a rial service in calling attention to a mea- sure generally abandoned by some as dangerous, and by others as useless, also proposes some rules of conduct, which I think it right to mention briefly. He uses Chaussier's canula, dispensing, however, with the lateral openings, and substituting for them a terminal one. 'fin child, whose temperature is to be maintained by warm coverings, should be placed with the breast higher than the pelvis, and the head thrown a little back, so as to render the front of the neck rather more projecting. Saving cleansed the tongue and pharynx from mucus, the forefinger of the left band should be conducted along the median line of the tongue to the epiglottis. The right hand holds the tube like a pen, and directs its small extremity along the linger to the opening of the larynx, inclines it towards the left commissure of the lips, and by gentle movements endeavors to raise the epiglottis; it is then only necessary to elevate the instrument, carrying it at the same time toward the median line, when its extremity will pass through the glottis. This is the only part of the operation which presents any difficulty, for it is not uncommon for the tube to enter the oesophagus. Before r< sorting to insufllation, we should make sure of its situation bypass- in.:' the tinger upon the larynx and trachea, and observing whether the larynx follows the instrument when the latter is moved from side to side- However, the first insufllation nveals the error immediately, for when the instrument has passed into the oesophagus, a considerable elevation of the ATTENTIONS TO THE WOMAN AND CHILD. 419 epigastrium precedes that of the base of the chest ; if, on the contrary, it is in the larynx, the chest is dilated uniformly, and the epigastric projection is produced exclusively by the depression of the diaphragm. To prevent the reflux of the air, and to oblige it to enter the air-passages, every point of exit by the oesophagus, mouth, and nostrils should be closed. The anterior wall of the oesophagus is applied against the posterior, by a moderate pressure with the instrument. The lips are pressed closely to the sides of the canula by means of the thumb and forefinger, whilst the nostrils are stopped by pinching the nose between the two middle fingers. The insufflations should be quite near to each other. M. Depaul thinks that from ten to twelve should be made in a minute. The greater part of the air is expelled after each by the elasticity of the pulmonary vesicles ; it may be useful, however, especially at the commencement, to render the expiration more complete, by pressure properly applied with the whole hand on the front of the chest. The length of time for which it is necessary to continue the insufflations varies much. Thus, there are facts showing that sometimes a quarter of an hour has been sufficient, whilst at others, it was necessary to continue them for three-quarters of an hour, an hour, or even an hour and a half. When, under their influence, the action of the heart has been so far restored as to be at from a hundred to a hundred and thirty times a minute, I think, says M. Depaul, that the physician should continue until spontaneous inspirations appear, and are repeated at the rate of at least five or six per minute ; since to stop after the first one, would in many cases endanger the life of the child. When, however, after having awakened the pulsations of the heart, and even obtained some efforts at inspiration, all become more feeble and disappear, the insufflation may be dispensed with after the lapse of from ten to twelve minutes, for, under these circumstances, I have never known a child to be saved. It is necessary to withdraw the canula from time to time, in order to clear it of mucus. When the trachea contains much mucus, which is manifested by gurgling, it may be drawn into the tube by suction, and the future in- sufflations be thus rendered more useful. When spontaneous inspirations occur, the insufflations may be suspended for the moment. Finally, all these means having failed, should a galvanic battery be at hand, currents of electricity might be passed through the muscles of inspira- tion; it is, however, an auxiliary upon which but little reliance can be placed. Electricity has, in fact, much less action upon the foetus than upon the adult. It has, for example, been proved by experiment, that well-developed foetal serpents were but slightly sensitive to the action of galvanism before having breathed, whilst shortly afterward they were endowed with a very delicate sensibility. The same measures should be used in cases of apparent death, in which the children are pale and colorless: here, however, far from allowing the umbilical cord to bleed, it should be tied instantly, even before dividing it. Some persons have recommended that the umbilical cord be not cut in cases of asphyxia, until after the pulmonary respiration has been fully 420 LABOR. established, hoping that the continuance of the foeto-placental ci culatim might replace the extra-uterine one that is wanting. Without admitting, with Dr. King, that this practice, by allowing the contractions of the heart to drive all the blood into the placenta, would expose tin: fetus to death from 1"-- ,>f the circulating fluid, I think that in the majority of cases the pre- caution Is, to say the least, useless, and even hurtful, by occasioning the loss of precious time. In fact, the placenta is almost always partly, or even entirely detached, shortly after the child is expelled; and even were this not the case, the retraction of the uterus following its expulsion, has so modified the circulation in the walls of the uterus and that of the utero-placental vessels, that the newly-born infant would certainly find its resources in thai direction exhausted. However, if the touch does not discover the placenta situated upon the neck, and, consequently, there is reason to suppose that it retains its normal relations with the womb, we may, when the fetus is pale and discolored, defer cutting the cord, especially should it still exhibit pulsations. 1 As soon, however, as the pulsations have ceased, or it is ascertained that the placenta is detached, its section should be practised immediately. Some children, after having cried and breathed quite freely, fall, after the Lapse of several hours, and sometimes even days, into a state of apparent death, which soon terminates in real death unless assistance is promptly rendered. Therefore it is prudent to be carefully on the watch for the first few days. This secondary apparent death may be due, like that just described, to a true asphyxia, or to a deficiency of nervous influence, foi which the stimulants employed immediately after birth have proved but a momentary remedy. Asphyxia may be produced either by a foreign body [•laced over the mouth and nostrils, or by an accumulation of mucus in the -. To remove the foreign bodies, and clear out the fauces with the aid of a feather, and the bronchia by exciting vomiting by tickling the palate, are the first measures to be used. If the face is of a violet color, a leech may be placed with advantage behind each ear, or, as recommended by Kennedy, upon the fontanelles. When the accidents are attributable to deficient cerebral action, the excitants already mentioned must again be had recourse to. Excessive debility of the child, due to some one of the circumstances already pointed out, should be combated by the same means used for apparent death. In those cases where the infant is only very feeble, because it i< horn before term, or in consequence of a prolonged sickness on the part of the mother, very great care is requisite to maintain a high degree of tem- perature by surrounding it with cotton wadding and bottles containing hot water, since heat is then the best stimulant. For the first few days, and sometimes even weeks, its alimentation demands some precaution. It is very important that a nurse should be procured at once, whose milk Hows so easily that she can herself project a few spoonfuls into 'he mouth of the child; for it.- feebleness often renders the necessary 1 Froi ota made by Budin, the amount of blood escaping from the placental end when : was tied immediately after ihebiith of the child was found to be about thn eoi than when a delay of several minutes was allowed, which shows a loss of that much blood v. hicn would otherwise pass into it- circulation. It has also been 'hown by Hofmeier and others that there i- less loss in weight ill the new-burn infant when the cord is nut tied until the pulsations have entirely ceased. PHENOMENA APPERTAINING TO THE LYING-IN STATE. 421 effort at suction impossible. It is equally important to give it only the first milk, which is easier digested. Umbilical hemorrhage of spontaneous origin has been noticed by some authors. Dr. J. S. Gibb has recently written a monograph upon it (Philor delphia Med. Times, May, 1884), in which the great fatality is shown, and the difficulty of treating it locally is considered. The hemorrhage may occur at any time. The blood is usually non-coagulable. The causes are involved in obscurity. It is usually associated with jaundice and the hem- orrhagic diathesis. CHAPTER IX. OF THE PHENOMENA APPERTAINING TO THE LYING-IN STATE. This term Tor that of the puerperal condition) is applied to the period immediately following the delivery, during which the uterus and genital organs, and indeed the whole economy, gradually return to their ordinary condition. 1 The attendant phenomena may be divided into the natural, and the un- natural or morbid, including under the latter head all the diseases to which the lying-in woman is exposed ; but the former only claim our attention here. A feeling of depression, or lassitude, such as that experienced after an unusual or an immoderate exercise, succeeds the agitation caused by the labor ; and it not unfrequently happens that the patient has scarcely reached her bed, when she is attacked by a chill, severe enough at times to produce x chattering of the teeth ; but this soon passes off, the pulse increases in strength, the heat of the surface returns, the skin becomes humid, a salutary moisture appears, and the various functions are re-established, while the most perfect calm and the most delightful slumber replace the past disorder. Now, although this slumber of the patient is to be respected, nevertheless it is desirable that it should not take place until a few hours after the delivery, unless the physician should be at hand to watch attentively over the state of the circulation, and the condition of the womb during this recuperative repose, because some women have been attacked when in this state with internal discharges, and have awakened exhausted by the loss of blood. Therefore, although on account of the rarity of this accident the patient shouid not be prevented from sleeping, it is necessary to watch over her during her slumber, or at least to have her carefully observed by an intelli- gent nurse. After the first nap is over, she might sit up in bed a few moments to take a little broth, as this position refreshes her, and also facilitates the escape of the lochia that had accumulated in the vagina. The patient is the more enfeebled as the loss of blood has been greater, or the duration of the labor prolonged. The nervous susceptibility is also highly exalted, and the skin, whose activity was diminished during gestation, now regains a more exalted vitality ; it is soft, humid, and is always covered with a dewy perspiration during the first week. This sweat, is sometimes very abundant, particularly when she is too warmly covered, and it is not at all unusual to find it followed by a miliary eruption and a distressing pricking sensation. Such eruptions were 1 The process by which tlic. uterus returns to its ordin ry non-puerperal condition i> known as Involution. 422 LABOR. exceedingly frequent in former times, when it was thought useful to push the skin, as it was called, and to make the woman perspire by surrounding her with thick coverlets; now, on the contrary, they are quite rare, and where they do show themselves, are easily made to disappear by taking the neces- sary precautions to diminish the cutaneous secretion. [After delivery the pulse becomes Bofter, fuller, and sunn slower. We propose, however going somewhat into detail in reference t<> this subject, for the examina- tion of the pulse in newly-delivered females is of such capital importance that by simply paying attention to the information which it affords, we are enabled to diagnosticate almost certainly a state of health or of disease. The study of the pulse, th< refore, yields extremely valuable information to the accoucheur, but we can- not in this place treat of the indications which it supplies in puerperal diseases, and shall confine our attention to the changes which it undergoes in a healthy woman after delivery. We would state in the first place, that the mean rate of the pulse in adult women is about seventy-five per minute, and becomes somewhat more frequent during pregnancy (see page 157) and especially during labor (see page 286). Immediately after delivery the pulse falls to some extent, but the diminution is generally followed in a short time by an acceleration, which lasts for several hours. In healthy women, this transient acceleration is very often followed by a second diminution in pregnancy. Without attempting to state the exact proportion of cases in which retardation is observable, I will only remark that it is so extremely common as to be found almost constant when sought for carefully. The diminution in the frequency of the pulse has been well studied and described bv II. Blot, in a memoir of which we give an analysis (Archives Generate de Mede- cine, May, 18G4.) The greatest diminution of frequency observed by M. Blot, was thirty-five beats per minute. "But," says he, "it must not be supposed that so great a difference is common, — for I have met with it in but three cases. Between thirty-five and sixty-live beats per minute, the latter of which we regard as the standard, we have observed every grade of diminution. Two numbers, however, forty-four and fifty- six, have impressed us by their relative frequency." The slowness of the pulse may continue from one to twelve days, generally last- ing longer in multiparas than in primiparse. In the latter, it rarely continues longer than three days, whilst in the former it is often observed for four, six, and seven days. The time at which it comes on varies somewhat in different women, though it generally is observable within twenty-four hours after delivery. In the twenty- four hours following its appearance, the slowness of the pulse increases; then, after remaining for a time stationary, gradually gives place to the rate which is habitual to the woman. The slowness diminishes and sometimes even ceases entirely as soon as the breasts experience the congestion which precedes the secretion of milk. Usually, however, the pulse gradually becomes more frequent. We shall have occasion to revert to this fact when we come to treat of the secretion of the milk and what is known is the milk-fever. The slowness occurs also after abortion and after premature delivery, whether spontaneous or artificial. When the slowness of the pulse is observed in a newly delivered woman, we may feel sure that she is in a perfectly normal condition, so that in respect to the prognosis it is an extremely favorable sign. In a lying-in hospital, the frequency of the diminution of the pulse in proportion PHENOMENA APPERTAINING TO THE LYING-IN STATE. 423 to the number jf puerperal women indicates, in a general way, an excellent sanitary condition: its rarity, on the contrary, should excite our apprehension of an un- healthy tendency in the newly delivered inmates. The cause of this slowing of the pulse is obscure. It would seem, however, from the sphygmographical experiments of MM. Blot and Marey, that, like the diminu- tion of frequency under all circumstances, it is connected with a certain increase in the tension of the arteries, which tension the authors just quoted think may be explained by the sudden and almost entire suppression of the circulation which existed in the uterine walls during pregnancy. When the uterus contracted, the blood which previously traversed it accumulated in the arterial system, from whence resulted a greater tension which became in its turn an impediment to the ventricular systole, giving rise to the temporary diminution in frequency of the pulse, followed by an establishment of equilibrium. Whatever the explanation, the fact is both established and shown to be of great clinical importance.] Crede has shown that a rise of temperature may take place at any period from any temporary cause, such as constipation, mental disturb- ance, errors of diet, etc. Should there be a rise, however, above 100 J F., some complication would naturally be expected. If the relaxed walls of the abdomen be examined after delivery, the womb is felt above the pubis as a large tumor, which henceforth diminishes in size. In thin women, particularly those who have often had children, the womb still remains at the end of two weeks about two fingers' breadth above the pubis, yet the fundus in primiparse, more especially in such as are at all inclined to embonpoint, cannot be distinctly felt after a week; and by the end of the sixth week this organ has nearly regained its primitive condition, being still, perhaps, a little larger than usual. [The diminution of the bulk of the uterus, its atrophy, so to speak, has been studied so carefully by Dr. Wieland, who noted its progress day by day, that we think we cannot do better than quote some portions of his excellent thesis, which are of interest in connection with the subject under consideration. At the commencement of labor, the organ has generally an elevation of from eight to nine inches above the pubis, and from six and a half to seven and a half inches in width. When the clots which follow the exit of the placenta are ex pelled, the uterus is found to have assumed a spheroidal form, and is hard, resisting, and contracted. Its vertical diameter is then only about from four and a half to five inches, and its transverse diameter from three and a half to four inches. After about half an hour and during the first few hours succeeding delivery, its size increases somewhat, — (vertical diameter, five to five and a half inches; transverse diameter, four and a quarter to four and three quarter inches;) but thereafter it diminishes gradually and almost uniformly. On the second day the decrease in the diameters amounts to from three-eighths to five-eighths of an inch, the vertical then being often rather less than the transverse. On the third day, in most cases, little change is observable except in women who have had in the interval of the two last examinations severe after-pains, accompanied by an abundant Lochia! dis- charge when the contraction takes place. Dr. Wieland observed that until the middle of the fourth day the size of the uterus was unchanged but seemed softer and less regularly rounded in form, and that this inactive condition always coincided with the commencing lacteal secretion. From the end of the fourth day the retro- cession of the organ progressed regularly and continuously. The distance which then separates the uterus from the pubic symphysis varies from two and three- eighths to two and seven-eighths of an inch, and in exceptional cases only is it less 4 2 1 LABOR. During each of the following days the observed difference varies from three-eighths to three-sixteenths of an inch. By the sixth day the uterus has become hard, its anterior surface less convex, and its fundus readies from an inch and a half to two inches above the superior strait. Usually not before the tenth day, and sometimes not until the eleventh, has it disappeared behind the symphysis pubis; but even then, if the abdominal walls are very thin upon the median line, the fundus may be felt in the pelvic cavity by pressing downward with the bent fingers. During all this time the tendency of the womb, which in the majority of cases (79 in 100) 'is situated to the right, is to resume its position in the median line. The organ, however, is far from having attained its primitive condition, even when the hand is unable to feel it through the abdominal wall; and its state can be determined only by the vaginal or rectal touch. The laxity of the ligaments, the mobility which it still retains, and its diminished size, cause it to settle into the excavation, so that its inferior segment, still con- siderably developed (being nearly an inch and a half or two inches in diameter), depresses the vaginal cul-de-sac. The neck is lower down in the vagina, and the posterior surface of the organ is felt to be hard, convex, and of a size which can only be approximative^ determined. The absorption seems now to go on more slowly, bo that no sensible difference can be perceived for eight or ten days longer. By this time its volume is slightly lessened, there is less depression of the vaginal cul- de-sac, and it is more movable. Finally, in women whom I examined three months after delivery, the original condition, as respects situation, form, direction, consistency, and mobility, seemed to be restored, the size only appearing to be somewhat greater. In no case had it resumed entirely its primitive condition cither by the sixth week or the second month. (Wieland.)] The rapidity with which the uterus after delivery tends to resume the volume and dimensions which it possessed before impregnation, is, to say the least, quite as surprising as the rapidity with which it underwent its enormous bypertropb.y during gestation. An examination of the various changes through which this rapid absorption is effected, induced M. Retzius, of Copen- hagen, to conclude that it is preceded by a fatty degeneration of the mus- cular fibres. The same observations have also been made by Kolliker. This diminution in the size of the uterus is not always so regularly gradu- ated as described, for when the contractility of the tissue has been feeble after delivery, the Avails of the uterus often preserve a considerable thickness for tour or five days, the fundus being found all this time close up to the umbilicus. The same observation may be made at a still later period, in cases where an inflammation of the peritoneum, of the uterine mucous mem- brane, or of the neighboring organs has supervened. Again, it happens that, after having been diminished, its volume augments anew, for some hours, at times, even for a day or two, and then soon returns to its former size. I can *x plain this circumstance only by supposing some local congestion, which has not been acute enough to produce an active hemorrhage, but whose action has been limited to distending and engorging the uterine vessels, and consequently to increasing the thickness of the walls; or this abnormal volume may be owing, in certain cases, to the presence of newly formed coagula. But, however that may be, I felt bound to point out these anoma- lies, to prevent the inexperienced practitioner from falling into error. [The interna] surface of the uterus alter delivery, has lately been studied care- PHENOMENA APPERTAINING TO THE LYING-IN STATE. 425 fully by MM. Colin, Kobin, Pajot, and Behier. Two parts, dissimilar in appear- ance, may be distinguished in it; one of these, which is extensive, was in relation with the decidua during gestation; the other, having a lesser surface, presents traces of the insertion of the placenta. We have next to study these two parts in succession.] A few hours after delivery, says M. Colin, the internal surface of the w )inb is covered with clots of hlood, which, upon being removed, discover a soft, moist, reddish layer, lining the whole internal surface of the uterus, except where the placenta was attached. If the surface be scraped with the blade of a scalpel, a layer varying in thickness from the one-eighth to the one-sixteenth of an inch may be raised from it. This layer, which increases in thickness towards the middle and fundus of the organ, is of a reddish- gray color and friable, tearing like a newly-formed pseudo-membrane, and even giving way beneath the fingers. Below it is found the muscular tissue, of a white or grayish appearance, entirely distinct from this layer, and easily recognized by its clearer hue, the appearance of fibres and their trans- verse direction, as also by its greater consistency. It is now demonstrated that this membrane is formed by a new uterine mucous membrane in process of regeneration from the fourth month of ges- tation. (See page 177.) At the upper boundary of the cavity of the neck, this membrane is termi- nated by an irregular edge projecting above the latter, and from which are put forth small shreds or laminae, from one to three-sixteenths of an inch in length, of the same nature as the layer covering the wall of the uterus. The cavity of the neck contains a glutinous, transparent, and slightly- reddish mucus. The color of its internal surface varies greatly according to the mode of death, from a reddish-gray to a blackish-brown. The thickness of the mucous membrane lining the cavity of the neck varies from the one- thirty-second to the one-sixteenth part of an inch ; it is very moist and flex- ible, although firm and torn with difficulty. It remains intact, and does not participate in the exfoliation which that of the body undergoes. The condition of the mucous membrane at a period still more remote from delivery, has also been studied by M. Colin. Not until after about the ninth day are epithelial cells found upon the surface of the uterine mucous mem- brane in process of restoration. Until the twentieth day its tissue is com- posed chiefly of fusiform bodies, nuclei, and granules; glands and numerous capillary vessels are found in it about the twentieth day. Thus, from the twenty-eighth to the thirtieth day, the membrane has assumed a rose-red or grayish color, especially in the vicinity of the neck ; it is smooth, moist, and soft, but resists the action of a stream of water, though it may be scraped off entirely by the scalpel, so as to expose the muscular fibres. Numerous vessels, whose greatest diameter does not exceed the one-ninetieth part of an inch, proceed from the muscular tissues and ramify ad infinitum in its substance. By the fortieth day, the membrane is of a rather deep-red color, opaque, and of about the one-thirty-second part of an inch in thickness, toward the fundus; it is semi-transparent and thinner in the lower part of the body, where it is continuous with the mucous membrane of the neck, which presents no peculiarities. It is soft, and easily removed by the back of a scalpel. It 426 LABOR. is traversed by a very close network of capillary vessels. By the sixtieth day, it is smooth, gray, and supplied with small vessels; it has the true con- sistency of a mucous membrane, and the scalpel removes from it but a slight pellicle, which has no longer the pulpy appearance of the substance detached from it at an earlier period. This new mucous membrane, which, according to M. Robin, begins to be formed by the fourth month of gestation, is, therefore, after delivery, the seat of a reparatory process, which ends in the completion of a new mucous membrane. The mucous membrane of the neck is not thrown oft"; it is simply hypertrophic'! during pregnancy, and after delivery continues to exhibit the arbor vihe, though of a somewhat modified form. The point of attachment of the placenta is marked by an elevation, presenting to the view a surface mammilhited, rounded, anfractuous, and projecting to the extent of a quarter of an inch .above the level of the sur- rounding surface. The anfractuosities are tilled up with coagulated blood, which is removed from them with difficulty. It is the placenta wound These inequalities, which have been regarded by some anatomists as tufts destined to dip down between the cotyledons of the placenta, are due, accord- ing to Desormeaux, to the excessive distention which the arteries and veins, the last especially, have undergone during pregnancy, and upon the slowness of their subsequent retraction ; though, according to Velpeau, they are owing, in women that die shortly after delivery, to the swelled and fungous charac- ter of that portion of the internal uterine surface which corresponded to the placenta. We prefer the following explanation, given by M. Jacquemier, viz. : the internal muscular layer of the womb is perforated in all the space occupied by the after-birth, by a great number of holes, which give a pecu- liar aspect to this portion of its inner surface, and render it less contractile than at other parts; and consequently, as the organ retracts, it has a ten- dency to project into its cavity, and when it arrives at the final state of repose, a tumor is formed, which is ordinarily larger than the palm of the hand, with a very irregular lacerated surface, spongy, as it were, in charac- ter, and often standing out in considerable relief; the torn utero-placental vessels are comprised in this mass, which renders them tortuous and nearly inextricable. But whatever the explanation may be, it is highly important, adds M. Jacquemier, to bear this arrangement constantly in mind, for an attentive perusal of several cases of artificial delivery of the after-birth, has convinced me that, in those instances, the tumor formed by the most inter- nal layer of the womb was mistaken for debris of the placenta, which the medical attendants endeavored ineffectually, though not without danger, lo extract. [Rubin has shown that this projecting portion is formed simply by the utero- placental mucous membrane, which remains adherent to the uterine wall, with t lie exception of the thin superficial layer which was carried away by the placenta. (See Decidua, and Placenta.) The retraction of the uterus after delivery diminishes greatly the superficial ex- tent of this part of the mucous membrane, being soon reduced to a diameter of from two and a half to three and a quarter inches, and so progressively. At firsi it was circular in form, hut Boon becomes irregularly oval, with the greater diameter PHENOMENA APPERTAINING TO THE LYTNG-IN STATE. 427 corresponding with the longer diameter of the uterus. What it loses in length, however, it gains in thickness by the contraction of the organ. A few days aftei delivery, it has a thickness of from five-eighths to six-eighths of an inch, and in some places even more. At the same time, its surface becomes folded and rough- ened, and its substance brownish or reddish ; it also softens gradually, and assumes a pultaceous or mucous consistence. Its projecting and irregular edges are con tinuous with the thin, newly-formed mucous membrane which lines the remaindei of the uterus. It is not uncommon to find on the surface of the part just described vascular orifices plugged up by reddish or bleached clots, and if the latter be traced by dis- section into the deeper parts of the membrane, they will be found to lead into the subjacent uterine sinuses. The cavernous appearance given to this layer by the membranous anastomoses of its vessels is very striking, and one cannot but observe at the same time that its thickness and the projections which it forms upon the internal surface of the uterus are principally due to the clots which fill and distend the sinuses to a greater or less extent. If the latter be emptied, the intervals between them will become very slight. The clots lose their color and lessen gradually, but they are still found up to the twentieth day after delivery, and often much later. The tissue of the serotina it- self atrophies, and finally becomes continuous with and indistinguishable from the newly-formed mucous membrane. In some women, however, the mucous membrane remains for several years both thicker and more projecting at this point than else- where. It was a mistake, therefore, to suppose, as has been heretofore done, that the serotina is carried away with the placenta, or that it is exfoliated and eliminated during the continuance of the lochial discharge. (Robin.) In autopsies of puerperal fever cases, the layer, with a reddish, flocculent, black- ish and pultaceous appearance, formed by the serotina, has often been mistaken by- persons not fully acquainted with what had taken place previously, for portions of the placenta remaining adherent to the uterus, and then in course of decomposition. To recapitulate: At the moment of labor there is already present a newly- formed but very thin mucous membrane between the muscular layer of the uterus and the parietal decidua. The new membrane makes its appearance at the fourth month, but does not continue to grow between the muscular layer and the utero- parietal mucous membrane. Finally, when the placenta is detached, the greater part of the serotina remains adherent to the uterus. This utero-placental mucous membrane does not, therefore, deserve the name of decidua, inasmuch as it continues and diminishes gradually in thickness until its surface corresponds with that of the recrudescent mucous membrane.] Professor Stoltz has studied the modifications that occur in the neck of the uterus, after the delivery, with a great deal of care, and we extract the following passage from his excellent thesis on this subject: "As soon as the child is born, the cervix is partly formed anew, but it is soft, short, wide, and irregular, and one or more fingers can easily be made to penetrate it; the internal orifice oilers the greatest resistance, as is proved when an attempt is made to introduce the hand into the womb, for it enters with considerable difficulty, and only when this orifice has been progressively dilated. The latter is sometimes so contracted as to induce inexperienced persona, who endeavor for the first time to carry the hand up into the womb, to believe they have succeeded, when in fact they have only reached the dilated vagina, where they find a large cavity, but no opening to get any further, and the clots of blood, then collected at the upper part of the vagina and around the cervix, add still more to this confusion.' 428 LABOR. The internal orifice, formed after the expulsion of the child, offers hut little resistance; and, consequently, it has scarcely occasion to dilate again for the passage of the placenta, as it yields readily ; and when the delivery of the after-hirth is effected, the womb contracts, and the neck becomes longer and more consistent ; although it must again open several times to permit the numerous clots of blood to escape. During the lying-in, it gradually returns to its natural size; sometimes, even, it is longer; but it acquires the ordinary disposition more or less, as it regains its proper con- sistence, and by the end of the first month it generally exhibits about the same dimensions as it had prior to gestation ; at times, however, it is a little shortened, and the consistence is nearly as firm as usual, although the infe- rior part has seemed to us rather more softened. It no longer presents a conical shape, but is more cylindrical, from the fact of the summit having become larger. As a general rule, the scars on the lips are proportionably more numerous as the patient has had a greater number of children, and her labor has been more tedious. The transverse fissure is deeper and more angular ; and, in such women, the upper part of the cervix is some- times larger than the base, though it is much shorter than usual, and at limes is divided into two lips that are more or less flat, broad, and unequal, and the anterior of which is longer than the posterior; indeed, in some cases the latter seems to have been altogether destroyed, while in others it is well marked, and the anterior one is scarcely perceptible. In fact, almost as many varieties exist on this point as there are different subjects. The vagina becomes shorter, and the ridges that were effaced during the last stage of labor, gradually but slowly reappear, and the orifice of this canal, and the vulva, also regain their primitive condition. At first, the labia externa, as well as the perineum, are thin and distended, and the pos- terior part of the contour of the vulva is flabby, wrinkled, and projecting outward. Sometimes the epidermis is fretted, at others, actual lacerations are found, which produce a smarting sensation ; and as to the fourchette, it is almost inevitably torn in the first labor. The broad ligaments seem to re-form by the approximation of their two constituent layers, while the round ligaments gradually become shortened and retracted. The abdominal muscles and integuments, which were at first soft and flabby, and exercised but a very imperfect pressure on the viscera and ves- sels contained in their cavity, again retract; although this process is very often incomplete in women of a soft fibre, or who have had many children. This slow and gradual retraction of the uterus takes place, in some in- stances, without the least pain, and without the knowledge of the patient ; but it more generally becomes intermittent and distressing, and as the suf- ferings the women then experience have a great analogy to those of child- birth, they are called the after-pains. At the same time, a more or less abundant discharge takes place from the vulva, consisting at first of pure blood, then of blood mixed with a white fluid, and, lastly, of a white sero- purulent liquid ; and these discharges have received the name of the lochia Finally, a function altogether new sets in, in the course of the first few days, which may be considered as the complement of the puerperal functions; PHENOMENA APPERTAINING TO THE LYING-IN STATE. 429 this is the milk secretion, whose onset is attended by certain general phe- nomena, which are ordinarily described under the term of the milk fever , we shall therefore have to examine, in turn, these three principal phenom- ena of the lying-in state. § 1. Of the After-Pains. The after-pains are certainly occasioned by the contraction of the womb , to be satisfied on this point, it is only necessary to place the hand over the hypogastric region, when we will ascertain that the uterus becomes harder just at the moment when the patient complains the most. These pains are much more frequent and intense in women who have borne many children than in primiparse ; as, also, after an easy than after a long and painful labor; and when the womb incloses some foreign body, such as coagula, or a portion of the membranes or placenta, than when its cavity is entirely empty. Now, all these differences in character will be readily compre- hended, if the reader will only bear in mind that the object of the contrac- tions is to express from the uterine parietes those liquids with which the walls are still engorged after the delivery, and to expel from its cavity all the foreign substances contained therein ; that, in very prompt labors, the urgan, from being evacuated too rapidly, does not retract so perfectly as it ought, and allows the blood to coagulate and accumulate in its interior, and that the very feeble contractility of its tissue force* out but very im- perfectly the fluids remaining in the thickness of the walls. The pains generally commence soon after the delivery, being at first feeble an J distant, then more frequent and painful; and, at the moment of their occurrence, the uterine globe retracts, becomes harder, more resistant, and sometimes even seems to rise up, by resting on the posterior plane of the abdomen, as a point d'appui, and projecting in the form of a globular tu- mor through the walls of the abdomen. The escape of the lochia is ordi- narily more abundant towards the end of, or just after each pain, and nut un frequently a few small coagula come away from the vulva ; but where the uterus contains a large one, the pains constantly increase in force and frequency, until it is expelled, after which they again diminish. In most cases, they cease during the milk fever, though they may continue for the first seven or eight days. They are very commonly excited by putting the child to the breast. Sometimes they return after having entirely disap- peared, are followed by the discharge of a little blood from the vulva, or the expulsion of a clot, or of a portion of membrane that has remained in the uterus, and then everything returns to its natural condition. They are sometimes so severe as to extort cries from the patient, and some women insist that they suffer more from them than from the labor pains. As regards the diagnosis, it is highly important to distinguish the after- pains from those caused by peritoneal inflammation, but fortunately this is not very difficult; for however strong the after-pains may be, they arc gen- erally intermittent, and are separated by an interval of variable duration ; besides, the distress attendant upon them is rather alleviated than augmented by pressure, and a rather more abundant lochia! discharge accompanies or follows them. While they last, there is an absence of febrile movement; 430 LABOR. finally, when the child seizes the nipple, especially if the latter is the seat of any ulceration, the sufferiag thereby caused most frequently brings on an after-pain, and this circumstance alone has often sufficed to make them re- appear, even after a suspension of several hours. When existing, these, dif- ferential characters are quite sufficient to distinguish them, but unhappily they are not always so well marked; for, where they are very acute, or fol- low each other in rapid succession, they are accompanied by fever and sharp pains in the hypogastrium. But even then, there is always a remission, which, conjoined with the absence of the other signs of peritoneal inflamma- tion, may aid in determining their character. Dr. Dewees states that he had several times an opportunity of observing a singular pain which was manifested almost immediately after the delivery, and vet was altogether different from the ordinary after-pains. It is a very acute pain, referred by the patients to the lower part of the sacrum and coccyx. It commences as soon as the child is born, and continues without interruption, and of a frightful intensity. It is declared by the patient to be vastly more insupportable than the after pains, for it is quite as violent, besides being constant ; the latter character serving as a ready means of dis- tinguishing it. Camphor and opium appeared to him the most successful means of relieving it. The after-pains, of which we have just spoken, are sometimes so severe as to claim the attention of the physician, and although they may be useful when caused by the retention of a foreign body, they are so annoying, that it is certainly advisable to endeavor to prevent them. Dewees states that this may often be effected by observing the following precautions: 1. Do not rupture the membranes before the neck is completely dilated ; 2, after the head is born make no tractions, but allow the uterus to expel the shoul- ders and trunk ; 3, do not extract the placenta until the womb is thoroughly contracted ; 4, after the placenta is delivered, excite the womb so as to oblige the muscular fibres to contract as much as possible. It is evident that all these measures have for their object to insure the slow and complete con- traction of the walls of the uterus, in proportion as its contents are expelled. In the cases of women who have suffered much from after-pains in pre- vious confinements, I have made it a practice to administer a few r doses of ergot immediately after delivery, with the effect, I have thought, of pre- venting their occurrence in many cases, or at least of lessening their violence. When the womb contracts feebly, it has seemed to me of advantage to add pressure upon the uterus to the use of the ergot. This is done by means of the ordinary bandage, and made more effectual by placing a compress, formed of one or two folded towels, upon the fundus of the organ. If the after-pains are feeble, nothing need be done ; if, however, they are very violent, the physician should interpose. Provided the patient has not suffered from hemorrhage, or been threatened with it, we may begin by placing warm and emollient cataplasms upon the abdomen. Lotions con- taining laudanum may be used upon the belly, and the cataplasm may be wet with the same substance. An injection may also be given of from twenty to forty drops of Sydenham's laudanum, in as small an amount of vehicle as possible. Dewees professes to have derived great advantage from PHENOMENA APPERTAINING TO THE LYING-IN STATE. 431 a camphor mixture, consisting of a drachm of camphor to six ounces of vehicle, a tablespoonful to be taken every hour or two. When the mixture disagrees with the patient, ten grains of finely-powdered camphor, every hour or two, mixed in a little syrup of any kind, may be substituted for the julep jnst mentioned. When the after-pains are accompanied by signs of general plethora, blood may be taken from the arm. Finally, should there be cause to suspect the presence of large clots or portions of the membranes in the cavity of the uterus, one or two fingers may be introduced within the neck, in order to seize them, or at least to bring about their expulsion. These are, perhaps, the only circumstances under which the use of ergot, so highly vaunted by Crozat and Velpeau as a remedy for after-pains, is likely to be successful. § 2. Op the Lochia. Of all the various excretions that take place after the delivery, the lochia are certainly the most interesting to us as practitioners. This name is applied to the matters that escape from the vulva during all the period from the delivery of the after-birth until the womb has regained its normal size and consistence. Immediately after the delivery of the placenta, and the escape of the accompanying blood, all further sanguineous discharge becomes tem- porarily suspended, probably because the blood that transudes from the surface of the womb accumulates in the cavity of that organ ; but the pure fluid soon begins to flow again, although, in the course of twelve or fifteen hours, it loses its consistence, and its color becomes lighter, and after a short time it is changed into a bloody serosity. At the expiration of the first day, the fluid secreted contains only about one-third part of red globules ; the other elements consisting of white globules in rather smaller proportion, and very numerous epithelial cells. The suspending fluid is sprinkled with grayish molecular granules and granulations of fatty matter. After the second day, the proportion of white globules increases, and the red ones diminish or even disappear. The secretion of milk soon commences, and then the flow of the lochia is either diminished or entirely suspended. When it is over, the bloody discharges reappear, and continue during the four or five succeeding days, though with characters varying greatly in different individuals : thus, in some women, those especially who menstruate profusely, they appear with the same characters, quantity excepted, as before the milk fever. They are still composed of pure blood, which sometimes contains numerous small clots ; with the majority, however, they become more and more serous, though still exhibiting here and there some bloody streaks, or perhaps are slightly tinged by the blood, the quantity of which diminishes every day. it usually disap- pears altogether about the eighth day; the lochia being thenceforth coin- posed of a more or less consistent yellowish-white liquid, and they thus continue for two or three weeks or a month ; though in some women, wdio do not nurse, they do not pass off until the menses reappear, that is, in about six weeks or two months after the delivery. These discharges have been divided, according to their color, into the sanguinoleirf, the serous, and the milky, puriform., or purulent lochia. As the uterus retracts, its walls gradually disgorge the fluids they had imbibed, 432 LABOR. and these naturally run towards its central cavity. So long as the large venous canals in its substance are aol empty, the discharge consists of* pure blood; somewhat later, it is composed of serum, together with the detritus of the ovum and the mucosities of the orpin; and still later, a true suppu- rative irritation is established, the products of which, analogous in some respects to the non-contagious discharges of the urethra, constitute, in a great measure, the white or the purulent issue. The lochia have a peculiar odor, called gravis odor puerperii, which varies in Strength according to the individual and her habits of cleanliness; and to this is also added the scent from the perspiration and the milk, which latter, distilling from the breast, is imbibed by her garments and turns sour. Sometimes the lochia become fetid, and where this circumstance is not owing to slovenliness, it is always an unfavorable sign, since it most generally announces that coagula or some other foreign substances are putrefying in the uterus ; and where the lochial fluid has the color of coffee-grounds, and a cadaverous smell, it is almost uniformly an evidence of the existence of an inflammation of the womb or vagina, which has terminated in gangrene. Again, whenever the patient is afflicted with carcinoma uteri, the discharges resemble the washings () f flesh, and have a very nauseous smell. In all such cases aromatic injections, infusions of elder or chamomile flowers, which are rendered more useful by adding some disinfecting fluid, should be made several times a day. The lochia are also very variable in quantity and duration, though we may state, as a general rule, that the patient soils ten or twelve napkins in the course of the first twenty-four hours, eight on the second day, six on the third, four on the fifth, and two on the following days. After the milk fever is over, the flow diminishes more and more, its amount being usually proportionate to that of the menstrual evacuation. It is more copious in women who have borne many children, or who make use of an overnour- ishing or a heated regimen, and in those who do not nurse. The sanguineous discharges vary much in amount during the first days, according to the force of retraction with which the uterine walls were endowed immediately after or during the delivery of the after-birth ; thus, at times, they are very copious, frequently coinciding with a considerable development of the organ ; and in such cases I have known the womb to continue as high up as the umbilicus for several days after the delivery. This condition, which Leroux calls humoral engorgement, depends, in his estimation, on the fact that the vessels and pores of the womb, from being distended with blood, do not become empty as soon as usual, because the contractility of tissue is not then active enough to expel it; for the walls of the uterus constitute a true sponge, whose meshes are composed of muscular fibres, and which must retract forcibly so as to express all the liquids con- rained in t'ne vessels and vacuities which they form ; hence, if this contraction is not strong enough, the parietes remain engorged, and preserve an abnor- mal thickness, which singularly augments the whole volume of the uterus, although its cavity may be entirely effaced. Soon, however, the contractile action of the tissue is aroused, and the muscular fibres forcibly compress and flatten the vessels that ramify between them, and thus force the liquids PHENOMENA APPERTAINING TO THE LYING-IN STATE. 133 which had hitherto remained there to discharge into the cavity of the organ, whence they flow towards the exterior in considerable quantities. This dis- charge might very readily be mistaken for a flooding, occasioned by a reten- tion of some part of the after-birth, or of voluminous coagula, the more especially as it is accompanied at times by sharp after-pains ; but if one fingi i can then be introduced into the uterus, the accoucheur will ascertain thai it contains no foreign substance, and by placing the other hand at the same time on the hypogastric region, he will easily satisfy himself that the unusual size of the organ depends only on the engorgement of its walls. In these cases, there is nothing to be done, as the sanguineous discharge is itself the best remedy ; for it slowly empties the uterine texture, diminishes the after- pains, and the womb gradually returns to its normal size. This slowness of the retraction also prolongs the flow of the sanguineous lochia, and the same result is observed whenever one of the layers of the uterus or its enveloping cellular tissue is affected with inflammation. Indeed, we can readily understand that from this sluggishness of the uterine fibres, this defect of reaction, as Leroux called it, to a more or less perfect inertia of the womb, there is but a single step, and that a secondary hemorrhage might result from the absence of contractility, if it were carried to the extent of relaxation. [The time at which the lochia assume a purulent form is also liable to remark- able variations. In thirty-seven cases observed by M. Behier, in which everything was favorable, it occurred on the third day nine times, on the fourth day four times, on the fifth day ten times, on the sixth day six times, and from the seventh to the tenth day seven times. Finally, in one case, in the most auspicious condition, the lochia became decidedly purulent only on the sixteenth day. (Behier, Clinique Mfrlicale.)] Lactation lessens the duration and amount of the lochia. Some women have them for a few hours only (Van-Swieten), and others have none at all (Millot). An instance of the latter kind came under my notice quite recently (1855), in the case of the young wife of a medical friend. After an easy and happy labor, the lochia were almost completely suppressed. She hardly lost a few spoonfuls of blood within the first twenty-four hours; after the second day there was no discharge whatever, and the husband, who ex- amined the linen daily with the greatest care, assured me that he was unable to detect the slightest evidence of lochial discharge. Everything went on well during the lying-in, with the exception of a very fetid odor from the genital parts during the first seven or eight days. After satisfying ourselves that there was no foreign substance in the uterus, we recommended the use of injections, frequently repeated, and all passed off well. This young lady had been delivered once before, on which occasion she had a perfectly regular lochial discharge. In a case observed by Bruckmann, and quoted by Velpcau, the lochia were substituted by haematemesis. In some instances, the sanguineous lochia are prolonged far beyond the usual term ; while in others they reappear at various intervals, but this latter circumstance, in the absence of inflammation of the uterus or of its appendages, is ordinarily owing to some error in regimen, more especially to lis 13-t LABOR. getting up too soon ; and, therefore, the best plan is to persuade the patient to remain in bed. In the course of a short time the lochia cease their con- tinual flow, and intervals of several hours of duration are observed at first, then of a day, and sometimes of two days. "When, in spite of this precaution, the bloody discharge continues for two or three weeks after labor, its cause should be sought for in a local alteration of the uterus and of the neighboring parts, or else in the general condition of the patient. Thus, it is not unusual for it to be kept up by a circum- scribed peritoneal inflammation, an inflammation of the uterine mucous membrane, a chronic or acute engorgement of one or both ovaries, or a phlegmon of the broad ligaments, of the iliac fossa, or of the cellular tissue surrounding the uterus. It is important to diagnose these various affections from the outset, as it is they which should be attacked, in order to stop the discharge, which is here but a symptom of the disease. The continuance of red discharges is connected, perhaps, more frequently with ulcerations of the neck of the uterus, having their origin in many cases in the lacerations which occur during labor, and the cicatrization of which is prevented by circumstances which elude our detection. When, therefore, it is certain that no symptom of engorgement or inflammation in the pelvic or hypogastric region is present, the patient should be examined with the speculum, taking care to separate the lips of the neck with the valves of the instrument, wheu very often a fungous and bleeding ulceration will be dis- covered either within the cavity of the neck or upon the os tincae. The only means of arresting the discharge consist in cauterizations with nitrate of silver or acid nitrate of mercury, and even, if the fungosities are very pro- jecting, with the actual cautery. In some cases, it is necessary to repeat the cant cii /ution several times. Amongst the causes of these anomalous lochial discharges, should be reckoned a local irritation sustained by obstinate constipation. Here the use of purgatives is demanded. Sometimes no lesion can be discovered, but the discharge seems evidently to be connected with an over-excited condition of the entire organism. This condition is indicated by heat of the skin, fulness of pulse, some febrile movement towards evening, and disturbed sleep. Notwithstanding the ap- parent weakness of the patient, great care should be taken in reference to the use of tonics, which, unfortunately, are too often employed ; a moderate antiphlogistic treatment, on the contrary, is the one indicated. A small bleeding from the arm, mild laxatives, and a restricted vegetable diet, might be directed with advantage. Stimulating or even tonic drinks should be proscribed, and only after the general irritation shall have been quieted, is it proper to endeavor to increase the strength of the patient by the appro- priate means. In some rare cases, however, the abundance and persistence of the bloody discharge se< m to be sustained by the general debility. The absence of the g aeral symptoms, just now mentioned, allow of recourse being had imme- diately to a tonic treatment ; then it is that infusions of cinchona and sul- phate of in»n are capable of rendering effectual services. (See in Tart Fifth the article devoted to Secondary Hemorrhage.) PHENOMENA APPERTAINING TO THE LYING-IN STATE. 435 The white or purulent lochial discharges sometimes become very profuse, and have at the same time an exceedingly disagreeable odor. The discharge is no longer covered with blood, but appears as a reddish water flowing in large quantity, and sometimes even escaping in gushes. They are occasion- ally so acrid as to inflame the parts over which they flow. The patients are almost always much weakened by the evacuation, and their general health evidently demands the use of tonics. The irritated parts should be washed frequently with warm water, and injections of infusion of chamomile flower-, afterwards made rather more astringent, should be thrown into the vagina five or six times a day. A few spoonfuls of chloride of soda might be added with advantage. [Carbolic acid 3i. ad Oj. is at the present time most fre- quently used.] These purulent lochia, also, sometimes continue long after the usual period of their cessation. This circumstance is sometimes connected with some one of the causes mentioned as productive of the anomalous persistence of the bloody discharge, though it has oftener seemed to me to be the result of a catarrhal metritis or peri-uterine phlegmon. Both these affections may hinder the gradual retraction of the uterus, which may remain of consider- able size for a month or six weeks after delivery. Large flying blisters upon the abdomen, frequent alkaline baths, and bleeding from the arm, when there is fever and the strength permits it, have appeared to me to be the most effectual under these circumstances. The suppression of the lochia long before the time at which they usually disappear is an unfortunate symptom only when it seems to be connected with the development of a serious inflammatory affection, or when it is re- placed by a supplemental hemorrhage. It then merits the closest attention of the physician ; but when the contrary is the case, there is no occasion for uneasiness, since it is the evidence of a rapid and forcible contraction of the uterus, which is a favorable circumstance. § 3. Of the Milk Fever. One of the most important phenomena appertaining to the lying-in state, is that usually designated under the name of the milk fever. It has already been seen, when studying the modifications impressed on the whole organism by gestation, that the breasts in most women, even in the very commence- ment of their pregnancy, are apt to become tumefied, that the swelling per- sists, and that sometimes they become the seat of an abundant secretion long before delivery. After the delivery, they yield on suction a liquid of a yellowish color, and somewhat more consistent than the preceding, which in some women escapes during the latter months of gestation. This fluid has a sweetish taste, and is called the colostrum. It retains these qualities for twenty-four hours; but becomes whiter after that period. In the course of forty to sixty hours, the breasts enlarge greatly; the subcutaneous wins, seen through the skin, are more swollen than during the pregnant state, and the former become manifestly harder. The secretion of milk in healthy women is not usually attended with fever, the diminution of the pulse hardly being prevented by it (see page 422.) Still, if the swelling of the breasts be considerable, headache may occur, as also, at times, though more rarely, I'.i; LABOR. slight si live riii us, <>r heal and dryness of the skin, which is succeeded in a few hours by a copious perspiration; there are thirst and hiss of appetite; the tongue is slightly furred ; the pulse, at first small and contracted, soon becomes full, soft, and accelerated; and the face is flushed and animated. M. Pajot maintains that the pulse rarely rises above 100, which is generally true, though there are exceptions due to individual susceptibility. M Behier has noted the pulse at 130 in a case in which everything went on very favorably. During this febrile movement, which is generally slight, the enlargement of the mamma? continually increases, extends as far as the armpits, and involves the surrounding cellular tissue, whence the patient can no longer bring the arms down alongside pf her body, and therefore hag to hold them off. The skin is sometimes so stretched as to become painful and incommode the inspiratory movements of the chest; and lastly, as else- where stated, the discharge of the lochia either disappears altogether, or else is greatly diminished. This fever lasts for twelve, twenty-four, thirty-six, or possibly forty-eight hours, and then is followed by a calm ; at times, however, it is continued for three or four days ; but in such cases it is often due to a deep-seated inflammation, or else soon exhibits a well-marked in- termittence, and may degenerate into a true intermittent fever, which yields readily to sulphate of quinine. The pulse is ordinarily not very rapid, and whenever it exceeds 100 per minute, the cause should be sought elsewhere than in the lacteal secretion. Authors have stated that the milk fever is less intense with primiparse than with others. The same is the case with those who begin to suckle their children very soon after delivery; indeed, it is not at all uncommon for the latter to escape it entirely. Finally, certain females, even of those who do not nurse at all, have no milk fever whatever, and this notwith- standing that the breasts are considerably swollen and the secretion of milk is abundant. This is a much more common occurrence than is generally supposed, and I have frequently had occasion to point it out to students. Still, I am far from supposing, as some do, that it forms the rule, and from regarding every febrile movement occurring in a lying-in woman, even when the lacteal secretion is commencing, as indicative of an apparent or concealed inflammation. Nothing, indeed, could be more reasonable than to regard the swelling and painfulness of the mammary glands as the cause of the general reaction which usually accompanies them, and which dimin- ishes or ceases, as soon as the breasts become soft, or the system habituated to the Dew condition of things. In some women the breasts remain inactive, and no milk it secreted ; it really would seem, as Prof. P. Dubois has remarked, that nature has left her work unfinished in them ; that, being capable of becoming mothers, and able daring the whole term of gestation to furnish the necessary materials for the child's nutrition, vet their organization is absolutely inadequate to supply its wants after birth. I have at this moment under observation a young priiniparous woman, convalescing, it is true, from an attack of vario- loid which came on immediately after delivery, who has not had a single drop of milk. The milk fever generally manifests itself about forty-eight hours subse- PHENOMENA APPERTAINING TO THE LYING-IN STATE. 437 quenttothe delivery; at times a little sooner, at others somewhat later; thus I have seen two patients at the Clinique (and all observers record similar facts), who had this fever, the one on the fifth and the other on the sixth day; and since that time I have often had occasion to make the same remark. I For the sake of greater precision, we think it best to quote M. Better's ob- servations on the subject. " I investigated," says this professor" the cases of 9, 4 women, in order to determine the precise period at which the flow of milk takes .lace In 22 it occurred within the first day after delivery; in 170 on the second day • 'in 347 on the third day ; in 2GG on the fourth day ; in 100 on the fifth day : in 22 on the sixth day ; in 5 on the seventh day; in 4 on the eighth day ; and in I not until the eleventh day."] Where the child's death takes place at an advanced stage of gestation, and the dead body is not expelled for several days afterwards, it is by no means uncommon to find all the phenomena of milk fever manifesting themselves In ordinary cases, by the time the fever is over, the breasts have acquired their highest degree of distention, and the secretion of milk is very abundant If the child draws well, they are emptied and the patient relieved ; but should the mother not suckle her infant, the engorgement continues for a longer period, though it wears away the more promptly as it was less considerable in the first place, or as the milk flows more easily from the nipple, and as the perspiration and lochia are the more abundant. The question as to the cause of milk fever has been discussed again and again- but without entering into all the arguments which this point of doc- trine has given rise to, we will merely remark, that the febrile movement (which, however, is not always constant) most probably is a consequence of the oreater activity the mammae then assume, and that it is nothing more than what takes place whenever any organ undergoes a very considerable and rapid development. To women who do not nurse, the lacteal secretion may be the cause ot accidents which are to be prevented or opposed. Everything that could tend to increase the secretion of milk, such as succulent food, and the prac- tice of drinking freely, should be strictly avoided. Warm and soft towels should be applied to the breasts, and renewed as soon as they become moist. A still better application is cotton wadding. By these means perspiration is excited and the heat of the parts maintained. Should the secretion diminish gradually, everything maybe left to nature, but should the breasts become too much swollen, the discharge from the nipple should be facilitated by the use of emollient cataplasms, or efforts be made to empty them by suction. In case of these measures proving ineffectual, recourse must be had to lotions containing laudanum for the purpose of relieving pain, and to sudorifics and purgatives as revulsives. As amongst the most commonly employed diaphoretics, we may mention weak tea, and the infusions of Pari©- taria and Borage. The purgatives are those which have, been already mentioned. Of all the preparations which have been extolled as lactifuge, the petlt-lait of Weiss 1 is, according to Desormeaux, the only one which is . The petU-laU (whey) of Weiss is prepared by infusing in boiling whey a Bpecies of galium, flowers of elder, hypericum, and of the linden-tree, together with senna and sulphate of soda. It acts as a purgative.— Translator. 438 LABOR. ptill employed. The same author states that he knew a lady to apply ac ammoniacal liniment with success. Neuter asserts, as proved by experiment, that the application of cups to the back diminishes the flow of milk ; and Van-Swieten knew a galactorrhea to yield to a strong infusion of sage, taken in doses of from one to two ounces every three hours. [M. Blot was the first to discover the presence of sugar in the urine of lying-in women as a phenomenon connected with lactation. It would seem from his re- searchea that sugar, whose presence in urine had been regarded as pathognomonic of diabetes, exists not only in the urine of all lying-in women but in all nurses, and in a certain proportion of pregnant females. The term Physiological glycosuria has been used to express this fact. "In all puerperal women (45 in 50)," says M. Blot, "the sugar begins to appear in the urine in determinate quantity coincident with the beginning of the flow of milk; and in many cases it does not exist until then. In a few cases it may be found previously, but generally in very small amount. If the secretion of milk continues, sugar continues to be passed in the urine with diurnal variations as yet unexplained. When the flow of milk is profuse, the proportion of sugar is usually large ; if the former be moderate, the latter is small. In this way an examination of the urine may enable us to judge up to a certain point of the value of a nurse. If the fl>i\v of milk be lessened or arrested from any cause, and especially by the development of a more or less serious morbid condition, the sugar diminishes in quantity or disappears entirely. If health be restored and the secretion re-estab- lished the sugar reappears. Finally, the urine contains sugar as long as milk continues to be secreted : I have found it in considerable proportion (8 grammes to 1000 of urine) in one case in which the woman had been nursing for twenty-two months. In fact, the urine is generally rich in sugar in proportion as the health improves and approaches must nearly to the normal or physiological condition. " When lactation ceases, the sugar disappears, and that at periods varying in different individuals; earlier in those who do not nurse, and later in those who, having nursed, begin to wean the child. " Sugar was found in one- half the observed cases of pregnancy. I think, with- out being able to affirm it positively, that this peculiarity is most likely to be observed when the breasts sympathize most with the pregnant condition ; that on the contrary, it is absent when the breasts remain indifferent, as it were, to what is going on in the uterus." (Blot.) This physiological glycosuria is also present in the different species of mammalia. As a test of the presence of sugar in the urine, M. Blot used successively Fehling's tlu LABOR. first be sought for, and will be known by its size and especially by its hardness" if the uterus cannot be felt, it is because it is concealed by the distended bladder. Repletion of the bladder has, also, upon the position of the womb an effect which should be 'well understood : when the distended organ rises into the lower part of the abdomen, it carries with it the uterus, whose fundus is then found as high as, and often even above, the umbilicus, and when the catheter is used, it descends as the water flows. Whenever, therefore, the fundus of the uterus is found too high up, the sub-pubic region should be examined carefully to ascertain whether the bladder projects there. If the latter be empty, the fingers will, without tfiineulty, feel the anterior surface of the womb throughout. Retention of urine sometimes continues in these cases for several days, and even for several weeks. So long as it lasts, the catheter should be used at least twice a day according to the rules already pointed out (see page 61). The bladder almost always recovers its power after a certain time, so that there is no occasion for alarm should the retention last for several days.] The constipation that is so common during the last stages of gestation, oftentimes still persists after the delivery for four, six, or even eight days ; and this prolonged retention of the fecal matters may give rise to anxiety, headache, loss of sleep, and sometimes even to a feeling of weight, or actual pain in one of the iliac fossae; all which symptoms disappear like magic upon the administration of some mild laxative. Where the costiveness continues, a state of suffering very frequently results, which may occasion a blight febrile movement; and the frequency of pulse, thus produced, coin- ciding with the pain caused by an unusual retention of the fecal matters, which pain is most commonly located in some part of the hypogastric region, and is augmented by pressure, may give rise to suspicions of a peri- toneal inflammation that really does not exist ; and I have known this error to be committed where the pain and fever that had resisted the application of leeches, rapidly disappeared after the exhibition of a purgative. The retention of the faeces may also result from a paralysis of the rectum, which paralysis itself is a consequence of the pressure made upon it by the head during its prolonged sojourn in the excavation. I have known, says M. Martin, of Lyons, the faeces to be retained more than twenty days after a laborious delivery, and to accumulate in such large quantities, and acquire such a firm consistence as to equal the size of a child's head at term ; and as all the usual laxatives failed, I was obliged to introduce a scoop, and bring the hardened matters away piecemeal ; but even then the gut did not at once regain its functions, though a fresh accumulation was prevented by the use of irritant injections, and the contractility of the intestine was not perfectly re-established until twenty-nine days afterwards, at which period the patient left the hospital. (Comptes Rtndus, p. 32.) A temporary constipation, prior to the invasion of the milk fever, is a matter of no consequence; but should it persist for several days afterwards, injections may be administered, either simple, or else rendered slightly lax- ative by the addition of an ounce or an ounce and a half of the vxiel mercu- r't'de, or a decoction of senna Leaves ; and where these measures do not answer, a mild purgathe, such as the following, is exhibited by the mouth, viz., from half an ounce to an ounce of castor oil, rubbed up witn an ounce of almond emulsion and a little lemon syrup. The compound licorice powder ATTENTIONS TO THE LYING-IN WOMAN. 44] of the pharmacopoeia is a very efficient and pleasant laxative, and, although recommended especially for the constipation of pregnancy, will be found to an- swer the same indications after labor. Many patients suffer from hem< >rrh< >ids during convalescence, and in these cases half-grain doses of aloes, administered night and morning, have been recommended by Fordyce Barker as a specific. The woman should make no exertion during the first few days, and if the labor has been long and painful, or attended with any serious accident, it is best that she should be protected from violent and rude motions, and that the bed be not made up until after the milk fever has subsided. When, however, the patients are but slightly fatigued, the bed may be made on the evening of the day preceding that on which the milk fever supervenes, after which it should be left until the next day but one ; thereafter it may be made every day. The woman should, on these occasions, be transferred to another couch. It is very important that the patient should not rise before the ninth day, which is a favorite time for getting up with the working classes, and where she is in easy circumstances, and can, without detriment to her interests, abstain for a longer period from her household duties, she should be required to remain in bed for at least two weeks. It were better not to adopt arbitrarily any particular day, but to regulate the conduct to be followed by the degree of atrophy of the uterus. When the latter has lost the greater part of its bulk, and its fundus descends and disappears in the lesser pelvis, the patient may get up. One woman may do so without danger on the eighth day, whilst another ought to remain in bed after the fifteenth day. At this period she may be carried to an easy-chair, where she will remain seated for an hour or two, and again, on the following day, for two or three hours. On the third, she might try her strength by taking a few turns around the chamber, and then through the apartments ; but it would be imprudent to venture out of doors, especially in the winter season, before the fifteenth or twentieth day, and only then in fine weather and about the middle of the day. Most women, actuated by a religious feeling, go to church on the occasion of their first going out ; and as these buildings are always cold and damp, they often return with the germs of an inflammatory disease, which sooner or later develops itself; and hence the physician should advise the deferring of this religious ceremony, called the churching, to a more distant period. As regards her diet, the articles ought to be of the mildest character, and of easy digestion ; thus, as a general rule, she will only need, during the first day or two, a little porridge two or three times in the course of the day, and Borne broth during the night ; and she should observe an absolute diet pend- ing the duration of the milk fever, for fear of adding to its intensity ; though even here, if the general reaction is moderate, she might be allowed some broth. After the fever is over, the quantity of nourishment is gradually augmented ; so that, by the twelfth or the fifteenth day, the woman has resumed her ordinary habits. In those who do not nurse, the regimen must be more restricted, especially when the breasts still remain engorged or painful. [The regimen of lying-in women, as jusl indicated, was rigorously observed until within :t lew years; but, we ought to add, there is now a strong disposition to act 442 LABOR. differently. Legroux, physician at the Hotel Dieu, introduced the innovation by showing that not only was there no danger, but often a real advantage in giving nourishment freely to newly delivered patients. Accordingly, he allows soups to the women in his wards on the first day, and solid food on the second day after delivery. I have followed his example for several years, and have had no reason to be other than pleased with it. Immediately after delivery, therefore, I allow soup, taken in small quantities, but freely. On the next day solid food is per- mitted; an egg or mutton chop, for example, with bread and claret and water. After the secretion of milk has begun, the patients can resume their usual diet. This plan has but the single inconvenience of eliciting the disapproval of those whe have grown up in other ways of doing; but inasmuch as it is better for the patients, we shall have to disregard these objections.] Throughout the whole lying-in period, the patient should use some diluted ptisan, moderately sweetened and rendered aromatic, as an ordinary drink ; such as a solution of gum, or an infusion of mallows, of violets or linden, the orange or chamomile flowers, &c, etc. ; but acidulated drinks must never be allowed to those who nurse. About the seventh or eighth day, most patients ask their medical attendant for something to drive away the milk, which, of course, is generally a useless precaution ; but, perhaps, it would be better to yield to a very popular prejudice, so as to escape all subsequent reproach. The Canne de Provence, and the infusion of periwinkle, &c, enjoy a high reputation for this purpose ; and as the root of the former is nearly inert, it will, on that account, be preferably employed. Most women think it necessary to be purged towards the end of their lying-in ; and though, when the physician discovers any positive counter- indication to the administration of even a mild purgative, he doubtless should not yield to their desires ; yet, under ordinary circumstances, he ought to purge them slightly, both on account of his own reputation and to avoid subsequent unjust reproaches; indeed, this will become necessary, if the tongue is broad, furred, and yellowish or greenish, the mouth bitter and clammy, and there is a loss of appetite. The Seidlitz waters and castor-oil are perhaps preferable, from their mildness and certainty of operation. The excitability of the nervous system is such, in lying-in women, that the greatest care should be exercised in keeping away everything that might excite them, and in avoiding all acute moral emotions. PART IV. PATHOLOGY OF PREGNANCY. THE pathology of pregnancy comprises all functional derangements occurring in pregnant women, as well as all spontaneous or accidental lesions of the ovum which may compromise the health or life of the foetus. As the latter class usually either escape detection, or are not discovered until it is too late to remedy them, they will be considered briefly ; all, in fact, that can be said of them is limited to certain questions of pathological anatomy, foreign to the main object of this work. [Some of the numerous diseases observed during pregnancy are the result of this condition ; others occur, as it were, by chance, and often happen under other cir- cumstances. On this account, they are treated of in separate chapters ; a division, however, which is far from perfect, as the distinction between the two classes can- not always be defined. The first chapter is devoted to the diseases which may occur during pregnancy, and the second to those which are the result of it. After- ward are described extra-uterine pregnancies, lesions of the ovum and of the pla- centa, and diseases of the foetus and its death. The last chapter treats of abortion.] CHAPTER I. OF THE DISEASES WHICH MAY EXIST DURING PREGNANCY, AND OF THE RECIPROCAL INFLUENCE WHICH THEY MAY HAVE UPON THEIR PROGRESS AND TERMINATION. Though, says Antoine Petit, pregnancy exposes women to various disorders, it also protects them from many very dangerous diseases, arrests the pro- gress of others, and sometimes even cures those with which they were pre- viously affected. This proposition, though asserted almost as a maxim by the author quoted, is, unfortunately, far from being strictly true. Antoine Petit was indeed strangely deceived in his appreciation of the influence of pregnancy upon acute diseases existing before it or occurring during its progress; still, as many physicians partake of his error, we have thought it right to notice it at the outset. § 1. Epidemic Diseases. 1. Influenza. — Though some epidemics have appeared to spare pregnant women, many have affected them as severely, at least, as other individuals exposed to the same influences. Thus I found, as did also M. Jacquemier, 4 13 444 PATHOLOGY OF PREGNANCY. at the Maternity Hospital, thai the epidemic of influenza attacked a great many pregnant women ; but, contrary to his observation, I witnessed numer- ous abortions as a consequence either of the disease itself, or of the violent spells of coughing which tormented the patients. 2. Cholera. — The severe epidemics of cholera which, in 1832 and 1849. were so fatal in the capital, did not span' pregnant women ; and we had the pain of witnessing the death of quite a number. Dr. Bouchut has endeavored, in a quite recent work, to appreciate the effect of pregnancy upon cholera, and vice versa. Relying upon 52 obser- vations, he commences by showing that pregnancy has no influence upon the invasion of cholera, that it protects from it no more than it predisposes to it, and that when the disease appears, it does so without any modification, in all its forms and severity. Cholera has, however, an incontestable influence upon the course of gesta- tion, often shortening its duration. Thus, 25 women out of 52 aborted in consequence of the disease, and the same would probably have been the case with others, had not the patients been removed by an early death. Except in some rare instances, abortion took place only in cases in which the disease lasted over twenty-four hours. Of the 25 women who aborted, 16 recovered ; 12 had the disease with moderate severity, though lasting for a considerable time; the attack in 4 was dangerous and rapid, and 9 died. The observations of M. Bouchut have elicited the remarkable fact that abortion is very common in cholera patients after the fifth month of preg- nancy, but very rare at its commencement. Thus, of the 16 women who aborted and recovered, only 1 was three months pregnant, 1 four, 6 five, and 1 six ; and the least advanced of the 9 who died after abortion, had reached four months and a half. Of the 27 women who did not miscarry, only six recovered and had their pregnancies to continue. The attacks which they suffered were of medium severity, and of several days' duration : 21 died with the disease in a dan- gerous and rapid form. Altogether there were 30 deaths out of 52 cases. We see, therefore, that the prognosis of cholera is not rendered more favorable by the state of pregnancy. We have said that 6 of the patients recovered, and had their pregnancies to pursue their regular course. Others, who had reached a more advanced stage, were delivered prematurely of living children. From this, it plainly results that cholera is not always communicated to the fetus, and that though the latter usually succumbs either before its expulsion, or before the mother, in those cases where her early decease did not allow the abortion to take place, its death cannot be attributed to a transmission of the disease. Besides, the autopsy of the children revealed nothing which could be regarded as pertaining to cholera. What, then, is the cause of the death of the fetus, preceding, as it almost always does, its own expulsion, or the death of the mother? M. Bouchut thinks that it is a consequence either of a mechanical com- pression of the uterus produced by the cramps and convulsions of the ab- DISEASES OCCURRING DURING PREGNANCY. 445 doniinal muscles, or to the severe diet to which the patients are subjected, again, he supposes that it may be occasioned by the profuse discharges from the bowels, which, by depriving the blood of its serum, dry up, as it were, the sources of nutrition. For my own part, I regard asphyxia as the only, or at least the usual, cause of the death of the foetus. The coagulation of the blood, and its stagnation in the vessels, are evidently calculated to sus- pend the utero-placental circulation ; and the interruption of the latter, depriving the foetus as it does of the means of respiration, must necessarily lead to its rapid death. M. Devilliers, Jr., read before the Academy of Medicine an observation tending to prove that abortion has a favorable effect upon the termination of cholera, and causing him to feel justified in recommending the provoca- tion of premature labor, as a means of diminishing the danger of the dis- ease. In examining under this point of view the results furnished by M. Bouchut, a result favorable to the opinion of M. Devilliers is at once dis- coverable ; since of the 27 patients who did not miscarry, 21 died, whilst 9 deaths only occurred after 25 abortions. Still, it should be observed, that of the women who recovered after aborting, 4 only had the disease in a rapid and dangerous form ; whilst of the 21 who died undelivered, the disease Was very severe, and barely lasted a few days. This early fatal termination was, very probably, the only cause which prevented abortion. The view of M. Devilliers cannot, therefore, be received without new con- firmatory observations. In short, though pregnancy does not affect sensibly the progress and dan- ger of cholera, the latter leads, in the great majority of cases, to the death or premature expulsion of the foetus. § 2. Endemic Diseases. Intermittent Fever. — There can be no doubt that, as M. Ebrard has en- deavored to prove, the grave disorders and deep perturbations produced throughout the economy by the febrile paroxysms, the obstinate vomitings which attended many of them, and the cough, diarrhoea, and colics, may disturb greatly the functions of the womb ; also that the fluxion and con- gestion so often produced by this fever, may cause the premature expulsion of the product of conception. The possibility of the occurrence being incontestable, the indication to remove the morbid condition follows as a matter of course. I mention this influence of intermittent fever upon the pregnant condition only as affording an opportunity of discarding completely the advice of some persons who recommend the rejection of sulphate of quinine, as likely to produce abor- tion or premature labor. The miscarriages laid to the charge of the sul- phate of quinine should certainly be attributed to the disease itself, and not to the remedy. For my own part, I have had occasion to use it six times at various periods of pregnancy, in doses of ten, twelve, and even fifteen grains in the twenty-four hours, without having had to repent of it. Many practitioners, who, like MM. Thezet, Delmaz, Alamo, and Ebrard, have long practised in localities where this fever is endeini:, have never been obliged in complain of the action of sulphate of quinine when administered 446 PATHOLOGY OF PREGNANCY during pregnancy. Not only is it an innocent remedy, but the surest pre- ventive means when abortion is imminent in consequence of the fever. [Some facts go to prove that pregnant women attacked with intermittent fever may communicate the disease to the foetus. Dr. Stokes, of Dublin, states, that he saw a case of tertian ague during pregnancy in which the foetus was affected with convulsive movements remarkable for their correspondence with the apyretic days if the mother. M. Pitre-Aiibanais relates two cases of intermittent fever communicated to the foetus by the mother. Both of these children were born with hypertrophied spleens, and their attacks of fever coincided both as to day and hour with those of the mother. (Bourgeois de Turcoing.) M. Jacquemier also says, that it would seem that intermittent fever may attack both mother and foetus at the same time, and the facts upon which he bases his assertion, though few, appear conclusive. Schurig relates that a woman had a rebellious quartan ague in the second month of her third pregnancy, and that in the last month either before or after the paroxysms she felt the child to be excited, shiver, and roll perceptibly from one side to the other. At last, after a severe paroxysm, she was delivered of a girl which had a violent attack of fever at the same hour with the mother, and which continued to return during seven weeks. Similar cases were observed by Hoffman and Russell. (Jacquemier, Tvaitt d' Ob- stetrique.)] § 3. Eruptive Fevers. i. Variola. — The eruptive fevers seem, generally, to be much more dan- gerous to pregnant women than to other individuals. Variola, especially, of all these diseases, has the most disastrous influence upon the pregnant condition ; some authors, indeed, state that it is almost uniformly fatal, par- ticularly when it produces abortion. It is important, as regards the prognosis, to distinguish between the con- fluent and discrete forms of small-pox. (Chaigneau.) The former, which is so fatal, independent of pregnancy, as to destroy a third of whom it at- tacks, is still more to be dreaded during gestation, sparing, as it does, almost none of its victims ; the latter, on the contrary, is far from always occasion- ing abortion or premature labor, and even where the pregnancy is ended before term, the mother often recovers. Dr. Gariel thinks that the lumbar pains, which are so severe in the first stage of variola, have a great tendency to produce abortion. I have seen in two cases of the discrete form, slight contractions coinciding with these lum- bar pains ; but 1 was able to arrest them by the use of opiate injections. In several other instances, I witnessed nothing of the kind, and I think with M. Chaigneau (Thesis, 1847), that abortion is specially liable to occur when the pustules are in full suppuration, and the secondary fever appears, in connection with the grave symptoms which usually accompany it. To recapitulate : confluent small-pox nearly always occasions abortion, and this is almost uniformly followed by the death of the mother : out of 23 abortions observed by M. Serres under these circumstances, there were 22 deaths. Discrete small-pox, on the contrary, generally allows the pregnancy to continue its course, and even when it interrupts its progress, the mother usually recovers, and in the latter months the child is expelled alive. When the foetus is not expelled, it may continue to grow, and often it does DISEASES OCCURRING DURING PREGNANCY. 447 not appear at birth to have suffered much from the disease which had endan- gered its mother's life so greatly ; in other cases, however, either because it receives the germ of the disease which affects the mother, or because the deep-seated disorders which the variola produces in the maternal system also exert an unfavorable influence upon the foetal life, it soon perishes. In the former case, variolous pustules, in every respect similar to those on the mother, may be detected on the body of the child. [We have just stated that the unborn child of a mother affected with variola may contract the same disease, a fact attested by various authors. In this case, the mother communicates a contagious disease with which she is herself suffering ; but it would be wrong to suppose that every pregnant woman having variola must necessarily transmit it to her child. M. Serres knew of twenty-two non-variolous children born of women who had the disease during pregnancy. Mead even holds that if the woman does not abort, her child is exempt from variola for the rest of its life, provided it be not born before the maturity of the eruption. The fact is curious, but denied by Contugno, whose opinion may find support in the following facts : Two pregnant women were inoculated ; the eruption was discrete, and gesta- tion progressed. At the usual period they were delivered of healthy children, which, at three years of age, were inoculated and had the regular disease. On the other hand, it seems that the foetus only may have variola before birth, even though the mother may never have had it. Though the fact may appear ex- traordinary, it cannot be questioned in opposition to the testimony of such credible authors ns Ebel, Kesler, Watron, Jenner, Deneux, Royer, Bouchut, and Chaigneau. all of whom have seen children born with variola, the mothers being free from the disease. In several of these cases, the mothers having been vaccinated were insus- ceptible to the epidemic influence, yet were able to communicate the virus to the foetus. Congenital variola appears at all stages of pregnancy. Before the third month it is rare; and generally it is discrete, so that there may not be at the utmost more than a hundred pustules on the entire body, and often many less. It is observed that the pustules do not follow the same course of evolution as they do in the open air, but being always bathed in the amniotic fluid present the same phenomena as those which affect the mucous membranes. They are whitish and flattened, but larger than such as are found in the cavity of the mouth. A few become resolved, but others ulcevate quickly when the slight pseudo-membranous disk covering them falls off. The wound suppurates little, never furnishes crusts on account of the moist state of the parts, and cicatrizes without leaving any mark. Occasionally, however, the characteristic scar is seen, but even then is very superficial. When mother and foetus have variola at the same time, the pustules appear at the same time in both. M. Chaigneau has, however, seen a few cases in which it was later in the children, not occurring until long after it had disappeared from the mother. The unborn child affected with variola is almost sun' to die. (Bour- geois de Tourcoinff.] 2. Scarlatina, when of some severity, acts in nearly the same way as variola ; the danger, however, is usually far less both to mother and child. It sometimes gives rise to abortion, and then the patients very often succumb. My opinion coincides with that of M. Serres, who thinks that women are much more likely to contract the disease when recently delivered than they are during pregnancy, for I have never seen scarlatina during gestation, though I have had the misfortune to lose two newly-delivered females from the disease. 448 PATHOLOGY OF PEKGXANCY. 3. Measles, according to Levret, is quite as grave as the preceding. In four cases, however, observed by M. Grisolle, the regular course of gestation was undisturbed, and two similar instances have come under my own notice. [Unfortunately, however, this is not always the ease, for M. Bourgeois de Tour- coing, from whose excellent memoir we have made several extracts whilst prepar- ing this chapter, has himself met with fifteen cases "| rubeola in pregnant women, eight of whom either aborted or were delivered prematurely. In the remainder the pregnancy was not interfered with. In the former the disease was most severe in the most advanced cases, and the first symptoms of abortion or delivery appeared toward the end of the disease. Very rarelv have children been born affected with rubeola; Rosen and Vogel relate some cases ; Guersant met with one, and Bourgeois mentions another, in wdiich the child lived but three days. I 4. Various Sporadic Diseases. 1. Typhoid Fever. — Typhoid fever may occur at any stage of pregnancy. It often causes abortion, which may take place in the first or second week of the disease. According to Bourgeois, of twenty-two cases attacked early in pregnancy, six who had the disease lightly did not abort, whilst out of sixteen grave cases twelve aborted. Of fifteen cases of fever occurring during and after the seventh month, the same observer notes nine cases of premature delivery. Of these, five occurred during the first week of the disease; five of the children were still born, one lived two days, and one survived. The remaining women were delivered during the second week of the fever; two of the children died during labor; one lived two days and a half, and one only was raised, being an eight-month's child. The two surviving children presented nothing peculiar.] Though I have rarely had occasion to observe typhoid fever during preg- nancy, I have frequently seen it occur during the lying-in. Its commence- ment is usually insidious, the first symptoms having always been those of a puerperal inflammation, and presenting all the characters of the typhoid disease only after the lapse of the first few days, and the disappearance of the abdominal symptoms. What is very singular, if I may judge by the cases which I have observed, the typhoid fever, so far from being influenced un- favorably by the puerperal state, is even less grave than in the ordinary conditions of life. Not one case of 17, of typhoid fever supervening a few days after delivery, proved fatal. The same remark is made by M. Fauvel, who d'nl not witness a single death in the cases of the lying-in women who had the disease. Although the cases are too few to warrant a definite con- clusioB from them, they seemed to me of sufficient interest to be recorded. 2. Pneumonia is, without doubt, of all the acute inflammations of the envelopes or of the parenchyma of the organs, one of the most likely to pro- duce abortion or premature labor. M. Grisolle has himself observed 4 cases of pneumonia in pregnancy, and collected the details of 11 others. Of these 1") women, 10 had not reached the sixth month, and 4 aborted the fourth, fifth, sixth, and ninth days from the commencement of the attack. In 3 cases, the abortion was followed by disease of the lungs of the severest char- acter, all proving fatal three or four days after ; only one, whose pneumonia was limited, recovered without serious symptoms. The <> who did not mis- carry, died without exception during the progress of the disease. DISEASES OCCURRING DURING PREGNANCY. 449 Of the 5 women who had reached an advanced stage, 2 were seven months pregnant when attacked with pneumonia; one was delivered prematurely on the twelfth, and the other on the fifteenth day, both dying two days after. The 3 others were in their ninth month : 2 were delivered of living children on the seventh and eighth day of the disease ; the other died undelivered on the fifth day. From the preceding data it may be concluded, that abortion usually fol- lows an attack of pneumonia during pregnancy. I think, says M. Grisolle, that its disastrous influence is explained by the importance of the organ affected, by the gravity of the disease, the intensity of the general reaction, and the numerous sympathetic disorders which it produces in all the func- tions, much rather than by the paroxysms of coughing. That the pregnant condition exerts a most dangerous influence upon the disease is shown by the fact, that of 15 women 11 died, though the general state of health was apparently very favorable in most of them. The prog- nosis seems to be more discouraging before than after the seventh month. Finally, if it be allowable to conclude from so limited a number of facts, abortion, contrary to what we have seen in regard to variola, would appear to be rather favorable than otherwise, since of the 4 cases of miscarriage one recovered, whilst the 6 who did not abort, all died. This would seem to confirm the following proposition of Desormeaux, namely : Abortion, w r hich occurs but too often in acute diseases, frequently leads to a favorable termi- nation in inflammatory affections. 3. Various Inflammatory Diseases. — We have but very imperfect data by which to judge of the reciprocal influence of pregnancy and of other acute inflammations. The statements of authors in regard to it are limited to a few isolated and often contradictocy facts, whose very restricted number allows no useful conclusion to be drawn from them. Whatever be the acute affection from which the pregnant female suffers, the treatment does not differ materially from that which is proper under ordinary circumstances. So long as there remains a reasonable hope of saving the mother by the use of mild and innocent remedies, none othnr should be resorted to; but if the disease be dangerous, and demands moie active but more efficient means, it should be treated as though the woman were not pregnant. Bleeding and purgation which have been reproached with a tendency to produce abortion, may doubtless have that effect ; but it must not be forgotten that they are used here to combat an affection which is, of itself, a much more active cause of abortion, besides endangering the mother's life so seriously. 4. Icterus. — Though icterus appears to affect the pregnant condition un- favorably, it is not exactly true to say that it always arrests its progress and produces abortion, either as regards the severest or the lightest cases of the affection. I have seen several cases of simple jaundice which constituted but a slight indisposition, and in no degree affected the gestation. The con- trary has, however, been the case in some instances, and the two following, quoted by M. Ozanam, seem to me to be evidently exceptional : A young primiparous woman, five months gone, had been sick lor live days with a very simple jaundice, when she entered the hospital; three day-; 29 450 PATHOLOGY OF PREGNANCY. after, she miscarried. Another, seven month's and a half pregnant, also aborted five days alter the commencement of a simple icterus. Neither of the children presented a yellow hue. Both mothers recovered. The life of the child is greatly endangered by its premature expulsion, though ii is rarely affected with the mother's disease. In none of the cases which have come under my notice did the foetus present an icteric hue, although the amniotic fluid was more or less colored. .). P. Frank, how- err, relates the case of an icteric female who was delivered of a jaundiced child. It is rarely that what is described as the grave form of essential icterus does not determine abortion, and it is also rare for the latter not to be fol- lowed by the death of the mother. Thus, out of the five cases reported by Dr. Kerksig, in the account of the epidemic which occurred in 1794, there were four deaths. M. Ozauam relates the case of a woman six months pregnant who died before miscarrying; and my friend, Dr. Fournier, has quite recently had a case of abortion followed by death. [Churchill quotes the following account by Dr. Saint-Yel of an epidemic of jaun dice in the island of Martinique in 1858. "This icterus, which presented all the characters of an essential disease, sur- prised the medical men by its epidemic character, and its gravity in pregnant w en, and in them only. It began at Saint-Pierre about the middle of April, reached its height in June and July, and having gone through the colony, ended with some isolated eases toward the close of the year. "Attacking the various races of which the population consists, the white as well as the negro and the Indian coolie, the Huropean as well as the Creole, it seemed to prefer adults, and was unattended with atfection of the liver. When pregnancy did not exist, its termination was almost invariably favorable. The only victims were women, amongst whom were three young females not pregnant, and a woman of sixty-three years of age. In these it was always of a grave character, always the same, always mortal, and always accompanied by coma. "Of thirty pregnanl women attacked at Saint-Pierre, only ten reached term with no other symptoms than those of essential icterus. The remaining twenty died comatose alter abortion or premature delivery. " In the gravest cases in pregnant women the disease always pursued the same course. It always had the essential form, and was often light, until the occurrence of abortion or premature delivery, which never took place before the jaundice ap They were generally brought about by the latter after it had existed for two, or, less frequently, three weeks. Until coma appeared, the symptoms had no apparent gravity, nor presented anything peculiar. Thecoma preceded or followed the abortion or labor by a few hours, in two cases only coming on three days after. " The women who died had reached the fourth, fifth, sixth, seventh, and eighth months of gestation. The coma Avas, in rare cases, preceded by a slight delirium, it never for a moment disappeared, but grew more and more profound until death occurred. It lasted but for a few hours, though in two cases it continued for twenty four and thirty-six hours. Until it came on there was nothing special to be observed in regard to the general sensibility, respiration, or circulation. The pulse was n< t quickened, nor had it that slowness which is sometimes observed in cases of jaun dice. None of the other features of grave attacks of icterus, not even uterine hem- orrhage, were observed. With perhaps one exception, the women who died had no hemorrhage after delivery, and when death occurred, three or tour days subsequently, the lochia were of a normal character. DISEASES OCCURRING DURING PREGNANCY. 451 •'Almost all the childisn were still-born, a few only living for a few hours, whilst but one survived and is still living. None of thorn were jaundiced, nor had any of the ten other children born at term of jaundiced mothers any sign of the disease." (Saint- Vel, Gazette des Hopitanx, Nov 20th, 1862.) On the other hand, Dr. Bardinet read in 1863 an account of a grave epidemic of icterus which prevailed in Limoges from the month of October, 1859, to March, 1860. In 13 women observed by him the pregnancy followed its regular course in five cases which were delivered safely at the ninth month. In 5 others the disease was followed either by abortion or premature lahor. In the remaining 3 the icterus assumed a grave form with ataxic symptoms followed by coma, and both mothers and children soon perished. Both multiparas and primiparge were attacked by the disease, but all had passed the fifth month of gestation.' Dr. Bardinet recapitulates as follows: 1. Icterus may appear as an epidemic amongst pregnant women. 2. It then assumes three different forms, viz. : a. In the first it is simple or benign in character, and allows the pregnancy to progress favorably to term. 6. In the second it assumes the first degree of malignity, forming what might be called abortive jaundice, and occasioning either abortion or premature delivery without other unfavorable consequences. c. In the third it assumes all the characters of the grave form of icterus, producing ataxic symptoms and coma, which soon terminate the lives of both mother and child. II. Blot, in the excellent report from which I have quoted the preceding facts, relates a severe case of icterus observed by him at the Hospital of theClinique. The patient died, and at the autopsy ecchymoses were found beneath the skin, and on the surface of the brain, of the heart, of the lungs, and of the intestinal canal. The liver was small, and of a deep-brown color, without yellowish spots. Micro- scopic examination showed that the tissue of the latter organ was destitute of a single trace of an hepatic cell. All the preparations showed merely fat globules in abundance mixed with biliary matter. The cause of grave icterus during pregnancy remains unknown. I am disposed, however, to believe with M. Blot that it is due to changes in the liver, which I described long ago as occurring in pregnant women. (See p. 157.) In regard to treatment, we are obliged to admit the inefficiency of all measures employed up to the present time. Premature labor or abortion would probably be more injurious than useful. As to prophylaxis, we should not hesitate in case of the occurrence of epidemic jaundice, to advise pregnant women to change their place of residence.] 5. Syphilis. — Syphilis may have the most disastrous effect upon the course of gestation, being a very frequent cause of abortion, and especially of pre- mature labor. Its mode of action is various : sometimes, for example, the mother is in such a cachectic condition as to be unable to provide the foetus with the material required for its development, her enfeebled constitution leaving the work incomplete; most generally, however, the health of the mother is not sensibly altered, and the action of the poison seems to be directed upon the foetus only. In most cases, indeed, the disease does not disturb the natural course of gestation, but attacks gravely the health of the foetus. Nothing is mo'e common than for the latter to perish at more or less advanced periods, and be evpelled prematurely. In these instances, numerous visceral lesions are discovered at the autopsy : sometimes it is an 1 II. BlcU, Bulletin dc V Academie de Midccine, October, 18C4. 452 PATHOLOGY OF PKEGN A.NCY. abscess of the thymus gland (P. Dubois); sometimes purulent collectioas it: the lungs (Depaul); sometimes, again, is found that singular alteration of the liver so well described of late by M. Gubler, or those traces of peritoneal inflammation and sero-purulent effusions pointed out by Dr. Simpson as due ;o the same cause. Neither is it rare to find numerous bullae of pemphigus upon various parts of the body of the child, especially upon the soles of the feet and the palms of the hands. For further details, see Diseases of the Foetus. Cases such as we have just mentioned are, unfortunately, but too common ; it is not, however, to be understood that every child born of infected parents must necessarily suffer all the consequences. We even insist that such is not the most frequent result, for considering the large number of parents who are diseased, or who have been, the syphilitic lesions of new-born chil- dren would be much more frequent than is really the case. M. Leo-endre, in discussing the question of the latent condition of syphilis in the parents, and of its influence upon the health of the child, arrives at a denial of this influence in the majority of cases. Of the 63 patients who came under my observation, he says, there were 14, who had altogether 68 children, during the period intervening between the disappearance of the primary symptoms and the development of the venereal eruption. Of this number, 35 died without ever having had an eruption upon the body. The mean of the ages of these children at death was 7 years; the extremes being 6 months and 22 years. All the 33 surviving children enjoyed good health, the mean of their ages being 17 years; the extremes 1 year and 38 years. [Inasmuch as it is said that syphilis may be transmitted by either parent, it is far more probable that it should be when both are diseased. We will examine i.nccessively the first two conditions. a. Transmission by the father. — The father only being syphilitic, can he commu- nicate his disease to the child? The question is, at present, much disputed, for although the affirmative is maintained by Trousseau, Diday, Depaul, and Bourgeois, a directly opposite opinion is arrived at by Cullerier, who bases his view upon the observation of healthy children whose fathers were syphilitic, but whose mothers were not. He believes that inherited syphilis is always derived from the mother, the father having nothing to do with it. The same doctrine is taught in the memoirs of Notta and Charrier, and our colleague M. Follin (Traite de Pathologie Externe) has observed six cases favorable thereto. It is not easy, therefore, to decide the question. For our own part, we think that although the transmission of syphilis from the father to the child can hardly be denied in some cases at least, it is certainly less common than has been supposed. u. Transmission by the mother. — This cannot be doubted. Two cases, however, present themselves: the mother may be syphilitic from the period of conception, or she may not have contracted the disease until after she became pregnant. In the first case there is no dispute as regards the fact of infection, but the unanimity ceases in the second case, when the question arises at what period of gestation the mother must be infected in order that it should be possible for her to transmit the disease to the foetus. Cullerier thinks that it may occur at any time during preg- nancy, whilst Ricord would restrict the possibility to the end of the sixth month, and Abernethy the seventh. The opinion which would attribute to the use of mercury the effect due to the DISEASES OCCURRING DURING PREGNANCY. 453 action of syphilis, is both false and dangerous. The observations of M. Dunal have (thuvvn that syphilitic women who had never been treated, or if so, in an imperfect manner, either aborted or were delivered prematurely of still-born or infected children which died: with those, however, who had the constitutional disease and were treated by mercury, the success was complete in many instances in respect both to mother and child. 6. Saturnine intoxication. — Women exposed to lead poisoning are very liable to abort. A former hospital interne, Dr. Constantine Paul (Archives Generates de Medecine, May, 1860), made a study of the effects of this action during gestation. He observed, in 1859, the case of a woman who had been three times safely de- livered before being exposed to the influence of lead, and who afterward, out of ten pregnancies, had eight miscarriages, one child still-born, and but one delivered at term, but which died five months afterward. Struck by the observation, M. Paul thought that this great mortality might be due to the action of lead. The woman also informed him that almost all her companions in the establishment in which she worked either miscarried or were unable to raise their children. Then it was that he began his investigations. M. Paul found 81 cases of women in whom saturnine intoxication occasioned either the death of the foetus or the premature death of the child after birth ; also miscarriages at from 3 to 6 months, and premature labors in which the children were born either dead or in a dying condition. Out of a first series of observations, 4 women afforded a total of 15 pregnancies, in which there were 10 abortions, 2 premature labors, 1 still-born child, 1 which died within twenty-four hours, and 1 only which survived. A second set of cases comprises the history of women who had been safely de- livered before exposure to the influence of lead, but whose children afterward suf- fered from its effects. Another set shows the alteration of results according as the woman gave up of resumed her occupation on several different occasions. A final series proves that the foetus may die of lead poisoning, even though the mother may have had no symptom of the intoxication. To recapitulate. Out of 123 pregnancies there were 64 abortions, 4 premature labors, 5 still-born children, 20 which died within the first year, 8 in the second, 7 in the third, and 1 death at a later period, 14 living children, of whom 10 only were more than three years old.] 7. Phthisis. — Most authors, in writing upon this disease, have given cur- rency to the idea, that its progress is arrested by the occurrence of preg- nancy, but that immediately after delivery, the pulmonary affection ad- vanced rapidly to a fatal termination. In a work read lately before the Academy of Medicine, M. Grisolle has endeavored to determine the reciprocal influence of these two conditions, and in so doing has arrived at somewhat different conclusions from those which had been received as a general expression of the truth. We think it right to give a brief analysis of this memoir. Of seventeen cases collected by M. Grisolle, and ten others furnished him by M. Louis, twenty-four were those of women attacked with the disease during pregnancy, at periods not far removed from its commencement; the three others had reference to individuals who presented the rational signs of tuberculosis at the time of conception, but in whom the disease became well-marked only at a later period. In none of these cases was the pulmonary affection arrested, nor did it ibi PATHOLOGY OF PREGNANCY. fail to progress quite rapidly. The symptoms peculiar to tuberculosis, whether local or general, were developed with the same order, the same regularity, and the same constancy as in the ordinary conditions of life. But, on the other hand, contrary to what might have been expected, the pregnant condition neither aggravated, nor rendered more frequent, the accidents of the disease; bronchial hemorrhage was noticed as being even rather less frequent than usual. The entire duration of the phthisis in 13 women who were followed to the eiiil was rather shortened than otherwise. Thus, in all of them it lasted on an average nine months and a half, which is a figure more than a third less than that which expresses its duration for women of the same age, but not pregnant. Pregnancy lias not, therefore, the power of suspending phthisis, which has been supposed. But is it true, as is generally believed, that labor, and the puerperal condition, give to the process of tuberculization such an unusual impulse as to make it prove fatal in a very short time? The facts appealed to bv M. Grisolle invalidate this opinion also. Thus, 12 women, in whom the disease had reached the second, and in most of them the third degree, at the time of delivery, resisted its inroads for four months on an average ; and in all, the symptoms followed the progression that is usually observed. In 10 others, in whom the affection was in the first degree, or at the begin- ning of the second, at the period of delivery, the pulmonary lesion was found in 3 to advance slowly ; in two only did it exhibit a notable aggra- vation; whilst in 5, or one-half the number, there was a considerable amelioration both of the general health and local symptoms, without, how- ever, encouraging the hope of a cure, or of a long suspension of the disease. Does phthisis exert an unfavorable influence upon the progress of gesta- tion ? In this point of view, it may at least be regarded as much less serious than pneumonia. Thus, of 22 women, only 3 aborted in the fourth and sixth months, 3 were delivered prematurely about the eighth month, whilst all the others reached their full time; however, in nearly two-thirds of the latter, the pulmonary disease commenced in the early months of gestation, passed through all its phases, and produced a deep-seated cachexia. With one exception, delivery was accomplished after four or five hours of suffering, which is explained rather by the relaxation and want of resist- ance of the soft parts, than by the small size of the children. Although the latter were generally feeble and emaciated, yet in more than a quarter of the number the tissues were firm, the form rounded, and of an embon- point contrasting remarkably with the reduced condition of the mother. In all the patients, except those who were in the last stages of consump- tion, and who died a few days or weeks after delivery, milk was secreted, and in the majority of cases so abundantly, that it was impossible to pre- vent them from nursing the children. The flow of milk, however, lessened, or even ceased, within a period vary- ing from one to four weeks; and even this short-lived lactation was always accompanied by a sensible aggravation of the disease, and had the most disastrous effects upon the children ; for they died shortly after of softening of the intestinal mucous membrane. DISEASES OCCURRING DURING PREGNANCY. 455 From a very interesting memoir upon the same subject, by M. Di.hr ueilh, of Bordeaux, "it appears that the result of his observations has been nearly the same. . In short, neither pregnancy nor delivery affect the progress of phthisis- nor does the latter disturb sensibly the course of the former. 8. Hysteria; Epilepsy; Chlorosis. — Some physicians have imagined *hat the occurrence of pregnancy might exert a favorable influence upon hysteria or epilepsy, either by suspending the attacks during the continuance of gestation, or even by ridding the patients of these affections entirely. Unfortunately these hopes have not been realized by experience; for although the convulsive attacks have seemed in some cases to be less fre- quenter have even ceased entirely, in others, they have occurred much oftener than before. M. Malgaigne mentions a remarkable case in which the first epileptic attack came on during pregnancy in an unfortunate female who had never before been affected with it, and who retained it throughout her future life. Marriage, and the consequent pregnancy,. have often been recommended as the best means of curing chlorosis. When this disease appears to have been produced by disappointed love, the cause may, indeed, be thus removed, and the remedies directed against it rendered more efficacious. Pregnancy may, in this way, regulate the uterine functions for the future, cure the dys- menorrhcea, and consequently have a favorable effect when the irregular or difficult menstruation was the cause of the chlorosis. Under all other cir- cumstances, however, pregnancy has seemed to me to aggravate the chlorotic symptoms. I, therefore, think it most prudent to defer marriage until after the general health of the patient is improved. § 5. Surgical Diseases. 1. The pregnant condition often has a favorable effect upon scrofuloiu. ulcers. Under the influence which it exerts upon the entire organism, glandular engorgements sometimes disappear, diseases of the bones are modified favorably, ulcers become clean and covered with bright, firm granu- lations, and cicatrization follows. In many cases, it has appeared to arrest the consolidation of fractures. A curious instance of the kind is mentioned by Alanson. A woman broke her tibia when in the second month of her pregnancy, and during the seven succeeding months, the solidification made no progress. Nine weeks after delivery, the callus was strong enough to admit of walking. As proving that no constitutional depravation could be adduced in explanation of the retarded cure, he adds, that three months before impregnation, she had recovered rapidly from a fractured thigh. My friend, Dr. Fournier, cites three analogous cases from Dupuytren's Clinic. In all three, there was no consolidation before delivery, though it took place rapidly afterward. Though other similar instances are on record, it must he acknowledged that there is also a considerable number in which recovery did not seem to he delayed by the pregnant condition. 2. Serious operations have several times been performed during gestation without producing abortion, whilst in other cases they have had this result. 156 PATHOLOGY OF PREGNANCY. From these opposite facts, I think it fair to conclude that none but indent operations should be performed, and that all others, such as fistula in ano, for example, which do not endanger the life of either mother or child, should be deferred to another time. 3. Tumors in the Abdomen and Pelvis. — Most authors think that tumors in the abdomen and pelvis during pregnancy, have no other effect than to impede mechanically the development of the uterus, or to present an obstacle to the delivery. (See Dystocia.) Sometimes, however, they assert, they may give rise to abortion or premature delivery, though, generally, thev are not otherwise dangerous. That this complication is of no danger, independent of the risk of abor- tion which it may occasion, cannot be admitted in an absolute sense. Dr. Ashwell has remarked, in his excellent work, that the uterus, when de- veloped until term, exerts a strong compressing force upon the pathological tumor; that this compression may give rise to an inflammation ending sometimes in suppuration at the centre of the diseased mass, at others, in a rapid increase of the tumor immediately after delivery. I have several times had the opportunity of verifying the accuracy of these statements. Death may occur in a short time, as the consequence of this inflammation or rapid enlargement, and the autopsy has several times exhibited the uterus in a perfectly healthy state, together with the more or less extensive altera- tion of the pathological tumor. Deeply impressed by the cases of this kind which he had occasion to observe, Dr. Ashwell asks, whether the development of the uterus, and the pressure which it exerts upon the neighboring tumor, are not the causes of the pathological changes of the latter, and consequently whether the induc- tion of premature labor would not be the surest means of guarding against the dangers to which the female is so often exposed in these cases, even after having overcome all the difficulties of labor. -When treating hereafter of premature labor, we shall have occasion to criticise the affirmative decision which he has come to ; but we have thought it right to direct attention to a peculiarity but little known in the history of the tumors which complicate pregnancy. 4. In tra-parietal fibrous tumors, or those developed in the substance of the walls of the uterus, may exert an injurious influence upon the course of gestation, and become a cause of abortion when they are of large size ; though, generally, they have no effect whatever when small. In the latter case, the physiological evolution of pregnancy may accelerate wonderfully the increase of the pathological tumor. The usually slow growth of these in tra-parietal tumors is well known ; now I have known them in several in- stances to acquire a size in the first three or four months, which they would not have done in several years in the non-pregnant condition. Developed as they are in the midst of the uterine fibres, they participate in the in- creased vitality with which the latter are endowed during gestation; and, like them, they undergo a considerable hypertrophy. In some cases I have seen this hypertrophy of the morbid tumor continue, and .'vcn increase after delivery ; but in others, the latter event was followed bva notable diminution of the size of the tumor, which gradually grew less DISEASES OCCURRING DURING PREGNANCY. 451 its the womb resumed its normal condition, finally attaining the size which it had before conception. In one case, observed in 1852, this process jf absorption went on, and the tumor disappeared. \l 6. Hypertrophy of the Thyroid Gland. It is by no means rare for the thyroid gland to undergo hypertrophy during ges*- tation apart from any endemic influence. The enlargement is generally slight and gives no trouble, though some women complain that their necks become large and unsightly. The swelling diminishes somewhat after delivery, though it rarely dis- appears entirely. I knew one case in which the hypertrophied gland inflamed and suppurated, giving rise to an abscess which discharged for a long time; nor was the cure com- plete until after the lapse of several months. Although this hypertrophy of the thyroid gland in pregnant women is not usually dangerous, it may in some very rare cases imperil the life of the patient. Two instances of this kind are related by M. N. Guillot. The first was that of a lady who was surprised during her first pregnancy to find that the front of her neck was gradually enlarging. When again pregnant, the swelling increased and became uncomfortable ; still, the delivery was favorable, and she nursed the child for fourteen months. The gland, however, continued to enlarge, respiration became painful, and finally the symptoms were so threatening that tracheotomy was performed. The patient died. In the second case, the hypertrophy also appeared during the first pregnancy and increased during the succeeding one, so that nineteen months after the second delivery it formed a tumor of about eight inches in circumference. The breathing was obstructed, slow, and whistling, during both expiration and inspiration, and the voice was broken and painful. Paroxysms of suffocation came on, during one of which the patient died. At the autopsy the trachea was found to be flattened and the pneumogastric nerves compressed. I witnessed for myself a similar case at the hospital of the Clinique in 1861. A woman, who for a long time had a goitre, found the tumor to increase rapidly in size during her first pregnancy. At the sixth month, respiration had become very difficult, and attacks of suffocation brought her to the hospital. By the end of the eighth month the symptoms were so severe that premature labor had to be induced, but the patient died in an attack of suffocation a few hours after delivery. My friend Dr. Tillaux, then prosector of the Faculty, dissected the tumor and found the trachea compressed by the enlarged gland.] § 7. Ulcerations of the Neck of the Uterus. It is rarely that cancerous affections of the neck of the womb seem to disturb the course of gestation, and the impediments which they but too often present during labor prove sufficiently that they are rarely a cause of miscarriage. On the other hand, I have never observed that the increase or degeneration of these tumors was sensibly hastened during gestation. Therefore, I shall treat no further here of this subject, reserving its discussion for the article on tedious labor; but propose to speak briefly of ulcerations of the neck during rvegnancy. It has been but a short time since surgeons have used the speculum in the cases of pregnant women. A just fear of the mischievous effect which might follow its repeated introduction prevented them from obtaining a correct idea of the condition of the neck at the various stages of pregnancy. These fears 458 PATHOLOGY OF PREGNANCY. were, however, somewhat exaggerated, for, if introduced carefully, the speculum never causes serious accidents. In all cases, the instrument with two or four valves is, in my opinion, the best. In default of great experience, there is considerable difficulty, no matter what instrument be used, in engaging the cervix in the extremity of thp speculum, unless the situation of the neck is first ascertained by the touch This difficulty is known to result from the fact of the direction of the cervix toward the anterior surface of the sacrum. The engagement once effected, it is only necessary to separate the vahea of the instrument slightly in order to bring the os tincae into view. A- the touch should have led to anticipate, the changes which the eye detects in the intra-vaginal portion of the neck, are very different in the primiparous female from what they are in one who has had children; we would also add, that the appearance is far from identical at the beginning and termination of pregnancy. As seen in the latter third of gestation, the neck is generally of a deep violet-red color; and, if it be a first pregnancy, is usually quite smooth throughout its extent; the external orifice is ordinarily more or less rounded, and though larger than in the unimpregnated condition, it barely permits the sight to penetrate its cavity, even though the valves of the instrument be separated considerably. The circumference of the external orifice and the free portion of the neck rarely exhibit signs of ulceration, though it is quite common to observe a series of granulations of a cherry-red color, of sizes varying from that of a large pea to that of a pin's head. These species of vegetations bleed upon the slightest touch with the cotton used for wiping them. In the female who has had several children, the neck is usually much less voluminous, and it is somewhat difficult to include it entirely in the speculum. The lips of the os tincse seem divided in several portions, a sort of segmenta- tion caused by the ruptures which occurred in the preceding labors, and which give to the orifice considerable irregularity. In consequence of these numer- ous solutions of continuity, the opening is much larger, and is dilated with great facility, provided the valves be separated, thus allowing the eye tc explore the cavity with readiness. The walls of this cavity are very unequal, frequently presenting an unin- terrupted series of fungous projections, separated by depressions of variable depth. Home of these projections are transparent, being formed probably by hypertrophied follicles; others resemble soft vegetations. The latter are generally covered by an intact epithelium, so that they may be touched without being made to bleed ; again, what is by no means rare, they seem destitute of this external covering, and bleed upon the slightest touch. It is more especially in the furrows which separate these, that linear ulcera- tions of variable depth are discoverable. These ulcerations sometimes extend over a considerable surface, and are then readily perceived, though they are usually concealed in the depth of the anfractuosities, and, in order to see them, it is necessary, after a thorough cleansing, to unfold the neck, as it were, by expanding the speculum considerably. According to MM.Gosselin, Danyau, and Costilhes, these linear ulcera- DISEASES OCCURRING DURING PREGNANCY. 459 lions are much less frequent than I had supposed, and are met with in barely tnoie than half the cases, whilst I had observed them iu seven-tighths. However, as I stated very plainly, I intended to be understood as speaking only of multipara? who had reached the latter months, whilst M. Gosselin includes in his statement all stages of pregnancy, and M. Danyau does not appear to have distinguished primipara from multipara?. Must we admit that, as M. Huguier supposes, we have been deceived ? According to this gentleman, a muco-pus of variable consistence is frequently deposited in and adheres closely to the bottom of the furrows observed on the internal surface of the neck. This matter bears a complete resemblance to the bottom of an ulcer; but efface the folds and wipe them well, and the supposed ulcerations disappear It is difficult for us to believe that we have been so deceived ; still, the assertion of M. Huguier merits serious attention, and shall receive it hereafter. Unless my observations have been for a long time subject to a series of singular coincidences, it is probable that what we have just described is the normal condition, and should not be regarded as pathological, but simply as a consequence of the progress of gestation. As the violet- red color, the swelling, the softening, and the almost fungous condition of the walls of the neck, are peculiar to pregnancy, and in no wise interfere with its progress, so I regard the ulcerations as a consequence of a physiological process, extreme in degree, and of no greater importance than the other physiological changes. Especially am I convinced of their non-injurious character, and therefore regard all treatment employed against these ulcerations, even when fungoid, as much more hurtful than useful. I say, even fungoid; for, contrary to the opinion of M. Coffin, who attributes a great prognostic value to this character of the ulceration, I think that they are fungoid, not because they have a natural tendency to become so, but because the tissue which they affect always presents at a certain period the color and consistence of fungous tissue. If, therefore, I am not deceived, and if the peculiarities just described really form a part of the pregnant condition, and are merely an exaggeration of the changes which the structure and vascularity of the walls of the uterus undergo at this period, the condition should disappear with the cause which produced it. Like the vomitings, varices, hemorrhoids, and other sympa- thetic disorders of pregnancy, it should disappear with it. Now this is exactly what happens, and it may be regarded as a principle, that no traces of it remain two months after delivery. The non-specific ulcerations some- times met with in recently delivered women are of different appearance, and have their origin, in my opinion, in the non-cicatrization of the ruptures which took place during labor. In short therefore, the fungous condition of the neck, and the ulcerations of greater or lesser depth which complicate this state of the parts near the termination of pregnancy, seem to me to be the consequence of the active or passive congestion with which the organ is affected. I think that, except in a few rare instances marked by specificity of character, or strong tendency to spread, — a tendency, by the way, which I have never observed, — all local treatment should be refrained from. itiO PATHOLOGY OF PREGNANCY. Is the case the same at a less advanced period, and are the uleerawuns which may affect the neck in the early months of an equally innoxious character ? MM. Boys de Loury, Costilhes, Coffin, and Bennett, who have directed their attention more particularly to the ulcerations occurring in the first half of gestation, have been so forcibly struck with their tendency to produce aborti >n and puerperal diseases, that they class them with the most common causes of miscarriage. Mr. Bennett goes so far as to call them the keystone of all diseases of the pregnant female, and the most frequent cause of difficult labors, obstinate vomiting, (see page 465,) moles, abortion, and hemorrhage. Notwithstanding the smallness of their number, the observations which I have been able to make differ so completely from the results obtained by these gentlemen, that I was tempted to accuse them of some exaggeration. Hovcver, after having heard MM. Huguier, Gosselin, Danyau, Cloquet, &c, proclaim the innocence of these ulcerations, I have no hesitation in saying that they have misconstrued the facts observed by them. Finally, we would add, that after having read their observations, there seemed reason for inquiring whether, in many cases, syphilis may not have been the principal cause of the accidents, and in others, whether the frequent introduction of the speculum and the numerous cauterizations which had been practised, may not have played the most important part in the production of the abortions. I ought, perhaps, to except the peculiar species of ulceration described by my friend M. Richet. All the varieties of ulceration, says this learned surgeon, which are observed in non-pregnant women, may occur during pregnancy ; but it has seemed to me that they had a tendency in some cases to assume a fungous character, to excavate the lips of the cervix, to bleed readily, and give rise to serious accidents : abortion, for example. In all my patients, these ulcerations with well-defined edges, and red and bleeding bottoms, were covered with reddish fungosities, which projected between the partly opened lips of the cervix. Of six patients, four miscarried, and two left the hospital apparently cured ; of the four who aborted, one only had been cauterized, the three others not having undergone any treatment. Whoever, like myself, has examined women at the end of gestation, will find the ulcerations observed by M. Richet in the early months, and which he has had the kindness to show me, to bear a close resemblance to those sometimes met with in the latter stages. I see no difference except in the rather greater extent of the ulceration. Their size leads me to suppose that their origin dates back long before impregnation, and their sharp, well- defined edges excite a suspicion of their being specific in character (five of these six women had syphilis at the time, or had previously been affected with it). Now we may readily conceive that under such circumstances the soft- ening, congestion, and fungous condition which pregnancy usually produces at an advanced period, may here take place prematurely, and give to the ulcerated tissues the livid hue and fungous aspect described by M. Richet. Thus, we may understand how such an affection of the cervix, connected most frequent ly with a general disorder, under whose influence it has a con- DISEASES OF PREGNANCY. 461 etant tendency to increase, may ultimately give rise to abortion. Tt alsc seems to me important to distinguish the ulcerations which existed before pregnancy, and continued, and even increased after conception, from those which were developed after the formation of the germ : the former, in con- sequence of the irritation which they may suffer as a consequence of fatigue, and especially of too frequent coition, might readily excite the contractility of the uterus and occasion miscarriage; the latter, on the contrary, should. it seems to me, rarely exert such an influence. I agree, therefore, with the opinion of M. Richet, that when an ulceration presents in the first half of gestation, possessing the characters which ho describes, and which, in my opinion, are an evidence of its chronicity, mis- carriage should be anticipated, and means be taken to prevent it. Now, aside from a specific treatment in those cases which indicate it, I may be allowed to ask of those who would have these ulcerations treated as a matter of necessity, what are the best local means to be used ? Which caustic is preferable? Is not the solid nitrate of silver accused of producing abortion by the partisans of the caustic of Filhos, of the acid nitrate of mercury, or of the actual cautery ; and has not each of these latter means also been reproached with giving rise to miscarriage ? The thesis of M. Coffin affords some curious details on this subject, and evidently proves, that though cauter- ization by any agent whatever may claim some doubtful successes, the latter are generally compromised by the abortions which have followed it. From the statements of Bennett and Boys de Loury, the same inference follows. M. Coffin himself, though attributing such great importance to these ulcer- ations, arrives at this discouraging therapeutic conclusion, viz., thus far, nc treatment has succeeded, and the question remains open. This, which was true in 1851, is so still; for quite recently we heard M. Chassaignac speak emphatically of the inefficiency of all methods, and M. Richet declares bimself undecided as to the best course to pursue. The insufficiency of local treatment, and the mischievous effect which it may have upon the progress of gestation, should, it seems to me, in the present condition of science, lead us to dispense with it whenever the ulcer- ation has no marked tendency to invade a large extent of the cervix. CHAPTER II. DISEASES OF PREGNANCY. Tftose who have studied the various affections of the womb are well aware that its diseases excite numerous sympathetic disorders. The commence- ment of the physiological acts which devolve upon it, and their periodical fulfilment, exert upon the functions of the alimentary canal, and upon those of the nervous system, an influence which has for a long time attracted the attention of practitioners. It were useless to mention all the morbid phe- nomena which sooften precede, accompany, and follow (he first menstruation. The«e are more striking when the latter is postponed or difficult. In som« 462 PATHOLOGY OF PREGNANCY. inclivi Juals they appear at eaeli menstrual period for a long time, thus seem- ing to show an impossibility on the part of the organ to perform its functions, without occasioning extensive disturbances of the economy; and it is only, so to speak, when the sensibility of the womb has been blunted by habit, that the return of the menses ceases to produce the general disorders which accompanied it previously. If the diseases of the organ, and even the simple monthly congestion, are capable of giving rise to such troubles, it is easy to foresee that pregnancy, which changes simultaneously the form, size, and even the structure of the uterus, can hardly pass through its various periods without deeply affecting all the functions. The effects produced by the pregnant condition vary greatly, as regards both the degree and the nature of the symptoms; all of them being influ- enced by the constitution of the female. Occasionally, it results in a salu- tary change in the entire system, better health being then enjoyed than at any other period. In the majority of cases, however, tiresome, or at least very disagreeable symptoms are experienced, which are the expression of the unpleasant influence exerted by the uterus upon important functions. The*e troubles, which are so slight in some individuals as to amount merely to discomforts, are, in other cases, so great as to injure their health, and even to excite fears for their existence. These accidents may appear at almost any time ; for though some persons ; to suffer at the very outset, and are relieved by the third, fourth, or fifth month, others are attacked only in the latter half of gestation. The pregnant condition operates differently at the different periods of gestation, in the production of the accompanying discomforts or diseases; this fact, which is important in a therapeutical point of view, was felt vaguely to be so by Burns, but clearly expressed by M. Beau, who, I think, has thrown much light upon the pathology of pregnancy. Most of the functional disturbances may occur in the early, as well as in the latter months. At first they were regarded as the result of the numerous sympathies existing between the uterus and the digestive apparatus, and, at a later period, the purely mechanical difficulties produced in the neighbor- ing organs by the pressure of the uterine tumor were thought to assist in their production. Now, the pressure of the womb is of quite secondary importance, if, indeed, it be of any whatever; for, according to M. Beau, I he following is what usually occurs: The womb, as modified by pregnancy, affects the digestive functions through sympathy, giving rise to the dyspeptic symptoms described hereafter. The disturbance of these results necessarily, it' prolonged, in deficient nutrition, which, in a woman who is obliged to furnish the material for the development of the child, must soon occasion iter or less diminution of the blood corpuscles, and a considerable increase of the serum ; in short, to all the anatomical characteristics of chlorosis or polyamia. Now, this impoverishment of the blood soon occasions new morbid symp- Loms in the pregnant woman, as well as in the young chl orotic female, and 60 serves to explain the reappearance of the disorders of digestion, verti- headaches, congestions of the face, palpitations, and difficult respira- DISEASES OF PREGNANCY. 463 tion, so frequently observed at an advanced period of pregnancy. "We thus see that the functional disorders, which at the outset are purely sympa- thetic, become afterward intimately connected with the chlorosis which they themselves helped to produce. (See Disorders of the Circulation.) Though we shall have occasion to treat hereafter of this latter etiological peculiarity, we cannot help calling attention, at present, to the importance of taking it into consideration in the choice of remedial measures. For, though it be proper at the commencement to reduce the over-excitement of the uterus, and the sympathetic irritation produced by it in other organs, by soothing reme- dies, as baths, mild laxatives, antispasmodics, and sometimes even by moderate blood-letting, an entirely different course should be pursued toward the end of gestation. All the restorative agents, as iron, animal food, and tonic wines, are here the surest means of opposing the plethora and removing the disorders which it occasions. Still, it is right to observe, that beside the chlorosis, which plays the principal part in the production of the disorders of the latter months, the uterus still retains its sympathetic influence, and is subject at all times to congestions, which increase its irritability, and cause it to react upon other organs; of all which account should be taken in the treatment. The subject will claim attention hereafter. Finally, the connection which we have endeavored to demonstrate as existing between the sympathetic troubles of the beginning of pregnancy and the chlorosis of the latter months, cannot always be readily discovered. The sympathetic influence of the uterus upon the digestive functions is not always manifested by vomitings, nausea, and strange and depraved appetites. All these symptoms may be wanting, and yet the stomach fail to perform its functions with its normal regularity. Nutrition may be disordered, giving rise to a dyspepsia, which M. Beau proposes to distinguish as latent; a dyspepsia which cannot fail to occasion eventually a general deterioration of the blood. Exactly the same thing occurs in young girls whose menstrua- tion is either difficult, irregular, or imperfect. Confirmed chlorosis is always preceded in them by sympathetic disorders of digestion ; though sometimes the deranged function is evinced by very marked symptoms, at others it is hardly a cause of discomfort. Desormeaux, in his excellent article on this subject, ranges all the diseases of pregnancy under the following heads, viz.: lesions of digestion, of circu- lation, of respiration, of the secretions and excretions, of locomotion, and of the sensorial and intellectual functions. And we propose partly to adopt the same order in our description. ARTICLE I. lesions of digestion. § 1. Anorexia. The want of appetite, or the disgust for aliments, which pregnant women are so often affected with towards the end of gestation, and still more fre- quently at its commencement, may be referred to various causes, and con sequently will present different indications for treatment. When it seems to result merely from the sympathetic relations existing between the uterus I'il PATHOLOGY OF PREGNANCY. and the organs of digestion, there is little or nothing to be done, for it would he in vain to attempt removing the disgust which some patients have to certain articles of food. In general, they dislike all meats, and this is an indication, or rather an obligation, to permit the use of vegetables in such cases. Again, if at an advanced stage, the anorexia be accompanied or preceded by the phenomena of general plethora, venesection, proportioned to the general condition of the female and the stage of pregnancy, may relieve it. Care, however, should be observed not to mistake the symptoms pro- duced by anaemia for the indications of plethora; the former being far more effectually treated by ferruginous preparations. (See Disorders of the Circulation.) In those cases which exhibit evident signs of an overloaded condition of the alimentary canal, some purgative, such as rhubarb, or even the neutral salts, may be administered. Indeed, certain authors have recommended an emetic, when there is any gastric distress; but I think practitioners ought to be very reserved in the employment of this last measure, since the shock of vomiting has often produced abortion. § 2. Pica, or Malacia ; Pyrosis. Pica, or malacia, frequently accompanies the affection just described. Pregnant women, like chlorotic girls, often have irregular and depraved longings for the most absurd or disgusting articles. For instance, I have known a young female to eat pepper-grains almost continually. Another, at the Clinique, scraped the walls to appease her cravings for chalk ; and M. Dubois often relates in his lectures the history of a young pregnant woman whose greatest pleasure consisted in eating small bits of well-charred wood. Again, they have been observed eating greedily substances that are still more disgusting. Unfortunately, all our persuasions are useless with such monomaniacs in the majority of instances, and consequently we must, as a general rule, grant them an indulgence, and avoid too strong an oppo- sition, unless the coveted articles would evidently be injurious to their health. I have but little to say of the acidity of stomach, of the spasmodic pains of that organ, and of the pyrosis and other symptoms of gastralgia, which are also quite frequent during pregnancy. The treatment of the symptom is here the same as under ordinary circumstances. Thus, for sour eructations and acidity of the primse vise, magnesia and the absorbents, bicarbonate of soda, the water and pastilles of Vichy, may be administered. Pyrosis and cramps of the stomach are usually treated successfully by powdered columbo, and most of the antispasmodics, in connection with small doses of opiates. The latter may also be used after the endermic method. If, however, it be desired to attack the first cause of these gastralgic symptoms, it is important to remember that this is different for the first ind second half of gestation, and that the measures employed should vary accordingly. § 3. Vomiting. The vomiting <>f pregnancy presents two different forms. In the first, it occasions discomfort ami fatigue, without endangering life. In the second, DISEASES OF PREGNANCY. 465 it is sometimes so severe as to prove fatal. The first we shall term simple vomiting; the second, grave or irrepressible vomiting. 1. Simple Vomiting. — This symptom is so common that most females are affected with it; in fact, vomiting frequently commences in the very earliest stages: whence many women, taught by their former pregnancies, recognize it as an almost certain sign of a new gestation. At other times it doe- not appear until toward the third or fourth month, though seldom later than that ; but it is not at all uncommon to see it reappear near the end of preg- nancy in some who had been previously tormented in this way at its beginning. As an ordinary rule, the vomiting only lasts six weeks or two months ; some- times, however, it extends over four or five months, rarely persisting through- out the whole term. Some females have the unenviable privilege of vomiting every time they are pregnant ; others, more fortunate, pass through several gestations without feeling any digestive disorders whatever. It is a very remarkable fact, if we may rely on the testimony of numerous mothers, that the sex of the child is not wholly irrelevant to the production of this symptom ; and however ridiculous this may appear at first sight, 1 have heard it repeated by so many women that I cannot refrain from believing that it, like most other popular prejudices, has some foundation. But what is the cause of such vomiting? When it occurs near term, we may justly attribute it to the pressure, to the mechanical constraint which the uterus, whose fundus reaches the epigastric region, exercises upon the stomach ; but in the early stages it is much more difficult to explain it unless we content ourselves by referring it to the numerous sympathies existing between the uterus and the stomach : sympathies so intimate that they are manifested in certain women at every menstrual period, and even in nearly all those afflicted with a disease of the womb. Although the intimate nature of these sympathies is very obscure, we can admit them more readily in the etiology of vomiting than the influence of most of the anatomical causes adduced by some authors. In endeavoring to trace a relation of causality between the vomiting and an inflammation of the uterus, placenta, and membranes, like Dance; softening of the stomach and fatty degeneration of the liver, like Chomel ; or, finally, to the existence of organic lesions of parts in the neighborhood of the uterus, observers have merely noticed simple coincidences, without throwing the least light upon the question of etiology. How often, indeed, is nothing of the kind dis- coverable ! I am persuaded, says Dr. Bennett, that those gastric disorders and obsti- nate vomitings, which so often bring women to the portals of the tomb, are almost always caused by inflammatory ulcerations of the neck of the womb. For my own part, he adds, since my attention has been directed to this subject, I have almost invariably found ulceration of the neck in cases of this kind. 1 cannot, receive this opinion of the English accoucheur, at least as relat- ing to the majority of cases, for I have frequently examined with the specu- lum each of four primiparous women affected with incorrigible vomiting, and in whom I ascertained the cervix to be perfectly healthy. It has been said that primiparous women are more subject to vomiting xo 466 PATHOLOGY OF PREGNANCY. than others, on account of the uterus } T ielding less readily to distention in Bret pregnancies. Although this opinion is quite conformable to the theoretical views al- ready given, the fact is, that it is liable to very frequent exceptions. Some multipara-, who suffered very slight disorders of the stomach in their first pregnancies, have vomited almost constantly in later ones. The rigidity of the uterus is not, therefore, the only cause which is capable of sustaining an irritability of the organ which reacts sympathetically upon the stomach. I do not think that an epidemic influence can be admitted as a cause of these vomitings. The vomiting varies much as regards its frequency, intensity, and the greater or less ease with which it is accomplished. Thus, some women vomit only upon awaking or rising in the morning. They then throw up sonic viscid or glairy matters, which are generally colored with a little bile, especially if the retchings have been very severe. Others vomit only after eating; occasionally after only one of the daily meals, but sometime- after all of them. Again, in some unfortunate cases it continues even in the intervals of the repasts ; everything taken into the 6tomach, whether liquid or solid, being immediately rejected. There are cases, finally, in which the mere thought of food, or the sight or smell of it, is sufficient to provoke it. The vomiting is sometimes easy, and causes little pain , it i- indeed not uncommon to find ladies suddenly interrupted at their meals, who can return in a few minutes, and sit down and eat with a good appetite and pleasure. In other cases, however, the ingestion of food is productive of pain in the 6tomach or inexpressible uneasiness of variable duration, and it is only after five oi- six hours of suffering, that the food is vomited and then found to be almost unchanged, notwithstanding its long retention in the stomach. In such cases the vomiting is preceded by such prolonged and violent retchings as to reduce the patient to a state of extreme suffering and agitation. It is occasionally followed by considerable epigastric pain, which is in- creased by pressure, and might for a moment be taken as a sign of inflam- mation of the stomach ; it gradually diminishes, however, and disappears entirely after a time. The shocks and violent efforts sometimes extend their influence to the hypogastrium, and give rise to abdominal pains and even uterine contractions, which maybe active enough to produce abortion. But it must not be supposed that vomiting, even when prolonged and oft repeated, is necessarily disastrous. No doubt many women waste away, but I have often satisfied myself that the emaciation is not apt to be excessive, by examining females who, according to their own expression, could retain nothing at all ; and hence it is exceedingly probable that all the food taken by them is not rejected. Burns states that lie has never known vomiting depend on pregnancy alone to have a fatal termination. I might cite, says Desormeaux. examples of emesis accompanied by cruel pains and violent general spasms, yet the gestation has happily gone on to full term. At this time, I have myself under care a lady who has been vomiting throughout the whole period of gestation, and who has just been delivered of a daughter weighing seven pounds aild three-quarters. DISEASES OP PREGNANCY. 467 Finally, it must not be forgotten that in some cases which even appear serious, the vomiting may cease abruptly, either spontaneously, or because the sympathetic irritation of the uterus has been translated to some other organ, or again, as a consequence of a violent mental emotion. A remark- able instance of the latter has quite recently come under my notice. A young lady, two months and a half advanced in her pregnancy, had been tormented for three weeks with such obstinate vomiting, that, according to her own statement, the smallest mouthful of fluid excited it, and that she was unable to retain anything whatever in her stomach. All the remedies employed against it had proved useless. At this juncture, her husband fell suddenly and dangerously ill with symptoms of strangulation of the bowels, and from this time her vomiting ceased, nor did she suffer the least disturb- ance of her digestive functions afterwards. I have been induced thus to hold forth from the outset a favorable prog- nosis, which indeed is true for the vast majority of cases, in order to relieve young practitioners from the anxiety which some recently published articles on the gravity of this affection are calculated to produce. 2. Grave or Irrepressible Vomiting. — The vomiting is not, generally, serious, but only painful and fatiguing to the mother; it must, however, be acknowledged that in some very rare cases, it is so violent and constant as to exhaust the strength of the patient in a few weeks, and after producing extreme emaciation terminate in death. The display of symptoms given by M. Chomel in one of his clinical les- sons, applies to these exceptional cases only. The disease, he says, is char- acterized by frequent bilious vomiting, an acid, fetid breath, and fever; then the brain becomes involved, and we have delirium, coma, and death. The views of M. Dubois correspond closely with those of M. Chomel, and, like him, he describes three stages. [a. First Stage. — The irrepressible form of vomiting rarely begins suddenly, but almost always follows insensibly the simple form. The time at which it commences is very variable. Generally appearing during the early months, it may not come on until after the middle of gestation. In 43 cases collected in the excellent thesis of M. Gueniot, hospital surgeon, and former chief of the lying-in hospital, and from which we shall borrow largely, vomiting occurred 9 times during the first weeks of pregnancy, 15 times toward the end of the first month, 9 times between the first and second months, 5 times between the second and third months, I time between the third and fourth months, 2 times between the fourth and fifth months, and 2 times between the sixth and seventh months. The first of the cases enumerated are of the early and benignant form, and it is impossible to distinguish accurately the period of transition from the simple to the graver form. The irrepressible cases present in themselves nothing very characteristic. The vomiting, however, is very frequent, and occasions the rejection of all or nearly all the food and drink which the patient takes. The smallest quantity of fluid is often sufficient to excite it. The dejections in 'these cases are composed of mucous or glairy matter, bile or food, according as the bowel happens to be full or empty. Generally they are very acid, and sometimes streaked with blood. To these symptoms may be added a disgust for or aversion to food, so great as to be often insurmountable. S i appear the grave signs of insufficient nutrition: emaciation, debility, and 468 PATHOLOGY OF PREGNANCY. altered features. Certain accessory phenomena may also complicate the situation such as tlir almost constant ptyalism indicated by Stoltz and Vigla, and confirmed by an observation of my own. The first stage is devoid of fever, unless it he a little febrile action in the even- ing and slight perspiration during the night. We invite attention to this fact, inasmuch as fever is the dominant symptom in the second stage. b. Second Stage. — In this period the symptoms of the first stage grow more severe; the attacks of vomiting are more frequent and violent; the emaciation increases ; finally, fever sets in with a pulse of from 100 to 140 per minute. The mouth becomes dry, the thirst is intense, the breath acid and fetid. The acidity and fetidity of the breath are such, says M. Chomel, as to strike one on entering the room of the patient. Still, should we consult our personal experience, we should say the odor is uncommon, inasmuch as avo have never observed it in the many cases of irrepressible vomiting which we have seen. c. Third Stage. — In this stage the symptoms undergo a change, the attacks of vomiting ceasing or becoming less severe; but it is a deceitful calm which the experienced physician knows to be the prelude to death. There will, however, bo no risk of deception if we but observe that the fever persists with a pusle of from 120 to 140 pulsations per minute. Attacks of syncope and cerebral symptoms soon come on. These are: intolerable neuralgic pains, disordered sight and hearing, hallucinations, delirium, and, finally, coma, which ends shortly in death. D. Progress, Duration, and Termination. — The paroxysms of the graver form of vomiting often remit more or less completely ; the remissions being sometimes, as it were, spontaneous, or in consequence of almost insignificant circumstances. Thus an emotion, travel, some change in the mode of life, a new article of food, and numerous similar eventualities seem occasionally to produce a transient amelio- ration, or even a momentary cessation of the symptoms. The hope thus excited is, unfortunately, hut too soon destroyed by a more or' less rapid recurrence of the Jisease. (Gueniot, These de Concours.) At other times these remissions may be attributed to the use of a remedy whose action is exhausted, or the momentary cessation may follow and be due to prema ture labor or abortion. Then the vomiting returns with increased severity. The progress of this terrible affection is usually slow, as the patients do not gen- erally succumb until after the second or third month of the disease. e. Etiology and Pathological Anatomy. — We know nothing of the causes of irre- pressible vomiting. Some have attributed it to albuminuria, an opinion which nothing pics to confirm, and which would hardly be adopted were it remembered that vomiting is most frequent at the beginning or middle of pregnancy, whilst albuminuria is rarely observed except during the latter months. Of the silence of pathological anatomy in regard to this disease, I have lately had an additional proof. A woman with irrepressible vomiting entered my ward, at La Pitie, where I was temporarily on duty. She was delivered spontaneously during the eighth month, but, after a remission, the symptoms reappeared, and she died a few days subse- quently. The autopsy, conducted with the greatest care, discovered no lesion in any organ ; the genital organs, the abdominal and thoracic viscera, and the 3n- cephalon, being perfectly healthy.] F. Diagnosis. — In moderate cases the diagnosis is easy. Here, the absence of acute symptoms, such as redness of the tongue and pain upon pressure on the epigastrium, would settle the question, even were pregnancy doubtful. But if, in the cases just spoken of, the nature of the epigastric pain be misunderstood, the practitioner would be more liable to error; therefore he should be very careful in his proceedings. For example, I DISEASES OF PREGNANCY. 469 have known a case of vomiting, which the autopsy proved to have been dependent upon tubercular peritonitis attributed to a pregnancy which did not exist. In the case of another female, who had actually been pregnant for two months and a half, the examination after death discovered a serious disease of the stomach, amply sufficient to account for the vomiting. In the latter case, it is true, that an admixture of blood with the matters vomited, had, during life, excited suspicion of organic disease. This very case has, however, been quoted to me by some persons as one of incurable vomiting occasioned by pregnancy. Mistakes of this kind ought not to be made, and the same may be said in regard to epigastric and other hernias. ■ [g. Prognosis. — The prognosis in the grave form of this affection is serious. In 118 cases collected by M. Gueniot, there were 72 recoveries and 46 deaths, repre- sented as follows : Recoveries. Without abortion in very severe cases and after a very diversified treatment... 31 Following spontaneous abortion, also in very severe cases 20 After aborcion or induced labor in cases more or less desperate 21 Deaths. OS Without abortion m After abortion or spontaneous premature labor ' After procured abortion It is but just to say, that in this table of mortality, M. Gueniot included all the cases he was able to collect, and that amongst them are some in whicli death was evidently due to some other disease than the vomiting itself. Cases of irrepressible vomiting are serious from the outset, inasmuch as, notwith- standing all the modes of treatment employed, abortion included, it is impossible to know whether they will be certainly arrested. The prognosis becomes still more unfavorable in the second stage of the disorder, for when the patients are much debilitated and the fever constant, some will suc- cumb without having either the fetid breath or cerebral disorders. Of such cases, two have come under my notice. In the last stage, death is almost inevitable, and we ought not to be deceived by the remission of vomiting which then occurs. It should also be borne in mind that the cerebral symptoms which accompany this phase of the disease are various. In two cases, I observed only a little hebetude and slight strabismus without other nervous disturbance: so that, before reaching the correct diagnosis, typhoid fever, or a cerebral tumor might be suspected.] Generally speaking, even when the vomiting is not so great as to com- promise the life and health of the mother, it has but an indirect influence upon the life of the child, nor do I know of a single well-attested case of death of the foetus from inanition through defective nutrition of the mother. Still, we may understand how the violent efforts of the mother may some- times communicate such shocks to the uterus as to bring on premature con- tractions and even abortion. We can also comprehend how the same efforts may produce vascular congestion of the womb, giving rise to rupture of some of the utero-placental vessels and detachment of the placenta; such accidents are, however, rare. In grave cases, results of the kind are rather to be desired than deprecated, for vomiting generally erases upon the death of the foetus, and the mother escapes the threatened danger. -170 PATHOLOGY OF PREGNANCY. 3. Treatment of the Vomiting of Pregnancy. — There are but few medi- cines that have not been proposed, at one time or another, for this affection of pregnant women ; and at other times recourse has been had to surgical procedures. We will, therefore, examine successively the medical and sur- gical treatment. A. Medical Treatment. — "When the emesis is slight, and only occurring in the morning, we may recommend an aromatic infusion of the lime-tree, orangd-ilower, common tea, &c , &c. Where it comes on after a meal during the day, it is advisable to change the order of the repasts: for example, if it be generally more distressing after supper, the patient should sup sparingly and eat more breakfast. Cold aliments are sometimes retained when others are rejected. Iced drinks, mineral waters, and swallowing small pieces of ice, have arrested some cases of obstinate vomiting, which set at defiance the whole series of antispasmodics. The subnitrate of bismuth, in doses of from four to eight grains, hefore each meal, has appeared to me of late to be of some service. I have also directed two or three spoonfuls of kirsch to be taken after meals, and 1 think with some success. Should it persist, notwithstanding these measures, a resort maybe had to a remedy, which has often succeeded perfectly in my hands, — I allude to the narcotics. About an hour before the meal, let her take one-third or one-half a grain of the aqueous extract of opium made into a pill ; but when she is consti- pated, it will be necessary to administer some mild purgative to counteract any action the opium may have on the large intestine. Whenever the emesis is attended with pain and stricture at the epigas- trium, leeches have been recommended over this part, though I have rarely seen their application followed by any benefit. I should prefer laudanum lotions, or the application of a cataplasm well tinctured with this fluid. Sometimes I have successfully applied a small blister to the epigastrium, and subsequently sprinkled the sixth or the third of a grain of the muriate or acetate of morphia over it. M. Dezon mentions three cases of obstinate vomiting, which yielded to the continued application to the epigastrium of a towel wet with cold water and renewed every five minutes. If the vomiting occasions pains in the loins or hypogastrium, in a word, if it threatens an abortion, or if the patient be plethoric, and this condition is manifested by local or general phenomena, venesection in the arm should be resorted to, as this is one of the best measures I am acquainted with, especially during the last half of gestation. Enemata containing laudanum are also very useful for the prevention of abortion, as well as for alleviating the vomiting, and calming the irritability of the uterus. General bathing may be added to these measures with advantage. Dance reports two cases, from which he feels authorized to conclude that these vomitings are often an evidence of a morbid activity in the uterine system, of an inflammation of the membranes; and consequently he advises direct antiphlogistic measures, especially in the neighborhood of the womb; but as his opinion i~ founded on two cases only, which, after all, arc not conclusive, it seems to me that it cannot be admitted as a rule of practice. Still, leeching the nek of the uterus yielded unlooked-for results in cases of fih. Clay and M. Clertan (of Dijon)'. DISEASES OF PREGNANCY. 471 With regard to the regimen, doubtless a mild liquid diet, composed of aliments that are easily digested, seems at first to possess decided advan- tages over all others ; "but how many exceptions ! how many women reject the mildest articles — even liquids, and yet readily digest less suitable sub stances ! How often, indeed, have I not seen women eat ham, liver, pie &c, who could not digest a piece of sole, or the white meat of fcwl ! Of course, we must respect these peculiarities of the stomach. Among the various measures recommended, but which I have rarely had occasion to resort to, may be mentioned the application of cups to the pit of the stomach (Mauriceau) ; of a plaster of theriaca (Sydenham) ; a few spoonfuls of sherry-wine, or even some brandy, ether, peppermint-water, the potion of Riviere, and the Colombo root. In those cases in which there was some degree of regularity in the return of the pains, and febrile action, Desormeaux gave two or three grains of the dry extract of cinchona with success. ' Lastly, Walter and Blundell have highly extolled the use of hydrocyanic acid in the dose of one or two drops, in some mucilaginous drink, several times a day. With the same idea, I have successfully given kirsch after meals, either undiluted or on a lump of sugar. The latter plan has seemed especially useful when the vomiting was preceded by uncomfortable sensations in the stomach or long- continued nausea — a state of things resembling sea-sickness. To overcome the acidity of the primse vise, M. Chomel recommends the use of alkalies, as the water from the springs of Vichy and Bussang ; also dilute solutions of potash and soda, magnesia with milk, but never milk alone, and an avoidance of acids. Alcoholic liquors, given to the extent of intoxication, have met with real success. M. Bayer tells me that he has used them with great advantage, and champagne wine, recommended by M. Moreau in a case so obstinate as to cause great frequency of pulse and delirium, put an end at once to the symptoms. M. Jacquemin, who related the case to me, considered the pa- tient as lost, and had only called the professor in consultation, in order to obtain his opinion in regard to the propriety of producing abortion. M. Bretonneau, being induced to try belladonna, in the idea that possibly the vomiting might be occasioned by rigidity of the uterus, succeeded in quieting it, even in very grave cases, by rubbing the abdomen with a concentrated solution of that medicament. In one very serious case, in which the vomiting had resisted every effort, even Bretonneau's measure, and in which the poor patient seemed doomed to a speedy death, I conceived the idea of applying the belladonna to the neck of the uterus; this was done by means of the speculum. A brush, laden with the soft extract, was introduced, and the neck, together with the inferior segment of the uterus and the walls of the vagina, were be- smeared with it. From this moment, a marked change lor the heller was manifest, and after the same unctions had been repeated on four successive days, I had the satisfaction of finding my patient cured. It is my duty to add, that in another case the same means failed completely, though I think the failure due to the mode of application. When, as in this case, a brush is used, it is difficult to apply the ointment, and too little of it is sometimes 472 PATHOLOGY OF PREGNANCY. left behind. I have, therefore, for a long time preferred covering a tampon of charpie or cotton with the extract of belladonna, and, after placing it in contact with the cervix by means of a speculum, leaving it there. This may be done morning and evening. The first symptoms of intoxication, such as dilatation of the eyelids, a sense of heat in the throat and slight hallucinations, need occasion no alarm, inasmuch as the effects of the medi- cament are not felt until then. The patient ought, however, to be watched, and the tampon removed if the symptoms become more serious. This method has been thrice successful in my hands. M. Stockier overcame the vomiting in two cases by the black oxide of mercury, in the dose of one grain daily. The prolonged use of the remedy was unaccompanied by salivation. [Iodine in various forms lias been recommended. Eulenberg (of Coblenz), fol- lowing the example of Schmidt, has used the tincture successfully, whilst Ricord and Bacarisse derived equal advantage from iodide of potassium given to the amount of from ten to fifteen grains daily. "Simpson," say- M. Gueniot, "found the salts of cerium very efficacious, especially the oxalate, in 5-grain doses three or tour times a day. I would add that the latter sail failed entirely in a case related by M. Danyau, in which it was used by him and M. Dubois, nothing short of a partial detachment of the ovum sufficing to relieve the patient from the danger which menaced her." Copeman recommends dilatation of the os externum and cervical canal with the index finger, a method which has received the indorsement of Dr. Marion Sims. Dr. • rraily Hewitt recommends appropriate mechanical support to the womb, regard- ing the vomiting of pregnancy as due to displacements of thai organ. Dr.Jacob Price, in an address before the Penn. State Med. Society, May, 1884, advo- cated the application, at intervals of three days, of a solution of Iodine, Carbolic Acid, and Tannin, each two drachms, dissolved by heat in an ounce of Glycerine. He regards the pernicious vomiting of pregnancy as due to congestion and inflammation of the uterine cervix.] The obstinate constipation which the patients suffer is very remarkable, and has not received the attention it deserves. The bowels sometimes re- main unmoved for eight, ten, or even fifteen days. Strongly impressed with this fact, and supposing that the constipation might have some effect upon the continuance of the vomiting, I endeavored to overcome it; but, fearing the effect of emetics or drastic purgatives upon a weakened and pregnant female, my first efforts were too cautious to be successful. Encouraged since then by the experience of other practitioners, especially by M. Forgue, of Etampes, I have had every reason to be satisfied with a bolder course. The above-named physician addressed to the Academy of Medicine a memoir, in which he hauled the effect of emetics and purgatives, but in- sisted much upon what he called a preparatory treatment, consisting in the administration to the patient for two or three days, a ptisan of barley-water, weakened with homy, to each quart of which he adds a drachm and a half of Bulphate of potash ; giving also, morning and evening, an enema of a strong decoction of mercurialis annua. When some stools have been thus obtained, he orders a bottle of Seidlitz water containing a grain and a half of tartar emetic, alter which he continues the purgative for several days longer. M. Forgue claims to have treated five cases successfully by his method. DISEASES OF PREGNANCY. 473 [am in the habit of giving the emetic at once, when the sabnrral condition <» the tongue seems to indicate it : which is nut often the case. Generally, 1 order at once ten grains of scammony with fifteen .-rains of jalap. As the firsl dose is often rejected by vomiting, I order it to ho followed immediately by another, and sometimes even by a third, should the vomiting continue. * The ser ond or third dose is generally retained, and the purgative cFect followed bv a marked relief. In the case of a patient two months and a half advanced in pregnancy, to whom I was called in consultation by Dr. Briau, Professor Moreau dis- covered by the touch that the uterus was not only completely retroverted, but wedged, as it were, in the depths of the pelvic cavity. Suspecting that this displacement might have some effect to maintain the vomiting, he cor- rected it by lifting the uterus above the superior strait and bringing it into correspondence with its axis. Immediate relief followed, and the vomiting, which had proved intractable to a host of remedies, ceased on the same day, nor rtid it again return. _ M. Moreau said, that he had seen several similar cases. I had indeed myself, before this, observed the same accident, but not having acted upon the indication, our Honorable master conferred a real service in making known the fortunate result which he had thus obtained. In future, therefore, the state of the uterus should be ascertained in all cases of incorrigible vomiting. Experience has, however, taught me, that although displacement of the uterus often coincides with gastric disorder, M. Moreau's good fortune is not always to be expected. Three times since M. Briau's case have I observed the coincidence indicated by my colleague. In three patients suffering from obstinate vomiting, I found the uterus not retroverted, as in M. Moreau's case, but so far anteverted that the anterior surface of the womb projected considerably at the upper part of the cavity, its upper border resting against the posterior face of the pubis. The reduc- tion, though easily accomplished, could not be maintained, and the organ very soon resumed its primitive position. Several attempts at reduction were equally unsuccessful. Why, then, was I less fortunate than M. Moreau ? I am inclined to think it was because of the different stages of pregnancy in our patients respec- tively. That of M. Moreau had reached three months or three months and a half; two of mine were only two months gone. Now, if at three months and a half the size of the uterus is sufficient to keep it above the superior strait after reduction, and that it can only, in some exceptional instances, fall back into the cavity, the case is very different at an earlier period. At two months, in fact, the uterus is so much smaller, and therefore so much more movable, that it yields readily to every cause of displacement brought to bear upon it, and, as though by the force of a bad habit, readily resumes its faulty position when the restoring effort is no longer made. We ought, therefore, in reference to M. Moreau's plan, to have great regard to the duration of the pregnancy ; very efficient after the third month, it will generally be useless at six weeks or two months. Unfor- tunately it happens that incorrigible vomiting is more apt to occur at the latter period. 474 PATHOLOGY OF PREGNANCY. All my eff< rts to remedy the difficulty by means devised for keeping die uterus in situ after reduction, have been fruitless. I had made an elongated compress, which, when placed above tbe pubis, depressed strongly the wal: of the hypogastrium, and at first seemed to keep the womb in place. Soon however, it slipped beneath the pad, fell back into the pelvic cavity, and as the bandage thenceforth did more harm than good, I was obliged to give it up. It was natural to think of Gariel's pessary, but I dared not keep so laige a body in the vagina of a pregnant woman, lest it should have the effect on the uterus of a tampon which so often causes abortion or brings on prerna*- ture labor. In short, M. Moreau's success in the case related by M. Briau, is an en- couragement to make similar attempts, as, after all, they do no harm when prudently conducted ; yet, they are not to be relied on when the patient has nut advanced beyond the first two months of pregnancy. I have thus enumerated all these remedies, because they may be succes- sively employed in this affection. In fact, the same medicine may act on one female and have no effect on another. And it must be confessed that sometimes all will fail, and we can scarcely succeed in moderating the patient's sufferings. The change of medicine is, however, useful, either by really calming her distress in a measure, or by sustaining her spirits, not seeming to abandon her, but holding out the idea that each new remedy may effect some amelioration. In this way she gradually approaches towards term, or at least to a period of gestation when the symptoms often disappear of themselves. B. Surgical Treatment. — But where the vomitings continue, notwithstand- ing all the rational measures resorted to, the woman absolutely throwing up everything she takes, and the privation from food has reduced her tu such a state of emaciation as to endanger life, and the symptoms which we have described as belonging to the second ami third stages appear, some accoucheurs have advised (if her term is still remote) the production of premature labor. This operation has already been practised, in similar cases, by several English and .German accoucheurs, with full success, both for the mother and child. It seems to me that it cannot be improper to resort to this measure after the seventh month of gestation, for it then appears to be fully justified both by the dangers to which the mother is exposed, and by the possibility of the child living after its expulsion. But is the case the same before the sixth month, when the sudden termina- tion of pregnancy must necessarily lead to the death of the foetus. This is one of the gravest questions which can come up in practice. Although fully disposed to sacrifice the child whenever that sacrifice will surely save th*» life of the mother, as m cases of extreme narrowing of the pelvis, I make no hesitation in declaring myself against the production of abortion under the circumstances in question. I shall proceed to justify this proscription : — 1. When a woman having a contracted pelvis presents herself to a physi- cian, he knows very well that if the pregnancy be allowed to go on until DISEASES OF PREGNANCY. 475 term, he will have to choose between embryotomy and the Cesarean opera- tion ; also, that in some cases the latter operation will be the only resource. If, after mature consideration of the inevitable consequences of the one and the probable consequences of the other, he decides upon the mutilation of the child, it will doubtless appear to him reasonable not to wait until the increased size of the foetus at term shall add to the difficulties and dangers of embryotomy ; therefore, the production of abortion within the first fuur months of gestation will seem to be fully justifiable. But the conditions are different when the life of the mother is compro- mised by vomiting, however severe it may be. In the first case, the danger is inevitable ; and, unless abortion occurs spontaneously, the Csesarean operation is the only resource, and we are aware of the usual consequence of the latter. But however intense the vomitings may be, and notwithstanding the state of exhaustion to which they reduce the female, still they are not inevitably fatal. Patients, whose condition justly excited the greatest solicitude, have been known to resist until the latter months and even until the term of their pregnancy, and then give birth to strong and healthy children. Others, whom the vomiting had reduced to a hopeless condition, have been suddenly restored to the most complete health. A case of this kind has fallen under my own notice, and the following was related to me (June, 1849) by M. P. Dubois. A young German lady, two months and a half pregnant, had been troubled with the most obstinate vomiting from the first two weeks after conception. For the last six weeks especially she vomited almost without intermission ; the smallest spoonful of fluid exciting violent contractions of the stomach. She was extremely emaciated and feeble, and her breath was disgustingly fetid ; in short, her symptoms were so serious that M. Dubois, who was called in consultation, requested the additional advice of M. Chomel. Both these gentlemen came to a most unfavorable prognosis, and left the patient, under the impression that she had but a few days to live. Some cold appli- cations were the only remedies advised ; but the attending physician, being alarmed at her extreme weakness, limited them to slight aspersions. On the second day after the consultation the patient was attacked with violent purging, and from that time the vomiting ceased and never returned. The poor sufferer was at once able to take and retain some nourishment, which, being gradually increased in amount, soon restored her strength. Now, this woman, who had been so greatly reduced that two eminent men regarded her fate as sealed, is in the enjoyment of perfect health, and has almost reached the middle of her pregnancy with every prospect of a happy ter- mination. In two other cases, which the professor related with commendable frank- ness, he had deemed it his duty to propose the induction of premature labor. The women declined submitting to the operation, and reached the end of their pregnancies in good health. 2. When abortion is produced in cases of extreme contraction of the pelvis, there is a certainty that, when once accomplished, all the dangers which threatened the termination of the pregnancy are at an end, and that only the usual consequences of miscarriages can follow from the operation. 476 PATHOLOGY OF PREGNANCY. Even suppoiing that the artificial means should add to the ordinary risks of spontaneous abortions, the object is nevertheless certainly attained in ter» ruinating a pregnancy whose progress so greatly endangered the mother's life. The conditions are very different in cases of spontaneous vomiting, for if all the instances on record be referred to, it will be found that the operation ip far from removing the danger. I am well aware that four or five for- tunate cases have been cited from the practice of English accoucheurs, but we are not told how often it has been followed by death. Are the circumstances the same in cases of obstinate vomiting? If un- successful, the operation was performed too late, say they, when the pro- longed defective nutrition of the mother had exhausted the vital powers ; and had the uterus been emptied sooner, the chances of success had cer- tainly been greater. I believe this fully ; but here it is that the most difficult question arises. When is the operation proper ? If you act too soon, may it not be said, whilst instancing the cases of spontaneous cessation of the vomiting, as in those which have been quoted, that you have destroyed the foetus without advantage? If you act too late, may you not be equally reproached, in view of the failure of all known operations, with an attempt which may have hastened the fatal termination ? Where will the prudent practitioner place the limit of expectancy? If it be remembered that the ancient accoucheurs declared, as do Mauriceau and Delamotte, that the vomitings may possibly produce abortion, yet are not dangerous for the mother; also that many moderns assert, with Burns and Desormeaux, that they have never known them to terminate fatally, there would certainly be small temptation to operate before all hope has been dissipated by the gravity of the symptoms. Our hopes, indeed ! But does not nature sometimes mock at our expectations? Did not the patient of MM. Dubois and Chomel seem doomed to certain death ? I know it may be answered that it must be left to the tact and skill of the practitioner to think deeply, and choose conscientiously between the dangers of expectation and the chances of an operation ; that the difficulties which I raise, present in a host of surgical cases; that there is barely an amputation which may not be authorized by affirming, dogmatically, that a spontaneous cure is impossible ; that the exceptional preservation of a limb proves nothing against the propriety of amputation in a majority of similar cases. All this is doubtless true; but let us not decide too quickly, for the com- parison is far from being strictly just. When the surgeon has to deal with a serious traumatic lesion, he regards nothing but the interest of his patient; and after explaining to him the grounds of his conclusion, may, in cases of difficulty, consult his wishes, and then leave his life at his own disposal. The accoucheur has the serious interest of two beings to care for; and though the instinct of self-preser- vation may silence in the female the voice of maternal feeling, it is never- theless his duty to protect the foetus, with whose welfare he is equally intrusted. In a given traumatic lesion, all experience shows that spontaneous recovery DISEASES OF PREGNANCY. 477 is a rare exception. On the other hand, the experience of all accoucheurs goes to pn-ve that the spontaneous cessation of vomiting is of almost uni- versal occurrence. Dubois met with 20 fatal cases of intractable vomiting in 13 years. Tyler Smith mentions two cases that died before abortion could be induced ( Leish- man'8 System of Midwifery). [We shall proceed no further with this discussion, but first of all examine the facts. Experience having shown that abortion and spontaneous labor were, in cases of obstinate vomiting, often followed by recovery, it was naturally asked by physicians whether the process adopted by nature might not properly be effected by art. Some trials having been made here and there, M. Denieux succeeded in collecting 32 of them, which he quotes in his thesis, giving as a result 21 recoveries and 11 deaths. Of the 21 successful cases, 15 were abortions, and 6 premature labors. To these we would add a case of our own, in which the vomiting being severe, and death imminent, it was decided, in consultation with Dre. Millard and Charrier, that abortion should be produced. The operation was successful. It was a twin pregnancy of two months duration. Our conclusion is, that procured abortion, as well as premature delivery, is a valuable resource in intractable vomiting. It is nevertheless true that it has the great disadvantage of certainly sacrificing the life of the child ; therefore, before undertaking the operation, the conviction derived from mature consideration that no other course remains by which the mother's life can be saved, should be sus- tained by the concurrence of several medical friends in consultation. It is, in fact, more difficult under these circumstances than in a case of extreme contraction of the pelvis to determine the propriety of producing abortion, and that, too, without having the same certainty of saving the patient. We shall not revert to the comparison of such cases, already made on page 474. Another difficult question remains to be settled : At what time ought abortion to be effected? In reply, we can do no better than quote the opinion of P. Dubois. " The production of abortion in the third stage of the disease is liable to the grave objection of not saving the patients, but of hastening their end and compromising our art. If done in the first stage, there would be the not less serious error of sacrificing a pregnancy which might, perhaps, have progressed happily to its term. Therefore, we conclude that the operation is applicable to the period intermediate to those mentioned." We would here call to mind that this second period is characterized: 1, by almost incessant vomiting, produced by all kinds of food, and sometimes, also, by the least quantity of pure water; 2, by debility so great as to keep the patient at rest, and occasionally by syncope ; 3, continued fever; 4, in certain cases by a fetid and even putrid breath. When to these symptoms is added the failure of all the medication which has been tried, it is right to advise abortion, leaving with the family the responsibility of deciding upon it as a last resort. Different operative procedures may be employed, the comparative value of which will come under discussion hereafter. (See Operations.)] § 4. Constipation. Diarrhoea. Constipation is a very common affection in pregnant women, and it is usually attributed to the pressure of the developed uterus on the upper part of the rectum, by which not only the calibre is diminished, but its action is also paralyzed. Would it not be more reasonable to attribute it in many cases to a commencing chlorosis? We know, indeed, that constipation is - common in the Latter disease that Hamilton regarded it as one of its causes. 47* PATHOLOGY OF PREGNANCY. Tome authors attribute it to diminished secretion of bile. When carried too far it often produces anorexia, and disordered digestion, and becomes a cause of agitation and loss of sleep. Whatever be its cause, the straining? necessary to expel the hardened faeces that have accumulated in the intes- tine, may give rise to hemorrhage and abortion. The best measures for preventing and remedying this state are nearly identical with those used at other periods of life. The same remarks apply to the diarrhoea with which women are often tormented. [Constipation, as just said, is very common during pregnancy. Diarrhoea some- times occurs, and that more frequently than seems to be generally suspected. The diarrhoea of pregnancy varies in character, and is due to different causes. Sometimes it alternates with the constipation which gives rise to it, and which is relieved thereby. At other times it coincides so nearly with conception as to be its Bret symptom ; again, it may appear only during the last days of gestation, and indicate the imminence of labor. In none of these forms does it present any gravity, and is amenable to the treatment usually employed in such cases. Exceptionally, however, severe diarrhoea may supervene during pregnancy, with- out any assignable cause. The passages are profuse and frequent, and accompanied with tenesmus; emaciation takes place with exhaustion of strength, the mouth becomes dry, and fever sets in. Some of these cases resist all kinds of treatment, and may lead to abortion or premature labor. This form, to which the term intractable might well be applied, may prove fatal to the mother either before or after delivery. One case of the kind me under our own observation.] ARTICLE II. LESIONS OF RESPIRATION. Cough and dyspnoea are about the only affections claiming our examina- tion under this title. The dyspncea that supervenes towards the end of pregnancy is evidently produced by the crowding of the lungs from the excessive uterine develop- ment, and the delivery alone can cure it; but sometimes it is sooner mani- fested in consequence of a pulmonary congestion, which must be remedied by general blood-letting, a light regimen, repose in a suitable position, and loose clothing. The same may be said of such palpitations as are not due to organic dis- ease which existed before the pregnancy ; but it must not be forgotten that, though bleeding is useful when the dyspnoea or palpitations are very severe, by diminishing the local congestion for the time, the latter is much more frequently due to hydraemia than to a true plethora, and that the best means for preventing its return is to follow the bleeding by tonic remedies. (See the following article.) As to the cough, it is only dangerous as regards the pregnancy, by the violent jars sometimes given, which may produce an abortion. Indeed, all observers who have written on influenza have carefully noted the frequency of this accident in women who were affected with it. Winn tin cough is the effect of pregnancy, it may sometimes be attributed DISEASES OF PREGNANCY. 479 to local plethora, and then we should bleed. But at other times it has a spasmodic character resembling whooping-cough, with the exception of the alteration of the voice. In such cases, I have derived much advantage from baths, repeated for several days in succession. When it is the symptom of a chronic malady, existing prior to gestation, the treatment will vary with the disease that produced the cough. What- ever may be its origin, the accoucheur should always resort to such demul- cents and pectorals as are calculated to diminish its intensity. ARTICLE III. lesions of the circulation. § 1. Alterations of the Blood. Plethora and Hydremia. The general circulation is more active in pregnant women than in others (see page 157), and this increased activity manifests itself by a greater fre- quency of pulse, which is often harder and fuller than in the non-gravid state. Though all this may be regarded as normal, it sometimes becomes exaggerated and gives rise to a slightly morbid condition. Thus, some women experience, at the same time, vertigo, dimness of vision, ringing of the ears, sudden flushings of the face, spontaneous heats over the body, but more especially of the head. If bleeding be practised under these circum- stances, the blood will sometimes afford a large and consistent clot with but little serum ; though much more frequently there is much serum, and a small clot, covered with a distinct whitish coat, resembling that observed in inflammatory diseases. (See page 160.) The differences in the appearance of the blood drawn by venesection ought to have excited the suspicion that, notwithstanding their identity, these functional disturbances might be produced by different causes ; and although some scattering therapeutic measures induce the supposition that the idea had suggested itself to some good minds, it is also evident that it was almost immediately stifled ; for the majority of authors, even the most recent, do not hesitate to refer them to plethora, and making the treatment correspond with the etiology, recommend blood-letting as the best means of overcom- ing it. The little advantage which I had derived from this practice had, lor several years, excited doubts in my mind as to the value of the theory; which doubts were especially increased by reading the admirable investi- gations by M. Andral on the blood. Therefore, in treating, in 1844, in the second edition of this work, of the plethora of pregnant females, I wrote as follows: "After having read the curious statements just given (analysis <>/ the blood by M. Andral), the reader will perhaps find them to disagree with the title of this paragraph, and possibly also with the therapeutic measures hereafter recommended; for how, indeed, can we reconcile this denomination of plethora, applied to the totality of the phenomena observed in most gravid females, with the evidences of anaemia furnished by the analysis of the blood ? Is it not probable that the profession has heretofore been in error, in attributing to this cause what in fact is only due to an impoverishment of 480 PATHOLOGY OF PREGNANCY. the blood? Because, if to these results we add the beating of the carotids, the caprices of the stomach, the digestive disorders, and the varied nervous phenomena that occur during pregnancy, and which closely resemble those so often observed in chlorotic patients, are we not irresistibly brought to the conclusion, that the chlorosis which produces them in the one case also does in the other? and, consequently, that the bleeding generally recommended is more likely to augment than to diminish such disorders? A sufficient number of facts are still wanting to decide the question satisfactorily; but, while presenting in this work the views most generally received, we cannot conceal the effects produced on our mind by the experiments of Andral and Gavarret." From that time we have endeavored to test by facts the inferences which we had drawn from the documents furnished by the experiments of these two learned professors; and we have to say, that the theory is confirmed by practice. Therefore we now assert boldly, what we before expressed timidly in a simple note: That hydroemia is the most frequent cause of those func- tional disorders of pregnant women which have hitherto been attributed to plethora. However strange this proposition may at first appear, it seems to us to be proved by the results of the chemical analysis of the blood, by the symptoms presented by the patients, and by the happy effects of a tonic treatment. It is now well proved that the essential character of plethora is based upon a great increase in the proportion of the blood corpuscles, as their diminution is the distinctive fact in anaemia. And it is well known that diminution of the corpuscles and increased proportion of water are the essential characteristics of anaemia and chlorosis. Now we have shown (pp. 157 and 159) whilst describing the changes in the blood during preg- nancy, that the amount of corpuscles diminishes, whilst that of water increases. In this respect, therefore, pregnant women may be strictly com- pared with those affected with chlorosis. The increase of fibrin and dimi- nution of albumen also observed during gestation (see pages 157 to 159 , are of more difficult explanation. The deficient nutrition of the mother, who is obliged, whatever may happen, to supply the fetus with the food required for its development, may also explain the excess of fibrin, and in addition, the decrease of the corpuscles; for the experiments of M. Andral have shown that the blood of dogs, subjected to certain degrees of abstinence, presented the characters of chloro-anaemia, and coincided with a marked increase of the fibrin. Again, if we admit, with some modern chemists, that the fibrin is formed at the expense of the albumen of the blood, may we not find in the con- siderable diminution of the latter the cause of the increase of the former? Finally, we would add that MM. Becquerel and Rodier, the only ob- servers whose analyses give the proportion of iron in the blood of pregnant women, have shown that it is below the physiological average. Thus, in 1000 grammes of the calcined blood of a healthy and non-pregnant woman, the average proportion of iron is 0*54] ; in that of the pregnant female it is 0'449; and in well-marked chlorosis it is 0'oGG. The proportion of iron DISEASES OF PREGNANCY. 481 t&llows, therefore, that of the corpuscles, and the expression of its amount during' pregnancy will serve to indicate the transition from the healthy condition to confirmed chlorosis. From all that has been said, we think it may be concluded that the prin- cipal elements of the blood undergo alterations during pregnancy analogous to those of chlorosis. These changes are doubtless in many cases purely physiological, as we have already stated (see page 159), but may so increase as to become pathological by the establishment of hydrsemia and chloro- ansemia. The view which we take will become still clearer when we shall have proved the following proposition. The Functional Disorders of Pregnancy hitherto attributed to Plethora are those of Chlorosis. Most of the authors who have written upon the func- tional disorders of pregnancy have attributed them to plethora, on account of the peculiar physiognomy which they present. Thus, because in many pregnant females they observed fulness and hardness of the pulse, a feeling of heaviness in the head with somnolence, vertigo, ringing in the ears, flashes of heat, sudden flushings of the face, &c, they regarded them un- hesitatingly as the expression of encephalic congestions, themselves the con- sequence of general plethora. Now it is really only necessary to read the list of symptoms belonging to chlorosis, in order to be convinced that they are identical for the two affections. This is easily explained, says M. Andral, by observing that if the mere passage of too great an amount of corpuscles through the vessels of the brain appears to account sufficiently for the cerebral disorders witnessed in ple- thora, it follows that too small an amount of corpuscles traversing the same vessels will produce similar disorders ; so that too great or too small ar amount of corpuscles deranges certain actions of the brain in the same manner. Therefore, the true cause of the symptoms is not to be judged of by their external characters, but only by the changes in the bloody Now, the analysis of the blood of a large number of females, who complained of these supposed plethoric phenomena, has shown a marked diminution of corpuscles and an increase of serum. Besides, if we remember what has already been said concerning the pathology' of pregnancy, it will be found that there is hardly one of the functional disorders yet studied, which is not also observed in chlorotio women. What is more common than to find in chloro-ancemic patients the want of appetite, disgust for food, whimsical and depraved tastes, cramps and pains in the stomach, nausea and vomiting, — in short, all those symp- toms of gastralgia which render many pregnancies so suffering? Are not also the headaches, toothaches, faintings, and the facial, frontal, orbital, or temporal neuralgias, common, so to speak, to the two conditions? As re- gards the circulation, do we not observe the same modifications in the strength of the impulse, the rhythm, and the clearness of the pulsations of the heart, and is not a bellows murmur also heard in the principal vascular trunks? Some of these various disorders, such as the nervous phenomena, arc moif 31 482 PATHOLOGY OF PREGNANCY. particularly observed in the first half of pregnancy; others, such as the pretended symptoms of plethora, trouble more especially those females who have reached a more advanced period. It must, however, be confessed, that sometimes all of them appear at the beginning, and sometimes at the end of gestation, which fact some persons have thought to militate against my theory. Why, said M. Jacquemier, should the same symptoms, which are regarded as disorders due to sympathy with the uterus, if they appear during the first half of pregnancy, be considered as caused by chlorosis, it' they appear during the second half? Is there not something arbitrary and artificial in this, — something which seems to have been devised expressly for the support of a theory? In the first place, I would observe that I have only spoken of the un comfortable sensations which women experience in the latter months; bui in supposing the similarity of the symptoms, there is nothing irrational in attributing to them a different origin. I may be allowed to recall what takes place in t lie case of a young girl becoming chlorotic : it will be seeD that the succession of phenomena is absolutely the same as what I hav« supposed for the chlorosis of pregnant women. A healthy young girl reaches the age of puberty, when, under the influence of causes which we often cannot appreciate, the menstruation fails to become established, or takes place only in an imperfect or irregular manner. The uterus, being disturbed in the exercise of its monthly functions, soon reacts upon all the other organs. The appetite diminishes, the stomach becomes capricious, the tastes whimsical, the digestion painful ; and from the persistence of this difficult digestion results incomplete assimilation, and soon deficient nutri- tion. After the lapse of a few weeks or months, the defective nutrition produces an alteration in the composition of the blood, which, when carried to a certain degree, produces all the symptoms of chlorosis, — symptoms bearing a strong resemblance to those which preceded and caused the general disease of which they are the expression. No one, certainly, will deny the truth of the picture just drawn. Now, is not the same succession of phenomena witnessed in pregnancy? In both is it not the irritation of the uterus produced by the new functions, which lirst reacts upon the other functions of the economy, disturbing their regular fulfilment, which afterward interferes with the assimilation of nutri- tive matters, and which finally produces chlorosis? Is not the latter con- dition indicated in the pregnant woman, as in the young girl, by the same symptoms? Where then is the difference? And if it be allowed that the primary functional disorders of the young girl are purely sympathetic, whilst those which occur later are attributable to chlorosis, why should we refuse to acknowledge the same as occurring during pregnancy? After thus recalling the fact, that all the functional disorders of chlorosis are sometimes observed during pregnancy, it truly becomes a matter of astonishment that the resemblance between the two should not have been noted earlier, and that it should have been left for recent analyses to ( xcite the suspicion that the same symptoms might be due to the same cause. The pathological anatomy and symptomatology being then in accordance with each other, it remains to be .-ecu whether the treatment will afford another evidence of the nature of the disorder. DISEASES OF PREGNANCY. ±83 Plethora was formerly considered so common, and so exclusively the cause of the diseases of pregnancy, that blood-letting had become a general practice. So strongly impressed were many women with the idea of the necessity of bleeding, that they thought themselves under an obligation to have recourse to it by the time they had reached the fifth month of gestation, and even demanded it before consulting their physician. Most practitioners declined performing these so-called preventive bleedings, though all re- garded venesection as the best means of overcoming plethora, that is to say, the assemblage of phenomena attributed thereto. If the latter proposition were true, it would constitute an unanswerable objection to the theory we are endeavoring to establish. Fortunately, however, such is not the case. I certainly do not wish to deny the amelioration produced by bleeding in certain cases ; but it proves nothing against the poverty of the blood, and the chloro-anremia. The lessened proportion of the corpuscles does not necessarily involve a diminution of the entire mass of the blood, as the word ancemia applied to this alteration would seem to indicate. Generally, on the contrary, the amount of this fluid remains the same, and sometimes even is considerably increased'; thus corresponding with what M. Beau states to be habitually the case in chlorosis. A true plethora, which might be styled serous, then exists, in which case, especially to the usual signs of anaemia, are superadded headache, vertigo, ringing in the ears, etc. ; and under these circumstances, bleeding may afford relief by diminishing the amount of blood. The same result is obtained in ordinary chlorosis, when bleeding is practised for the removal of local congestions. But, in preg- nancy as in chlorosis, this alleviation is but temporary, and if the propor- tion of corpuscles be not brought up to the healthy standard by proper hygienic and therapeutic measures, the same symptoms will soon reappear, and with greater intensity. The abstraction of blood is, therefore, in any case, but a palliatory measure, only to be employed in extreme cases, when the general symptoms are very severe, but which might have been avoided by administering tonics and ferruginous preparations at an earlier period. An animal diet, and preparations of iron, have, for six years back, always appeared to me to be quite as useful against the functional disorders of pregnancy as against those of chlorosis. Unless they be very serious, I no longer bleed for palpitations, pains in the head, or suffocations, nor have I known them, in a single instance, to resist the use of the prepara- tions of iron longer than a couple of weeks. Even when the gravity of the accidents has obliged me to bleed to the extent of six or eight ounces at the utmost, I begin immediately with the use of iron, and it is very rarely that I am obliged as formerly to recur to venesection. Hemorrhage from the bowels might, in some cases, remove the necessity for phlebotomy, and M. Blot was certainly right in advising gentle purgatives under these circumstances. There is still another condition, in which I have associated iron and bleeding with advantage; with what propriety we shall next see. The excess of impoverished blood in pregnancy may, as in chlorosis, give rise to local congestion, which congestion, when carried beyond certain limits, explains the occurrence of epistaxis, and the l^ss frequent hoemop- 18-1 PATHOLOGY OF PREGNANCY. tysia and hrematemesis, all which seem to be the result of an effort on the part of nature to diminish the vascular fulness. These accidents are unusual during pregnancy, or, at least, rarely occur to an alarming extent. The reason seems to be, that from the moment of conception until delivery. all the vital powers appear to be concentrated upon a single organ, which forms a centre of fluxion, towards which all the troubles of the organism converge; this organ is the uterus. The congestion, which in the chlorotic patient occurs in the head or the chest, here takes place in the womb ; and the extraordinary development of the vessels of the uterus, and their more or less intimate connection with those of the fetus, sufficiently explain the danger of an over-determination of fluid. At a very early period, the congestion may occasion the rupture of one of the numerous capillary vessels distributed upon the internal surface of the mucous membrane [parietal or epichorial decidua) ; rather later, the congestion may be great enough to rupture one of the utero-placental vessels, and in both cases give rise to an effusion, which, by destroying wholly or in part the utero-placental relations, proves fatal to the child. These uterine congestions, which are properly considered, in some cases, as the consequence of general plethora, I have witnessed much oftener in feeble and anyemic women. They almost always appear at the menstrual periods, as though the monthly periodicity excited at those times a, more active vitality in the uterus. The woman complains of tension, of swelling of the abdomen, of a feeling of weight in the pelvis, the groins, and upper part of the thighs ; she also soon suffers pain in the region of the kidneys and in the loins. If the proper measures are not employed, the vascular congestion, and the pressure upon the uterine walls resulting from it, irri- tate the organ ; slight contractions occur, sometimes even a little blood flows from the vulva, and announces a threatened abortion. These symp- toms are almost always accompanied with marked vesical tenesmus. Can the latter be due to pressure on the neck of the bladder, produced by an increase in the size and weight of the uterus caused by the congestion ? It is evident that when these symptoms of uterine congestion appear, prudence dictates a recourse to all the means likely to effect a revulsion. Thus, sinapisms to the upper and posterior part of the back, seven or eight dry cups to the upper part of the chest, and finally, if these measures are insufficient, bleeding, to the extent of six or eight ounces, as a powerful revulsive, is very useful. But, even here, the bleeding may have only a momentary effect by destroying the local plethora, and by no means enables us to dispense with medicines capable of modifying the state of the blood. We shall return to this subject under the head of Preventive Treatment of Abortion. It is proper, however, that I should say in this place, that many of my patients who had suffered frequent miscarriages, have been enabled to attain their full period by the use of iron administered from the begin- ning of pregnancy. We see, therefore, and I call the attention of practitioners to this point, that if the medicament which cures a disease sometimes also proves it? nature, then the disorders which we have described are oftenest due to chloro-ansemia, and not to plethora. The latter proposition, confirmed as DISEASES OF PREGXAXCY. 485 it is by pathological anatomy and symptomatology, I hold to be incon- testable. I say oftenest, for I would not have my assertion regarded as absolute. Though true plethora, that which is distinguished from serous plethora by an increase in the amount of the corpuscles, be rare, it nevertheless is some- times met with, especially at a very early stage of gestation. Females of a really plethoric constitution, whose menstrual discharge is habitually abun- dant and high-colored, may retain this constitutional peculiarity during pregnancy, and sometimes even have it increased. The sixty odd analyses which w-e have quoted, show that, in several instances, the proportion of corpuscles underwent no diminution in the earlier months, and that in the case of one woman who had reached the end of the second month, M. Andral found them increased to one hundred and forty-five. It is even probable that, when analyses shall be more numerous, the same peculiarity will be remarked in some cases of advanced pregnancy. For my own part, I have certainly met with females whose antecedents, symptomatic expres- sion, and the physical properties of whose blood afforded every indication of plethora. The fact of our having observed but few instances of the latter class, is explained by our practising in the metropolis, where all debilitating influ- ences are collected. The hygienic conditions in which women live in the country, dispose them less to chlorosis, and it is exceedingly probable that their blood is not so much altered during pregnancy as in the cases we have noticed. To this, I think, is certainly due their exemption from the func- tional disorders, nervous or otherwise, which so commonly affect the females of large cities. This is an additional argument in favor of my theory. Though such women are exposed to the general consequences of plethora, they present more frequently the signs of local or uterine plethora, espe- cially during the first half of pregnancy, at the periodic returns of the menstrual periods. The local phenomena, as tension, swelling of the abdo- men, feeling of weight in the pelvis, are very strongly marked in their cases. The circulation of the foetus also, sometimes, appears to share in the troubles of the maternal circulation, for these signs of congestion are frequently observed to be followed by the weakening, diminished frequency, and even complete cessation of its active motions; and if the motions have not yet been perceived, the plethoric condition may greatly retard their appearance. However difficult the explanation of these peculiarities may appear, they are too common to be doubted. The best proof that can be given of the effect of this local congestion upon the motions of the child, is their prompt reappearance after a venesection made at the proper time; and it very frequently happens that a woman who is five months, or five months and a half, gone, without having felt them, perceives them suddenly after bleeding. It is unnecessary to state that here blood-letting constitutes the proper treatment, and that the quantity abstracted maybe regulated by the cir- cumstances of the individual cases. It is, however, better to practise several small bleedings at short intervals, than to depend upon a single uopious one. The pioduction of syncope should be studiously avoided. 186 PATHOLOGY OF PREGNANCY. We shall have occasion, when treating of ahortion, to finish (he stud) of the therapeutical indications. (See Abortion.) To recapitulate, the functional disorders of pregnancy, as cephalalgia, giddiness, vertigo, ringing in tin; ears, dyspnoea, palpitations, &c, are rarely due to true plethora, hut most generally to chloro-anaemia. We might iudeed distinguish for pregnant women a very rare sanguineous plethora, and a very common serous plethora. Independently of this marked diminution of glohules and albumen, the hlood is sometimes considerably altered by admixture with the elements of the urine. This alteration, which has been described of late by the Ger- mans under the title of uroemia, and of which we shall soon have occasion to speak, is a capital fact in the etiology of several diseases which are liable to appear in the puerperal condition. We merely state the fact for the present, leaving further notice of it uutil we come to treat of the lesions of the urinary secretion. § 2. Hemorrhage. [Hemorrhage from the genital organs is, unfortunately, but too common during pregnancy, and is an accident much to be apprehended. The hemorrhage may assume very different features according to the cause which produces it and the time of its appearance. On this account it would be so difficult to treat of it in a single chapter, that its history must necessarily he divided into several articles, which we think it best thus to indicate at the outset. Sometimes the effusion of blood is confined to the placenta, and has already been described as placental apo- plexy with the other diseases of the placenta (see Diseases of the Ovum). Uterine hemorrhage occurring during the first six mouths of gestation should, if it be some- what profuse, excite fears of abortion, which it often gives rise to or accompanies. Under these circumstances it is impossible to separate the study of the hemorrhage from that of the abortion. (See Abortion). Hemorrhage occurring during the three last months of gestation presents, on the other hand, the same symptoms, and requires the same treatment as though it occurred during labor. One description, therefore, suffices for both, and will be given in connection with the history of other accidents which are liable to occur during labor. (See Dystocia, article Hemorrhage.) Again, rupture of varicose veins of the vulva and vagina gives rise to effusion of blood in these organs. Such an effusion is known as a thrombus. As it rarely occurs except during labor, we refer the account of it also to the article on Dystocia. (See Dystocia, article Thromuus.) We shall merely refer in this place to a rather rare and curious form of uterine hemorrhage. Some women have a discharge of biood from the vulva a few days after conception. It is small in amount and is sometimes intermittent and some- time continuous; it is rarely attended with clots, but resembles a moderate men- strual flow. It sometimes lasts for three or four months without interruption, yet neither gives rise to serious symptoms nor interferes with the course of gestation; finally it ceases without assignable cause. In our opinion, the discharge has it? source in the neck of the uterus, which, in these cases, has appeared to us both large and softened. The explanation would at least seem probable, when we remember how readily blood exudes from the os tinea) when a pregnant woman is examined by means of a speculum. An ulceration of the cervix vfould facilitate the discharge of blood. It requires no treatment, the greatest danger being that it mighl Lead t<> the belief of the non-existence of pregnancy.! diseases of pregnancy. 487 § 3. Vaetctbs. Hemorrhoids. A varicose condition of the veins in the lower extremities, the vagina, And inferior parts of the rectum, is quite a common occurrence towards the latter part of gestation, though, as regards treatment, the varicose veins in the limhs only require the usual precautions to prevent their rupture. For this, methodical compression is the best remedy, and every attempt at a radical cure should be discountenanced. [Varicose veins of the limbs sometimes burst during pregnancy, and the result- ing hemorrhage is almost always serious in consequence of the pressure of the uterus on the iliac veins. Though some cases are said to have proved fatal, any hemorrhage of this kind is generally easily arrested by well-regulated pressure applied to the seat of the injury. The veins of the vulva, always dilated during pregnancy, sometimes become varicose, giving the sensation of well-defined cords. No annoyance usually results, though some women complain of a very uncomfortable feeling of weight whilst standing. Moderate pressure by means of a T bandage almost always affords relief. Rupture of one of these varicose veins may give rise to severe hemorrhage or even death, as in the following case which came under our notice at the hospital of the Clinique. A pregnant woman, in other respects in good health, was affected with varicose veins of the vulva. One evening, whilst about retiring, she attempted, whilst sporting with some of the other women in the dormitory, to leap from her bed. Falling backward, she found herself seated upon a chair, the edge of which had struck against the vulva. A hemorrhage so severe as to prove fatal in a short time, was the immediate result. At the autopsy, the only lesion that I could dis- cover was a contused wound about half an inch in length upon the external surface of the left internal labium. Water injected into the primitive iliac vein escaped rapidly from the little wound just mentioned. Had the cause of the hemorrhage been discovered as soon as the accident occurred, the effusion could have been cer- tainly stopped by pressure directly applied. As the rupture of the veins of the vagina and vulva occurs most frequently dur- ing labor, we refer for further particulars to the subject of Thrombus. (See Dys- tocia.^ Hemorrhoids, like varices, are an ordinary consequence of the uterine pressure on the hypogastric vessels ; but they may likewise be frequently produced by constipation, and the attendant accumulation of hard matters in the rectum. The bleeding piles are generally less disastrous ; but the others are more grave and very painful. In fact, it often happens that women affected with them can neither stand nor walk, and they are even troubled when seated. The first indication is tc combat the costivencss, and then to assuage the pain by tepid bathing, cataplasms, and emollient and narcotic lotions, or the poplar ointment may be applied to the tumors; and where they are in- ternal, a suppository of cocoa-butter might be introduced into the rectum. Liniments containing opium and belladonna will frequently relieve the patients; but this is all that we could prudently do under the circum- stances. When the inflammation and turgescence are very great, bleeding in the arm is advisable, as this is much preferable to the application of lc< ches in thi immediate neighborhood of the tumor; true, the latter calms the pain? ASS PATHOLOGY OF PREGNANCY. temporarily, but then, in certain females, they might bring on an abortion, I have never known, says Desormeaux, the application of leeches on tho tumors, or the incision of the latter, to procure any durable relief. Where the irritation from the piles seems to react on the womb, and threatens a uterine hemorrhage, M. Gendrin has derived signal advantage from cold applications around the pelvis. In those cases, says he, it ihe hemorrhage is imminent, we augment the activity of the topical remedies placed directly over the parts affected, by using cold baths to the breech at the same time, the temperature of the water never having been lower than 12° or 15° (Centigrade, equivalent to 54° or 59° Fahr.). I have several times employed cold injections successfully. The plan is to take every evening a large cold enema, which after being discharged is followed by a Pinal 1 one, which ought to be retained. We shall speak more fully of the varicose condition of the vaginal veins under the article Thrombus of the Vulva. ARTICLE IV. lesions of the secretions and excretions. § 1. Ptyalism. Ptyalism, or a hypersecretion of saliva, sometimes occurs during preg- nancy. It generally lasts but a short time, rarely more than two months. One case, however, is mentioned by M. Brachet, in which the salivation commenced in the second month, and lasted for a month after delivery ; and I have quite recently observed a similar instance in the case of the wife of one of my professional brethren. It frequently returns in several successive pregnancies. I have seen it continue between six and seven weeks in the two first pregnancies of a lady who has since had another child without a recurrence of the affection ; and M. Danyau, Jr., mentions a patient who was profusely salivated for five months in her first pregnancy, and still longer and more profusely in two succeeding gestations. However considerable the salivation may be, it is rather a disagreeable inconvenience than a serious complication. Though it has in no case mate- rially affected the health, some women have been so annoyed with the con- tinual spitting, and the flow of saliva which sometimes deluges the pillow at night, as to insist upon being relieved of it. Happily, in a large proportion of cases, the ptyalism ceases spontaneously, for no great confidence can be reposed in the measures generally resorted to for its removal. Some ad- vantage, however, may be derived from the use of aromatic infusions and Blightly astringent gargles. Like Desormeaux, I have found it useful to recommend the patients constantly to keep a little piece of sugar-candy in the mouth. Others, again, advise lumps of gum arabic, and pieces of ice. It is useful to be acquainted with these various measures, if only to keep up the patience of the sufferer, by varying them from time to time until the disorder ceases of its own accord. Some authors seem to have dreaded the effect of the sudlen suppression of a profuse salivation. Two cases are mentioned,in one of which apoplexy DISEASES OF PREGNANCY. 489 and in the other symptoms of suffocation, appeared to result from it. I do not think that the relation of cause and effect has been satisfactorily shown in these cases, and am tempted to believe that here, as in many other in- stances, it has been erroneously concluded, post hoc, ergo propter hoc. § 2. Excretion of the Urine. The renal secretion is rarely increased during pregnancy ; those writers who have stated the contrary, having been deceived by the frequent incli- nations to urinate which females experience at certain periods of* pregnancy. These repeated desires are due to a true vesical tenesmus, produced by the compression exerted upon the body and neck of the bladder by the uterine tumor. They occur every hour, sometimes oftener, and are relieved by the discharge of a few drops of urine. The pressure of the uterus upon the neck of the bladder is sometimes so great as to obstruct the emission of urine, and render it painful or even impossible. This difficulty in urinating may occur in the commencement of pregnancy, either when the pelvis is too large, and permits the uterus to remain a long time in the excavation, or on the occurrence of a prolapsus uteri, or those other displacements of this organ known as anteversion and retroversion. Most frequently, however, it appears towards the end of gestation, either because the uterus, from being pushed down by the presenting part of the foetal head, early engages in the excavation, or because the womb is forcibly carried forwards ; in the latter case the body of the bladder is pressed up- wards and in front by the uterus, and its neck forced against the superior margin of the symphysis pubis. When the anteversion is well marked, the body of the bladder forms an angle of the neck ; in some cases it is even lower, whence the introduction of a catheter is then exceedingly troublesome. After all, the difficulty of urinating still persists until term, whatever we may do ; for we can only alleviate it by tepid bathing, the horizontal position, and more particularly by the use of a bandage to sustain the abdomen. Where the retention is complete, the bladder, by becoming distended, may increase so much in size as to reach the umbilicus, and its excessive distention might produce an inflammation or even a rupture, especially during the throes of labor; but where the neck is not altogether obliterated by the pressure, an incontinence of urine may ensue, the fluid dribbling away drop by drop ; though, unfortunately, that is not always the case, and the catheter must then be resorted to. I have already said this operation is attended by difficulties under such circumstances, and when it is quite impossible to perform it, the distress may be relieved, in a measure, by pressing back the uterus from the sym- physis pubis with the two fingers introduced into the vagina, and the woman should be taught to aid herself in this way. In some instances, the female suffers at the latter stages a considerable smarting or pain in urinating, as sharp as if there was a stone in the blad- der ; these symptoms arise from a true catarrh of the body, or at least of the neck of this organ ; the urine, in fad, often contains whitish flakes of purulent matter. Such symptoms require the general antiphlogistic treat- 190 PATHOLOGY OF PREGNANCY. ment, local bathing, emollients, and mucilaginous drinks. As a general rule, women only suffer from an incontinence of urine during the last three months, and then the delivery is the only remedy; however, it shows itself in the early stages of gestation in certain females, being evidently produced by the pressure which the uterus, that is still within the pelvis, makes on the neck of the bladder, and it lasts until the womb rises above the superior strait. If the incontinence remains after the fifth month, the symptoms may be relieved by injections of warm water, and by the internal use of tonics. Though the amount of urine is not changed, its composition sometimes undergoes alterations which it is important to be acquainted with. I shall not return to the consideration of the peculiar pellicle called kyesteine by M. Nauche,and whose diagnostic value we have already deter- mined ; but I shall proceed to notice a very remarkable fact, which we shall often have occasion to refer to ; I speak of the presence of albumen, which is found in greater or less amount in the urine of some women at an advanced stage of pregnancy. (See Albuminuria.) § 3. Albuminuria. Uk.t.mia. The credit of having called the attention of physicians to the presence of albumen in the urine of pregnant women belongs to M. Raver, whose admirable and laborious investigations of the disease of the kidneys have thrown so much light upon the pathology of those organs. He was the first to endeavor, in his splendid work, to determine the effect of this altera- tion of the urinary secretion upon the health of the mother, and the regular development of the fcetus. Afterward, followed the observations of Dr. Lever and of Dr. Gahen, who, by the advice of his master, M. Rayer, pub- lished a good thesis upon the subject. Next came the interesting memoir Df MM. Devilliers and Regnauld, and another thesis by M. Blot. More recently, two manuscript memoirs by MM. Imbert Goubeyre, and Bach, and the researches of French, Schott, and Wieger, have shed some light upon this still obscure point of puerperal pathology. It is known that albuminuria is generally the symptom of an organic dis- ease of the kidneys, which almost always proves fatal; hence, it may be readily understood, that when this change in the urine is observed during pregnancy, it becomes at once desirable to ascertain whether it be neces- sarily due to the same cause, or whether it be merely one of the numerous modifications produced in the economy by gestation. In the first case, it is a very serious affection, calculated to awaken all the solicitude of the physician ; in the second, it is but a temporary func- tional disorder, which will most probably disappear with the cause that pro- duced it. Unfortunately, in the present state of our knowledge, it is very difficult to decide the question. For, on the one hand, 1. The normal diminution of the albumen in the blood of pregnant women, which diminu- tion is much greater in patients affected with albuminuria, since MM. Devilliers and Regnauld have observed it to descend to 56*39, would lead to the supposition that the cases under consideration were but exaggerations of what ordinarily occurs, and that the elimination of a larger amount of albumen than usual from the blood, be the cause what it may, accounts foi DISEASES OF PREGNANCY. 491 its evacuation by the urine. 2. The albuminuria of pregnancy is xut gener- ally accompanied by the functional disorders and the symptoms to which it gives rise when connected with disease of the kidneys ; aud the dropsy it- self, which is almost constantly observed in the latter case, is sometimes wanting in pregnant women affected with albuminuria, as was twice ob- served by MM. Regnauld and Devilliers, as I have myself witnessed, and as M. Blot found to be the case twenty-three times out of forty-one. 3. Lastly, in the majority of instances, it disappears immediately upon the termination of the pregnancy which caused it ; and when we consider the obstinacy of albuminous nephritis, it is difficult to account for this sudden disappearance of a disease, which, under other circumstances than the puerperal condition, so frequently has a fatal termination. On the other hand, however, observation shows that in almost all the cases in which women die of the convulsions which too frequently complicate albuminuria, the kidneys present the anatomical characteristics of albuminous nephritis, the more or less advanced degrees of alteration appearing to correspond with the duration of the disease and the amount of albumen discharged. Many times have I had occasion to observe this fact, and fearing lest I should interpret the alterations erroneously, have almost uniformly pre- sented the kidneys to the examination of M. Rayer, who generally recog- nized in them the second, sometimes the third, and only once the fourth degree of alteration. The learned physician of La Charite considers the more frequent occur- rence of the anatomo-pathological characters of the second degree of the disease to be due solely to the recency of the latter, and by no means to a d iilerence of nature. It is no less the consequence of a renal hyperemia, which he supposes may be caused in many cases by compression of the emulgent veins by the enlarged uterus, and the consequent obstruction to the return of the venous blood. That, in simple cases, it generally dis- appears promptly after delivery, is probably due to the consequent cessation of the congestion of the kidney which was maintained by the pregnancy. We see, therefore, that the question is far from being settled ; whilst M. Blot, for example, regards puerperal albuminuria as generally unconnected with Bright's disease, M. Bach, of Strasbourg (Memoir, crowned by the Academy), thinks that it is only sometimes due to albuminous nephritis, and M. Imbert Goubeyre (Memoir, crowned by the Academy) endeavors to prove that it is always a sign of Bright's disease. Now, is it impossible to throw a little light upon this question, which is still so obscure? Healthy urine contains no albumen, and the same is true for the healthy woman in the puerperal condition. Albuminuria, therefore, always indi- cates a pathological condition of which it is the symptom ; for every func- tional disorder, whether temporary or persistent, supposes a momentary or prolonged alteration of the organs whose office it is to accomplish the func- tion. Therefore, the investigation of the causes of albuminuria implies that of the general or local affections which are capable of producing it. But lest we should go astray in these researches, it is very important to ascertain a pi'iorl, what are the organs upon which the accomplishment of the urinary secretion devolves. The kidney is supposed to be exclusively -A92 PATHOLOGY OF PREGNANCY. intrusted with this office, and thus it happens that the material explanation of all the disorders of the secretion is sought for in lesions of that organ. Now, as M. Pidous has very judiciously observed, the secretin n of urine is not confined to the kidney, since it takes place previous to the formation of the latter. (Uric acid and the other elements of the urine have been dis- covered in the fluid contained within the allantoid.) The process of assimi- lation, which is so active in the foetus, can only be understood by supposing a contemporaneous process of decomposition. The blood which flows to the organ is already charged with the elements of urine which are to be separated from it in the passage. The function begins in all parts of the economy by this admixture of heterogeneous elements with the blood, and is completed in the kidney by their elimination from the circulating fluid, which is returned in a purified condition. M. Pidoux was therefore right in saving, that the secretion of urine is at once a local and general function: general, because it commences everywhere, and local, because it ends in the kidnev. To study the latter organ exclusively, when we wish to obtain a physiological idea of the function, is to neglect an important element; so, also, in pathology, always to expect to find the cause of the disorders of the urinary secretion in alterations of the kidney, is to overlook a multitude of other causes which may have a corresponding influence. The elements of the blood conveyed by the renal artery exist, in health, in a fixed proportion, and certain of them are destined to be eliminated by the kidneys. Now it is easy to understand that if an alteration in the structure of these organs is capable of modifying both the quantity and quality of the matters elimi- nated, an alteration of the fluid, such, for example, as the diminution or in- crease of its solid or fluid parts, may also have the same effect. Clinical observation and post-mortem examination give constant support to this idea ; for though we sometimes find a material lesion of the kidney to which we attribute the albuminuria, we are very frequently obliged to recognize the fact that it is very often absent. [In the present state of knowledge in respect to albuminuria it cannot be regarded as the symptom of any one single lesion, the passage of albumen being due to many different causes upon the nature of which great light has been thrown by physiological experiment. The most striking experiment is that of Claude Bernard, who, having injected a solution of the white of an egg into the veins of an animal, found that albumen soon made its appearance in the urine. The same result fol- lowed the injection of serum of blood. Albuminuria may also be produced arti- ficially by feeding animals with albuminous matters exclusively- All these experiments prove that an excess of albumen in the blood is always followed by albuminuria. A somewhat similar excess is found in the blood of pregnant women, for, we have here to consider not the relative proportions of the water and organic matters, but rather the comparative relations of the two. Now Mr. Gubler states that such a comparison shows, as a general rule, a marked predominance of albumen as compared with the corpuscles (see page 158). He therefore regards the pro- portionate superalbuminosis of the blood as the common determining cause of albu- minuria. During pregnancy, continues this author, the mother's blood has to supply the foetus with its nutritive materials, but only in a soluble and diffusible form, inasmuch as no inosculation exists between the maternal and foetal vessels. Albumen in its various forms is. therefore, required for the nourishment of the new being, and whilst this is the case the maternal organism has to provide for a double expenditure DISEASES OF PREGNANCY. 493 In consequence either of an increased ingestion or a moie perfect appropriation of protein substances, or to both causes conjoined, a greater amount of albuminous matter is continually supplied. Now, under the changes impressed upon the func- tions, a bad state of the economy or the perturbations produced by the first efforts, so to speak, in this novel direction, may cause the albumen to accumulate in pro- portions beyond the needs of the two conjoined organisms. In this view, the albuminuria of pregnancy implies an excessive production of albuminous matters in relation to the requirements of both mother and child. Sometimes it will be that the former produces too much, and sometimes that the latter appropriates too little; again, both these conditions may concur to produce the same result. Should the children, when born, be of the usual size and weight, it would be fair to conclude that the albuminuria resulted from disorder of the maternal economy ; should they, however, be small and puny, it would be equally just to suppose that their condition may have caused the excess of albumen in the blood and its consequent filtration through the kidneys. We would add, as a fact shown by experience, that children born of mothers affected with albuminuria are often of less than the medium weight and development. The remarks of Danyau, Depaul, and Blot put the truth of the latter statement beyond a doubt. (Gubler.) In connection with the superalbuminosis just discoursed of, we should consider the effect of the pressure of the blood upon the walls of the vessels as of no less importance in the etiology of the affection. If enough water be thrown into the vascular system to increase suddenly the mass of the blood and produce a strong vascular tension, albumen is found to escape immediately by the urine. A still more decisive experiment is afforded by ligating the emulgent vein. In this case, the sudden arrest of the venous circulation determines a progressive stagnation in the capillary vessels and albuminuria results. The same result is obtained if the ligature be gradually tightened, so that entire interruption of the flow of venous blood is not produced for several hours or even days. Whenever, therefore, sufficient pressure is made by a tumor upon the renal vein or vena cava inferior to slacken and obstruct the returning circulation in the kidney, the urine is liable to contain albumen. This, M. Jaccoud states, is the most frequent cause of the albuminuria of pregnancy. Generally, indeed, it does not begin until after the sixth month of gestation (Rosenstein, Braun), but then everything conspires to produce con- siderable obstruction of the abdominal circulation; that of the kidney is slackened as well as that of the liver or spleen (Virchow), and the pressure thus abnormally produced in the malpighian bodies leads to the passage of albumen into the urine. This view, now universally received (Frerichs, Braun, Rosenstein, Wieger, Beck- mann, Krassnig, Brown-Seguard), is evidently not applicable to that kind of albu- minuria which appears exceptionally during the four last months of pregnancy. At this period it can no longer be attributed to obstructed circulation in the renal veins, the pathological process being entirely different. (Jaccoud.) Superalbuminosis, therefore, on the one hand, and great distention of the vessels of the kidneys on the other, afford a satisfactory explanation of the albuminuria of pregnancy ; but are we to conclude that the kidneys themselves have nothing to do with the causation of the disease? Evidently not, for the albumen would remain imprisoned in the blood-vessels indefinitely, did not the kidney undergo such changes ns would allow the protein matters to pass through it, that is to say, did it not become affected with active congestion and certain transient parenchymatous alterations which are the instrumental conditions of the disease. Co-operative circumstances, such as the impression of cold, might increase the hyperemia to the state of inflammation properly so called, and thus give rise to what Gubler has termed secondary albuminous nephritis. In this case, the albuminuria is maintained by the kidney itself. 494 PATHOLOGY OF PREGNANCY. But this is rrnt all. The kidney may also ho the *oat of the iniliivl phenomena jf the disease; which would then he due to a primitive albuminous nephritis. To recapitulate: the albuminuria of pregnancy is produced by various causes, the principal of which, in our opinion, seem to proceed from and be connected with the three following conditions: 1. Superalbuminosis. 2. Over-distention of the blood-vessels of the kidneys. 3. Albuminous nephritis, which may be either primary or secondary.] This succession of pathological phenomena seems to me to throw much liL r lit upon the etiology and nature of puerperal albuminuria, and to recon- cile apparently contradictory facts and opinions. It were certainly going too far to say that all cases of albuminuria during pregnancy are attended with albuminous nephritis ; it is an opposite exaggeration, on the other hand, to insist that there very rarely exists a connection between the albu- minous urine and the disease described by Bright. The true statement, we think, would be: that pregnancy generally produces a notable change in the relative proportion of the elements of the blood, which change consists essentially in a diminution of the solid constituents, with relative predomi- nance of albumen. This general alteration is of itself capable of producing the elimination of albumen; but when existing in a slight degree only, and therefore un- equal to the production of albuminuria, may have its action assisted by the active or passive congestions to which the kidney may he exposed during pregnancy, and especially during labor. Those simple hyperemias of the kidney, which are so often seen after death, and which are really the first degree of granular nephritis, do not appear to have any other cause. The marked influence which a first pregnancy appears to have in the production of albuminuria (the resistance of the Avails of the abdomen increase greatly the pressure sustained by the parts situated behind the uterus) is thus explained, as also the rapidity with which the albumen frequently disappears after labor. [According to most authors, the presence of albumen in the urine is almost always coincident with diminution of urea, which would even seem to lessen in quantity in proportion to the ahundance of urine. The urea being imperfectly eliminated by the kidneys, therefore accumulates in the blood. For further dis- cussion of this suhjpct, see Urcemia, at the end of this article. Let us now examine the methods of detecting the presence of albumen in the urine and the symptomatic troubles to which its existence there gives rise. Notwithstanding all that ha< heen said respecting the appearance of alhuminous urine, its want of color, and the frothy bubbles which form on its surface, it would often pass undetected if care were not taken to examine it closely by peculiar pro- cesses. Many chemical reagents have been proposed for its analysis, but heat and nitric acid are almost the only ones to be relied on. The simplest process for detecting alhumen is as follows : having drawn the urine by a catheter in order to avoid the inconvenience of admixture with vaginal or lochial discharges, it should he paired into a tube and heated to the boiling-point. When ebullition commences, should the urine be albuminous, it grows cloudy, and a flocculent coagulum precipitates. It ought, however, to be understood that this eoagulum is not a certain indication "f albumen, since alkaline urine might pre- cipitate its earthy salts. An opp »site error might also occ lr, inasmuch as highly DISEASES OP PREGNANCY. 495 alkaline and at the same time notably albuminous urine contains but a small pro- portion of earthy salts and is not clouded by heat. In all cases, therefore, it is indispensably necessary first to test the urine by litmus-paper, and if alkaline to acidulate it with a small quantity of nitric acid ; after which it should be subjected to boiling. The testing by heat is liable to another objection, to wit, that urine which is albuminous but at the same time very acid, may not yield a precipitate by heat. The resistance to coagulation depends, in this case, according to Gubler, upon the presence of phosphoric acid. Here a little nitric acid, by neutralizing the influence of the phosphoric acid, restores to the albumen the power of coagulation by heat. On the other hand, a still larger proportion of acid would precipitate the albumeu directly, without the assistance of an elevated temperature. Instead of having recourse to heat, albumen may be sought for in urine by allowing a few drops of nitric acid to flow down the sides of the glass containing the fluid. The acid coagulates the albumen and a flocculent precipitate soon forms. This method, unfortunately, is not decisive, for the action of nitric acid upon cold and acid urine gives a precipitate of uric acid resembling considerably that of albumen. We may avoid deception, however, by Avarming the clouded fluid, which will resume its transparency as the temperature rises in consequence of the greater solubility of uric acid at high than at low temperatures. All the preceding considerations show : 1st, that albumen may be supposed to exist when it is absent; 2d, that it may be overlooked when present. The testing for albumen is not so easy as is generally supposed. Therefore, it were better, for greater certainty, to examine first by boiling and then by nitric acid. All the difficulties presented by the analysis have been thoroughly stated by Gubler (Diclionnaire Encyclopedique), whose work we refer to without being able to enter at present into greater detail.] The urine, in Bright's disease, presents other alterations besides its admix- ture with a certain proportion of albumen. Thus, when submitted to micro- scopic examination at a certain period of the disease, it is found to contain mucous corpuscles, scales of epithelium derived from the bladder, ureters, and pelvis of the kidney, besides elongated cylindrical bodies formed of amorphous fibrin, in the substance of which blood-corpuscles may be ob- served, either singly or in groups. These have been termed fibrinous cylin- ders, and are regarded by Frerich as pathognomonic of Bright's disease. According to some authors, all these peculiarities are observable in the urine of pregnant women affected with albuminuria; according to others, on the contrary, the fibrinous cylinders are very rare in the latter case, and M. Blot has quite recently examined the urine of three eclamptic patients without discovering them. I am not prepared to decide upon this point, though it seems to me very probable that this difference of results is simply due to the fact that, in the first case, the kidneys were diseased, whilst in the second the recent albumi- nuria was connected only with a general alteration of the fluids- After the indications afforded by examination of the urine, the next most frequent symptom of albuminuria is general infiltration or anasarca, which must not be confounded with bedema of the lower extremities. (See Dropsy of the Cellular Tissue.) The latter is occasioned simply by the mechanical obstruction of the venous circulation produced by the pressure of the gravid uterus. 496 PATHOLQGY OF PREGNANCY. General infiltration is not so uniform an accompaniment of albuminuria as I thought formerly. In order to determine its relative frequency, it is necessary not only to examine the urine of infiltrated females, as was my practice, but to investigate carefully the urine of all pregnant women, as was done by M. Blot. It will then be discovered that many patients with albuminuria present not a trace of oedema. M. Blot found it, we have said, iu 23 cases out of 41. It is proper to observe, that this absence of infiltration is also often noticed in the ordinary Bright'a disease. By a collection of observations with autopsies, derived from various authors, Frerich found that, of 220 cases of Blight's disease, 175 were accompanied with cedema, and 45 were free from it. Nervous disorders are sometimes attendant upon the anasarca. In the last edition of this work we stated that puerperal albuminuria did not usually give rise to the symptoms which accompany Bright's disease. This is true for the light cases; which, happily, are the most frequent ; but science has progressed, and modern researches have proved that certain of the affections of the pregnant female, whose cause and nature were entirely unknown, coincide with albuminuria, and very probably are, like it, the consequence of extensive elimination of albumen from the blood. Thus, in several cases of amaurosis occurring during pregnancy, MM. Simpson, Im- bert Goubeyre, and others, have detected albumen in the urine. The same is true of certain cases of obstinate headache, of lumbar pains and pleuro- dynia, of paralysis (hemiplegia or paraplegia), (Robert Johns, Simpson, Im- bert Goubeyre), and of contractions, hemorrhages (Blot), &c. (See Urcemia, and Paralysis.) Now, M. Imbert Goubeyre's remark is very important, namely, that all these phenomena are found in the symptomatology of Bright s disease, which confirms the comparison that w r e have made. To the symptoms just mentioned we might add eclamptic convulsions, which are, happily, quite rare, and hardly ever appear, except at an ad- vanced stage of the disease. We shall treat of them at length hereafter. (See Urcemia, and Eclampsia.) It is very difficult, not to say impossible, to determine with certainty when the albuminuria commences; to do this, it would be necessary to examine daily the urine of a large number of women during the entire period of pregnancy. Hitherto, it has generally been observed only during the latter months. M. Bach, of Strasbourg, however, says that he has seen it at six weeks in a very nervous person. I once detected it at four months in a greatly infiltrated primiparous female, who was delivered at six months of a still-born child, and whose urine was slightly albuminous eighteen months afterwards, although the infiltration had disappeared since six months. M. Cahen mentions in his thesis three cases, recorded in the fifth and sixth mouths, and M. Bach two others. Perhaps, now that attention is directed to this point, such facts will multiply; but those observed hitherto have almost always been noticed in the latter stages. Sometimes it appears only at the moment of delivery, under the influence of the parturient efforts, which are well calculated to produce congestion of the kidneys. DISEASES OF PREGNANCY. 497 When once begun, the progress of albuminuria is liable to great varia- tion ; sometimes it continues uninterruptedly until the commencement of labor, and increases during its continuance; at others, it varies greatly in intensity, and may even cease completely for several days, then reappear, and again stop at very indefinite intervals. When it begins during labor or shortly before, it often disappears a few hours or days after delivery ; but it follows from the facts collected by M. Imbert Goubeyre, that so prompt a cessation is not as common as I had thought, and as M. Blot had stated. Though there are cases, says M. Im- bert Goubeyre (memoir quoted), in which the albumen disappears with rapidity, in others it continues, and passes into chronic and confirmed Bright's disease. From a statement by this author, it appears that, of 65 cases of puerperal albuminuria unaccompanied with eclampsia, 21 proved fatal during pregnancy and the lying-in ; and 6 from the third to the four- teenth month after delivery ; 5 cases became chronic, and were found to be still existent, two, eight, ten, and fourteen months, and seven years after the labor. I but just now mentioned a case in which albumen was detected in the urine eighteen months after delivery. These differences appear to me to be due to the greater or less intensity of the disease. When the alteration of the fluids is but slight, especially when it has existed for but a short time, and occurs towards the end of ges- tation, or only during the labor ; when, finally, the active or passive con- gestion of the kidneys, produced by obstruction of the venous circulation, has had its influence in causing the albuminuria, we can understand how the removal of one of the causes, by delivery, may leave the other inca- pable of sustaining the functional disorder. But when the alteration is slight, especially when it dates back to the middle or first half of the preg- nancy, it may then continue for a long time after delivery. In these latter cases, granular nephritis is often present; but I am much inclined to believe that sometimes the kidney is unchanged, or very slightly altered, notwith- standing the persistence of the albuminuria. In respect to the prognosis, the coexistence of an alteration of the kidney is of the highest importance; unfortunately, however, the diagnosis during life of this organic lesion is extremely difficult, inasmuch as none of its symptoms are pathognomonic. It would appear, however, from the re- searches of M. Pickard (thesis, Strasbourg, 1856), that great light may bo thrown upon the question by analysis of the blood, sinc2, when the kidneys are diseased, the blood contains an amount of urea much greater than in any other cases of albuminuria; moreover, the quantity of urea is propor- tionate to the greater or less advanced degree of renal alteration, a very small proportion of urea in the blood generally coin ?iding with simple con- gestion of the kidneys. Has the albuminuria any effect upon the progress :>f the pregnancy, and upon the life and development of the foetus? M. Blot thinks thai it has not, whilst MM. Cahen, Rayer, and some others, hold the contrary opinion.- I still regard the view of M. Blot as entirely correct for the slight cases, which are, I repeat, the most common; but it does not appear to me well 32 498 PATHOLOGY OF PREGNANCY founded as regards those complicated with anasarca, or which begin before the latter half of gestation. I am very much inclined to consider it as being then a frequent cause of abortion, of premature labor, and of death to the foetus. We have noticed the views of Simpson and others respecting the frequent occurrence of albuminuria in numerous puerperal disorders. M. Blot con- siders it a cause of hemorrhage. It is, therefore, as relates to the prognosis, a sign which is always calculated to excite solicitude. As a diagnostic sign it is certainly destined to reveal the nature and etiology of a multitude of affections hitherto of very difficult explanation; therefore, it is now indis- pensable, in obscure cases, to examine carefully tbe urine of pregnant women, even when unattended with dropsy. It may possibly be shown in the future that albuminuria is a central point towards which converge a multitude of diseases of various characters, and these researches may throw light upon their treatment, which is still so obscure. If we have succeeded in showing that an altered state of the blood is the principal cause of puerperal albuminuria, and that this alteration consists chiefly in a diminution of its solid constituents, we shall have no occasion to insist strongly upon the advantages of a reparatory treatment. Unless very evident symptoms of general plethora or renal congestion be present, bleeding would be rather hurtful than useful, in a disease attended with so greal impoverishment of the system; therefore a tonic medication should be resorted to from the outset. A good animal diet, assisted by the use of whatever feiruginous preparation will be most readily supported by the patient, ought evidently to form the basis of the treatment. The prepara- tions of Peruvian bark, and other bitters, may be added with advantage. [Vrtrmia. — Wo have just said that albuminuria is often accompanied by various nervous disorders (amaurosis, paralysis, eclampsia), the production of which it is very difficult to explain satisfactorily. It will not, however, be forgotten that albuminous urine contains hut little urea (see page 494), which heing no longer eliminated by the kidneys, must necessarily accumulate in the blood. This fact is supposed to account for the nervous disorders in question, by giving rise to a peculiar poisoning to which the name uraemia is applied. We propose now to state the principal points and successive phases of the doctrine of uraemia, premising, however, that it is liable to numerous objections. Wilson first, and afterwards llayer, attributed the nervous complications of albuminuria to the presence of urea in the blood. At first accepted without limi- tation, this opinion was s i attacked in its very foundation. Cases were cited in which urea was present in large amount in human blood without being attended by any of the so-called uraemic symptoms. Finally, CI. Bernard, from experiments made by injecting urea into the blood of animals, came to the conclusion that urea is incapable of producing the nervous accidents of albuminuria. Thus Wilson's theory was ruined. Frerichs came, for a while, to the rescue of the doctrine of uraemia by explaining the facts differently. According to him, urea is, of itself, innocuous, the danger arising from the facf that it is easily decomposed in the blood, giving rise to car- bonate of ammonia, which really is poisonous. Frerichs' experiments appeared to be decisive. lie injected carbonate of ammonia into the veins of dogs in good health, and after a very short time the expired air contained carbonate of ammonia, and the animals were soon taken with convulsions and coma. The symptoms thus DISEASES OF PREGNANCY. AU[) artificially piDduced bore a strong resemblance to eclampsia, and Frericbs' position 6eemed fol a time to be thoroughly established. It was thus presented in a favor- able light in former editions of this work, but since then it has lost ground and its partisans become daily less numerous. The fact is, that the theory is not free from objections ; and out of a great number of experiments which go to contravene those of Frerichs, I again cite the opinion of Bernard, which is far from being favorable. This celebrated physiologist asserts that carbonate of ammonia is almost always present in human blood, whether in health or in disease, and the experi- ments which he undertook satisfied him, moreover, that it is far from being pro- ductive of the terrible nervous symptoms which have been attributed to it. " If," says the learned professor, "carbonate of ammonia be injected in small quantity, it produces no effect. When thrown in larger amount into the blood of a dog. the animal cried and was extremely agitated for a considerable time: nevertheless it recovered." From these experiments Bernard concludes that eclampsia cannot be explained by carbonate of ammonia. The same opinion is given in the excellent thesis for the Concours, of my colleague Dr. Fournier; and, for my own part, I would say with him that Frerichs' doctrine, ingenious and learned though it be, will not bear severe scrutiny. (Fournier, These de Concours pour V Agrijation, 1863.) At present, the position can no longer be sustained that urjemic symptoms are due to the presence in the blood of any single principle, whether urea or carbonate of ammonia. Schottin assumes that substances imperfectly known as yet, and vaguely styled extractive matters, may accompany the urea, remain in the blood, and give rise to a poisoning which Gubler proposed to call urincemia. This last mode of interpreting the facts is an approximation, perhaps, to the truth, though it is far from proven that it represents it precisely. "If the doctrine of uraemia or of urineemia be accepted as true, how shall the nervous troubles which it produces be explained? Here come in what have been termed the nervous theories of uragmia. Certain authors, as Traube and S£e, re- gard the nervous phenomena of urasmia as somewhat analogous, as respects the intrinsic mode of production, with the pathogenic process which Kusmans, Tenner, and others assign to epilepsy. Through some change in the blood an excitement is produced of the vaso-motor nerves and the cerebral arteries. These arteries contract, and there result either oligasmia of the medulla oblongata giving rise to convulsions, or the same condition of the encephalon giving rise to coma." (Four- nier, Thhse de Concours.) In short, the clinical facts are real, and all physicians have occasion to see how frequently nervous troubles arise in the course of an attack of albuminuria. How shall they be explained? Though the question seem at present to be unanswerable, I have deemed it my duty to exhibit the present state of knowledge on the subject, Should the doctrine of uraemia be false and that of urinoemia doubtful, plausible hypotheses would still remain whereby to explain the nervous disorders compli- cating albuminuria. Other changes in the blood, altered nutrition of the nervous tissue (Gubler), hyperemia or anaemia of the encephalon, serous effusions upon the surface of or in 'the cavities of the brain (Rilliet, Natalis Guillot), and oedema of the cerebral substance, are all circumstances capable of explaining the convul- sive phenomena and concomitant symptoms observed in certain forms of albu- minuria. (Gubler.) One other difficulty remains to be mentioned. What are the nervous disorders observed in cases of albuminuria? In the first place we would mention cephalalgia, troubled vision and hearing, vomiting, coma and eclampsia. Up to this point there is no disagreement, lint are cases of paralysis like hemiplegia or paraplegia <-ver witnessed? Here is a case of controversy : Churchill and Imbert Goubeyre on the one hand, admit that puerperal paralyses are not uncommon, whilst on Ue olhei 500 PATHOLOGY OF PREGNANCY. almost all pathologists, Addison, S6i% Lasegue, Fournier, and Grisolle, remars thai paralysis lias no place amongst the nervous disorders of albuminuria. When here- after we come to study puerperal paralysis and include uraemia in their etiology. we shall not lose sight of the difference of opinion upon this subject. In short, various nervous affections occur in women affected with albuminuria, to explain which the doctrine of uraemia and urinaamia has been invoked, although confidence in it has become very much shaken. All our knowledge on the subject is hypothetical, and further investigation is indispensable to reduce it to any cer- tainty ; therefore, whenever we shall mention uraemia in explanation of any patho- logical condition, our reservation on the matter will be brought to recollection.] § 4. Dropsy of the Cellular Tissue. Another affection of quite frequent occurrence, and one which is often connected with what accoucheurs call plethora, of which, according to Chaussicr, it is a variety (serous plethora), is serous infiltration of the cellular tissue. This infiltration begins in the feet, then extends to the legs, thighs, genital parts, and sometimes rising above the lower extremities, invades the trunk, lace, upper extremities, and is sometimes even accompanied by effu- sion into the great serous cavities. These dropsies, upon which MM. Devilliers and Regnauld have published an interesting memoir, are by them divided into: 1, simple oedemas; 2, oedemas connected with affection of the central organs of respiration and circulation; 3, oedemas with albuminuria. The oedema connected with lesions of the organs of circulation generally increases during pregnancy, but this increase is especially due to the un- fortunate influence which gestation has upon all organic lesions, and we have no occasion to speak of it further. As regards the two other species, we think it proper, in order to avoid repetition, to include them in the same description; for though they have some special characters upon which we shall have to insist, they resemble each other in a great many particulars. The causes of the serous infiltrations which occur during pregnancy, may be divided into general and local. As first in importance of the general causes, we must rank the decrease in the proportion of albumen; a decrease which has been discovered by all observers in the blood of pregnant women. According to M. Andral, this special alteration of the blood is the only one which necessarily produces dropsy. The amount of effusion is dependent upon the extent of the alteration, which, if considerable, is often attended with albuminuria. Hydraemia, or serous plethora, which also produces oedema in certain ehlorotie patients, may also give rise to the same symptom during preg- nancy, and assist in the production of serous infiltrations. When these jreneral alterations of the economy are but slight, they usually would be unequal to the production of oedema, did not the development of the womb add its local action to their own. The pressure of the womb upon the surrounding parts from early preg- nancy, and the obstruction which it occasions to the performance of the functions of the central organs of res] mat ion and circulation at an advanced stage, when by rising into the epigastric region it forces up the diaphragm and thus diminishes the thoracic cavity, explain why the oedema commences DISEASES OF PREGNANCY. 601 in the lower extremities, and why it generally does not extend until a much later period to the trunk and upper extremities. Progress and Symptoms.— Generally speaking, the oedema makes its appearance within the last three months of pregnancy, especially when it appears to he due simply to a mechanical obstruction of the circulation. But when it results from one of the general causes before mentioned, it may commence with the pregnancy, or in the third or fourth month. However, aj hydrcemia, the diminution of the albumen of the blood, and the albu- minuria, are most generally observed in the latter half of gestation, we may understand that the dropsy to which they give rise should also be more 2ommon towards the seventh, eighth, or ninth month. The progress of the cedema of pregnancy is generally slow and chronic ; sometimes,°however, it advances rapidly in a few weeks. Whatever may be the case in this respect, it generally begins by the lower extremities ; some- times affecting one of them, at others both. At first it is limited to the feet and neighborhood of the ankles; sometimes even it never gets farther than the lower part of the legs, though quite frequently it reaches the knees, the thighs, and external genital parts. Occasionally it invades the integuments of the lower part of the trunk, and in some rare cases, generally attended with albuminuria, it affects even the face and hands. In the early stages, while limited to the lower part of the legs, it dis- appears at night, in consequence of the horizontal position, and is only well marked towards the close of the day. But when the disease has advanced farther it continues, whatever position the patient assumes ; and although the horizontal posture seems to diminish the swelling of the legs, it it only because the infiltrated fluid is displaced to the lower part of the trunk. The amount of fluid extravasated varies between a slight puffiness and the extreme swelling which makes standing and walking impossible. ^ In the latter case, the parts affected are generally the seat of pain, of sensations of pricking, and sometimes of burning and extreme tension. The cedema rarely disappears before delivery ; on the contrary, it gen- erally increases until near the end of pregnancy. Sometimes, however, as MM. Devilliers and Regnauld have indicated, it undergoes remarkable variations. Thus, it may disappear entirely and finally, or it may return shortly after ; sometimes it is observed to leave one member and fix upon the other, which had been but partially affected. These changes are doubt- less owing to mechanical causes, the action of which varies or ceases with alterations in the situation of the uterus (Devilliers and Regnauld); but they certainly may also be occasioned by fluctuations in the albuminuria, which may be suspended for a short time and then reappear, as I have wit- nessed in one case after labor. Terminations. — The dropsy of pregnanl women, however caused, generally disappears quickly after labor; and in cases of albuminuria, the secretion of albumen often ceases with equal rapidity. Prognosis. — If the dropsy'be viewed as :i simple fact, independent of tin complications which so often attend and follow it, it assumes the position of a merely troublesome affection ; but to appreciate the prognosis rightly, it is. important to remember that some authors regard the oedema as favoring 502 PATHOLOGY OF PREGNANCY. abortion and premature labor. They also suppose it to be almost unit )nnly connected with the etiology of eclampsia, and often with the development of puerperal levers; and finally, that sometimes the disappearance of the effusion alter delivery has been followed by a frequently fatal serous conges- tion of the nervous centres or respiratory organs. The facts related by M. Lasserre leave no doubt in ray mind of the truth of the latter proposition. li is especially important to bear in mind, that although these dangerous complications are possible as a consequence of simple oedema, they have been chiefly observed in cases of albuminuria with infiltration, and consequently that the presence of albumen in the urine adds greatly to the gravity of the prognosis. Hence the interest which then attaches to the examination of the urine. The treatment of the dropsy of pregnant females should be conducted with the double purpose of overcoming the organic; cause which so frequently produces the oedema, and to stimulate the absorption of the effused fluids. The preparations of iron and a tonic regimen appear to me to be especially called for in a disease which is so frequently connected with hydremia. The presence of albumen in considerable quantity, even supposing it due to a nephritis, docs not contraindicate this treatment. The antiphlogistics recom- mended by some authors seem to me likely to be more hurtful than useful ; and unless the patient suffers very severe lumbar pains, or to the general infiltration are superadded dyspnoea, palpitations, extreme giddiness, and especially evident indications of uterine congestion, threatening abortion, I should think it right to prescribe bleeding. Even under the latter circum- stances, I would employ it less as an antiphlogistic than as a revulsive, nor would I discontinue the use of the iron. To assist the absorption of the effused fluids, mild laxatives, diuretics, and dry frictions may be used. To these may be added vapor-baths, provided the patient is able to bear them without danger of cerebral congestion. If the distention and size of the lower extremities is so great as to make walking impossible and cause great suffering, and if the genital parts are greatly swollen, their disengorgement may be facilitated by practising small incisions, or, at least, a number of punctures, with the lancet or a needle. In several cases I have derived benefit from keeping compresses, saturated with cold water, applied to the limbs for several days. Levret advises blisters between the thighs and external labia, aided by slight punctures on the feet; but inasmuch as the application of blisters upon a highly oedematous limb U sometimes attended with serious consequences, I think it prudent to ab stain from them. § 5. Ascites. We have already stated, that dropsy during pregnancy was so far from being limited to the subcutaneous cellular tissue, that collections of fluid of variable amount might take place in the great cavities of the body. The effusion within the abdomen may occupy different locations: thus, it may accumulate within the amnion, and constitute dropsy of the amnion; or between the membranes of the ovum and the internal surface of the womb, in which case ii furnishes the fluid that gives rise to hydrorrhoea ; finally, by collecting within the cavity of the peritoneum, it forms a true ascites. DISEASES OF PREGNANCY. 503 Either of these varieties of dropsy may occur separately, or two of them iuay coexist in the same female, as is often the case with ascites and hydram- uion. We shall treat first of ascites. This affection sometimes makes its appearance in the first half of the preg- nancy, though usually towards the fifth or sixth month, rarely later. When the accumulation begins very early, it sometimes progresses so rapidly that the abdomen is larger at the fifth mouth than at the usual term of ges- tation, and as the infiltration of the lower extremities generally keeps pace with the effusion in the abdomen, the patients find it impossible either to walk or pursue their occupations. The progress of the ascites increases rapidly ; the face is puffed and livid ; the abdominal walls, much thickened by infiltration, add to the size of the belly ; the skin covering them, although distended and shining, sometimes has a tuberculous appearance, as in elephantiasis. The umbilicus usually forms a smooth, rounded, translucent tumor, of the shape and size of a hen's egg, at the base of which the umbilical ring may be felt, though it is too much distended to produce any circular constriction. The greater labia share in the general infiltration, are enormously swollen, and affected wfith a painful irritation, produced by their constant friction against each other, and contact with the urine. The skin of the lower extremities is so distended as to seem ready to burst at several points, and is exceedingly painful. The progressive accumulation of fluid in the cavity of the peritoneum soon obstructs the regular performance of the thoracic functions ; the dyspnoea becomes extreme, the respiration very short, wheezing, and painful ; the patient is obliged to remain seated night and day ; yet, notwithstanding this position, the ha?matosis is so imperfect that she seems threatened with suffo- cation at every instant, and has frequent attacks of faintness. The suffering condition is aggravated by almost constant insomnia, intense headache, ex- treme thirst, and disgust for food. Percussion of the abdomen detects readily the presence of a large amount of fluid in its cavity, though the fluctuation is not equal in all parts of it. As Scarpa remarks, it is slight or absent in the hypogastrium and towards the flanks, is manifest near the hypochondriac regions, and very well marked in the left hypochondrium, near the edges of the cartilages of the false ribs. The enormous distention of the parietes of the abdomen frequently pre- vents the uterus from being felt, and its elevation determined with precision. The motions of the child, though generally obscure, are, however, still per- ceived by the mother. The prognosis of ascites complicating pregnancy is grave in proportion as it dates farther from the term of gestation. When it appears only in the latter months, there is every reason to hope that, notwithstanding its rapid progress, it will be arrested by delivery, before producing such disorders as seriously to compromise the life of the mother, and that, as in the observa- tion of M. Prestat, the recency of the effusion will render its absorption easy after delivery. But when the ascites begins within the first half of the preg- nancy, there is great cause for fear, should it progress rapidly, lest paracen- tesis should be demanded lon^ before the ninth month. It were useless to 504 PATHOLOGY OF PREGNANCY. add, that the prognosis will be far graver, if, as unfortunately very tTten happens, the ascites should coexist with dropsy of the amnion. If, say9 Scarpa, there should fortunately be no uterine dropsy, the paracentesis may allow the pregnancy to progress favorably through its usual stages; but, under the oppo.-ite circumstances, it almost always happens that the womb, being excited bj sympathy, contracts, and delivery follows. Treatment. — The general bleeding, purgatives, and diuretics, employed with the design of retarding the advancement of the disease, have not seemed to influence its later progress, and it is conceivable that a too long-continued use of them might be prejudicial to the pregnancy. They should, therefore, be resorted to with the greatest reserve, and relinquished as soon as found to be unsuccessful. When the disease has increased to such an extent as to threaten the life of the patient, it is evident that the only resource consists in the evacuation of the fluid. But where should the puncture be made? The development of the uterus makes it impossible to insert the trocar at the place of selection in ordinary ascites. From the circumstance of the fluctuation being particularly well marked in the left hypochondrium, the prominence of which was greatest near the edge of the false ribs, Scarpa introduced his instrument between the uppermost part of the external border of the rectus muscle and the edge of the false ribs in the left hypo- chondrium. The patient aborted two days after, and recovered. George Langstaff made an incision two inches above the umbilicus, ex- posed the peritoneum, and punctured it with a medium-sized trocar, being careful to introduce it but a short distance so as not to wound the uterus, lie had thus given issue to about ten pints of fluid, when the womb came in contact with the end of the canula, interrupting the flow, and occasioning so much pain as to oblige him to withdraw the instrument. As the patient was unable to endure any pressure, he introduced a medium-sized gum- elastic catheter by the opening, directing it between the peritoneum and the anterior surface of the uterus. Peritonitis followed eight hours after the ope ration ; three days subsequently to the operation she aborted, and three weeks later she was well. Finally, in a case in which a considerable tumor existed at the umbilicus, Ollivier, of Angers, was decided by the tension and thinness of the skin at the part to make use of the lancet simply. This instrument was introduced in the same manner and to the same depth, as for bleeding, at the middle and front part of the tumor, at the distance of half an inch from the circum- ference of thp ring. The water flowed immediately to the amount of six- teen pounds. For twelve days, the serum continued to flow by the little wound, which was closed hermetically on the thirteenth. The patient, who had been re- lieved at once, experienced a return of the accidents with the fresh accu- mulation of fluid. Twenty-eight days after the first puncture, it became necessary to repeat it; eight pounds of fluid were discharged, and the same alleviation followed. Twelve days after this, the woman was delivered of a living, though feeble child, and in fifteen days was discharged cured. This simple process, consisting of a small puncture with the lancet, seems DISEASES OF PREGNANCY. 505 to me preferable to Scarpa's operation in the hypogastriurn. Tin; latter might, in some cases, endanger important organs, and could only be pre- ferred on account of the existence of an old umbilical hernia with adhesions of the intestines to the sac. The presence of this complication can be readily discovered by holding a candle behind the thin and transparent walls of the umbilical tumor, as for the diagnosis of hydrocele, when the opacity of the exomphalos will be at once detected. There is no advantage in placing a foreign body in the small opening, since the flow of serum keeps the sides separated, and the density and ex- treme thinness of the walls of the tumor prevent infiltration of the abdomi- nal parietes. The observation of Langstaff, above cited, as also another fact related by M. Danyau, prove that the introduction of a foreign body exposes to peritonitis. When the pregnancy has made but slight progress, the only resource evi- dently consists in the puncture ; but when the ascites endangers the mother's life only at the eighth or ninth month, is it allowable to think of premature artificial delivery? If the uterine dropsy, of which we are about to speak in detail, compli- cates the ascites, and we are able to ascertain that the sufferings of the patient are in good measure due to the extreme size of the uterus, I think the tapping would be insufficient, and that the artificial induction of labor may be attempted with advantage ; still, though common, the hydramnion is not a necessary complication, and it seems to me that ascites can very rarely require premature delivery. In the eighth, and especially the ninth month, the evacuation of the peri- toneal fluid will afford sufficiently lasting relief to enable the woman to reach the regular term of pregnancy ; or, at least, it will rarely be necessary to repeat the operation more than once. Such was the case with the patient of Ollivier. The only fault to be found with the puncture is that of being merely palliatory, whilst it exhausts the strength if frequently repeated. But should the relief afforded be such that one or two punctures enable the patient to reach the end of the ninth month with moderate suffering, I see no reason for not preferring it to premature delivery, which always places the child in unfavorable conditions. ARTICLE V. LESIONS OF INNERVATION. (J 1. Eclampsia. On account of its danger and the nature of the convulsions which charactei 'izo it, eclampsia takes the foremost rank in the diseases of women. It is liable to appear suddenly either during pregnancy, at the moment of delivery, or subsequent to the removal of the placenta; it occurs, however, more frequently during labor, and will, therefore, be studied in connection with the accidents of dystocia. (Seo Dystocia. 2 2. Vertigo. Giddiness. Lipothymia. Syncope. Those affections arc due to various causes. Usually they seem to depend upon great nervous susceptibility, occasioned by pregnancy and heightened by chlorosis; 506 PATHOLOGY OF PREGNANCY. less frequently they result from plethora, in which case blood-letting beco.nes, ex- ceptionally, the best method of treating them. Sometimes, also, vertigo and giddi- ness accompany albuminuria, and precede eclampsia. (See Albuminuria, and Eclampsia.) In the majority of cases, neither plethora, albuminuria, nor eclampsia are observed in connection, so that the above named affections seem to be due simply to a perverted action of the nervous system ; an unsatisfactory explanation, but really the only one which can possibly be given] Thus some delicate, nervous women are subject to faintings, from tlie most trifling cause, when they are pregnant ; any strong moral impulses, such as joy, or anger, and sometimes even an odor that is a little too pene- trating, or the sight of an unpleasant object or person, may give rise to this condition. , Gardien relates an instance, where the simple movements of a child produced swoonings ; and I have attended a lady who fainted three or four times a week, during the second, third, and fourth months of her gesta- tion, without any satisfactory cause being discovered for it. Ordinarily, the syncope attacks the woman when standing, and she at once experiences a ringing in her ears, vertigo, dimness of vision, weakness in the knees, and she has scarcely time to sit down, before she faints away. Some females, however, are warned of the attack by the occurrence of yawning, and a sensation of heat in the precordial region ; soon after, the extremities become cold, the face grows pallid, and is covered with a cold sweat ; the senses and intellectual faculties are almost lost, the pulse and respiration have nearly ceased, though a total loss of the intelligence and sensibility is very rare. For my own part, I have never seen any woman in this latter state, since nearly all those whom I have carefully questioned on the subject have stated that they had a confused idea of what was passing around them ; and therefore, if there really be any instances of a complete abolition of the faculties, they certainly are not so frequent as the authors would have us believe. While the syncope lasts, we should employ the ordinary means, such as ammonia, vinegar, cold water, &c, &c. The tonics combined with anti- spasmodics have been recommended for its prevention : for instance, Van Swieten highly extols the use of orange-peel with canella, or lemon-rind and canella, in the proportion of two or three drachms to three pounds of sherry-wine, of which three or four tablespoonfuls are to be taken daily. Chambon has employed an infusion of peach-blossoms with success. All these nervous disorders are more alarming than serious. We have never known them to endanger the life of the mother, or to disturb the regular course of gestation. The attacks of fainting, though generally short, are sometimes quite pro- longed. In the latter case, they are frequently accompanied or followed by some hysterical symptoms, as sense of oppression, hypogastric pain, constric- tion of the fauces, and sometimes true hysterical convulsions. In the case of a young lady, a patient of M. Raver's, these symptoms occurred almost every evening after dinner, during the last three months of her pregnancy. They had no serious consequence, unless a threatening of premature labor towards the end of the eighth month be so regarded, which, however, yielded to a small bleeding and opiate injections. DISEASES OF PREGNANCY. 507 \ 3. Various Forms of Neuralgia. Odontalgia. Various forms of cephalalgia and obstinate hemicrania are oft 3D observed during pregnancy. Other neuralgias may also occur with their usual syorptoms in various situations. The sensibility of the skin sometimes becomes sc acute that the slightest touch gives pain ; again there may be the sensation of intense heat in the feet and hands, or else an impression of cold which nothing will remove. (Jacque- mier.) '1'he walls of the abdomen are often affected with neuralgic pains, which will be studied hereafter in an article devoted to the subject. (See Abdominal Pains.) Odontalgia is the most common of all the neuralgias of pregnant women. The lower jaw is the one usually affected, the pain sometimes invading one side, some- times both sides together. It usually occurs during the first half of gestation, not unfrequently commencing shortly after conception, of which it is sometimes the first sign. It commonly ceases from the fourth to the sixth month. It were not exactly correct to say that every case of odontalgia is a true neuralgia, inasmuch as it is often occasioned by a carious tooth. It therefore becomes necessary, in view of treatment, to make a correct diagnosis, and in order to do so, to give the mouth a very careful examination. (Churchill.) Mauriceau considered bleeding the best remedy for the toothache of pregnant women, yet it is a measure by no means certain, and in some cases entirely inad- missible. It is recommended to guard against constipation by the use of mild purgatives taken at short intervals, and as local applications, the use of gargles containing opium, and plasters of opium and hyoscyamus. Internally, some of the preparations recommended for facial neuralgias may be tried ; such as pills of eynoglossus or Meglin's pills. Should the paroxysms and remissions be well marked, and more especially should there be an actual intermission, the best effects might be anticipated from the use of quinine. No active measures should be resorted to unless the pain be very great, depriving the patient of sleep and render- ing mastication almost impossible, for the contact of foreign bodies with the teeth is sometimes insupportable. (Jacquemier.) Capuron says that toothaches which had resisted all kinds of remedies have been known to subside spontaneously about the third or fourth month of gestation. Should the gums be inflamed, one or more leeches might be applied. If the trouble is occasioned by a carious tooth, efforts should be made to relieve it by the measures commonly employed, the best being cauterization of the offending tooth. As most authors think that extraction might cause abortion, it would be well to advise patients not to undergo the operation. § 4. Paralysis. Pregnant women are not exempt from the causes which produce paralysis under ordinary circumstances, but are even more liable thereto than other females of i heir age. That such is the fact the recent researches of Fleetwood Churchill and Imbert-Gourbeyre have established beyond a doubt. Churchill reports 34 cases of paralysis derived from various authors or observed by himself. In 22 of them, the attack occurred during pregnancy, and in the remaining 12, either during or after labor. The location of the paralysis is noted as follows: 17 cases of complete hemiplegia and 1 in which it was partial; 4 of paraplegia, in 2 of which but one leg was paralyzed; 6 of facial paralysis, 3 of amaurosis, and 3 of deafness ; in some of the latter cases, however, the local affec- tion was connected with hemiplegia. Of these 34 cases, 4 were fatal. Of the 22 cases occurring during pregnancy there were 12 of hemiplegia, 1 of paraplegia, 4 of facial paralysis, 2 of amaurosis, and 3 of deafness, Analysis of these cases shows no regularity in regard to the period .,f gestation at which the attack occurred, though it seems thai the patients were inure liable to Lhe affection 508 PATHOLOGY OF PREGNANCY. during the latter months. Must of them recovered before or after delivery, tlioiign somo continued to be affected for a considerable time. But one case was fatal, and in this it was evident that the result was due to a disease of the brain antecedent to the pregnancy rather than to the paralysis which had increased during the latter ; so that this single case by no means invalidates the conclusion as to the relatively trivial character of these attacks during pregnancy. It is often very difficult to determine precisely the influence which pregnancy may have in the production of the paralysis. In our brief exposition of the state of knowledge ou the subject, we shall have in view only such cases as occur during pregnancy, and thus endeavor to avoid being led off into the general subject of internal pathology. The causes of puerperal paralysis are various ; in the first place we would men- tion cerebral apoplexy, which is not very uncommon in pregnant women. Meniere reports in his excellent treatise several cases of the kind, and, at a later date, M. P. Dubois, whilst discussing the subject in a clinical lecture, came to the con- clusion that the frequency of its occurrence proves the existence of some connection between it and the pregnant condition. How then shall the connection be ex- plained? By plethora or hypertrophy of the heart? Both these views could doubtless be well defended, but M. Imbert-Gourbeyre believes that the apoplexy is due to albuminuria, which is well known to be common during gestation. He cites in support of his view several cases of Bright's disease which terminated in cere- bral hemorrhage, and calls to mind that it is by no means a rare attendant upon eclampsia. More well observed cases are necessary to enable us to determine con clusively the value of this opinion, According to Churchill and Imbert-Gourbeyre, urcemia is almost the only cause of puerperal paralyses, such as amaurosis, deafness, and hemiplegia. As regards amaurosis and deafness, we freely accept their opinion, but have some doubt as regards hemiplegia. Most authors, in fact, think that uraemia never occasions either hemiplegia or paraplegia (see Urcemia), but however this may be. the so- called uraemie paralyses sometimes accompany an attack of eclampsia or else are preceded by it. After cerebral hemorrhage and uraemia, anaemia deserves to be mentioned, as also hysteria, a reflex action whose point of departure is located in the uterus, but whose influence extends to the spinal marrow; — rheumatism, etc., may also be noted as causes. We have thus endeavored to show that the causes of puerperal paralyses are both numerous and variable, so that it will be evident that the prognosis and treatment will have to be modified in the different cases. The ordinary rules of pathology must serve as a guide in the course of medication to be followed. 1. Amaurosis, — which is of common occurrence in cases of albuminuria. It varies in degree from the slightest amblyopia to perfect blindness. It usually affects both eyes, though Imbert-Gourbeyre says that he has known but one eye to be involved. Though generally of short duration, it may sometimes become permanent and incurable. It may also be the first symptom to call the attention of the physician to the possible existence of albuminuria, and is therefore of the greatest value as a premonitory symptom in the diagnosis of eclampsia (see Eclampsia). It may make its appearance before, during, and after labor, and recur in several successive pregnancies. If the eyes be examined with the ophthal- moscope, the retina will sometimes appear to be healthy, whilst at others a fatty alteration will be observed or an effusion of blood; regard will be had to the lattei In the formation of a prognosis. 2. Deafness. — Puerperal deafness is less frequent than amaurosis, and like it is connected with albuminuria and caused by urajmia. The deafness is generally imperfect and almost always preceded by roaring in the ears. Like amaurosis, it DISEASES OF PREGNANCY. 509 may be intermittent, permanent, periodical, single or bilateral; may change into exaltation of the sense of hearing, be connected with other symptoms of albuminuria, or exist alone, although it accompanies amaurosis as it were by preference. We shall learn hereafter (see Eclampsia), that buzzing in the ears and deafness often precede and announce an attack of eclampsia (Imbert-Gourbeyre.) 3. Facial Paralysis. — In connection with amaurosis and deafness may be wlaced paralysis of the third and seventh pairs of nerves — although it is much less frequent. 4. Hemiplegia. — Hemiplegia during pregnancy is of common occurrence, and M. Imbert-Gourbeyre has reported a large number of cases in his memoir. Sometimes it is caused by cerebral apoplexy; at others, no lesion of the nervous centres is dis- coverable at the autopsy, whilst the numerous examples of rapid and permanent recovery seem to prove that there could have been no grave lesion of the brain or spinal marrow. Albuminuria alone and often eclampsia have been observed with hemiplegia, so that Imbert-Gourbeyre feels no hesitation in saying that uraemia is the usual cause of this form of paralysis. As has been said, we do not partake wholly of this view (see Uraemia). Hemiplegia may sometimes also be caused by anaemia, as shown by the following case: A young lady had, during the early months of her pregnancy, an imperfect hemiplegia characterized only by weakness and numbness. The symptoms were of short duration and recovery rapid and complete. In the absence of any other appreciable cause, the affection seemed to be due to a well-marked chlorotic condition. Paralyses are not rare in hysterical women. There is nothing to prove that pregnant females enjoy any immunity in this respect, so that should any of the symptoms peculiar to hysteria exhibit themselves, it would be reasonable to attri- bute the paralysis to the pre-existing neurosis. In some patients even, the hysteria may appear for the first time during pregnancy and be attended by various paralyses. It ought, however, to be noted that hemiplegia is rarely dependent upon hysteria. Finally, when no cause can be discovered, we sij in order to conceal our igno- rance, that the paralysis is essential. 5. Paraplegia. — Beside the usual causes of paraplegia, and independently of all those above noted, this paralysis may be occasioned by pressure of the foetal head upon the nerves of the pelvic cavity or by reflex action. Paraplegia from pressure upon the nerves by the head ought to be rare during pregnancy ; it has been more commonly witnessed during labor and after delivery, especially when the labor has been severe or attended with hemorrhage ; we have nothing further to say in regard to this cause. It is acknowledged, as stated, that paraplegia may be caused by reflex action ; but how, in these cases, can its production be explained? How can a partial ex- citement of the uterus so react upon the spinal marrow as to suspend its functions? Without pausing before the various theories proposed by modern physiologists, we would say that, according to M. Jaccoud who wrote a remarkable work upon the subject, paralysis is occasioned by exhaustion of the nervous system, and that numerous experiments upon animals tend, at least, to prove the correctness of his view: "A long continued, abnormal, excitement is transmitted to the spinal cord by the uterine nerves: after a longer or shorter time it exhausts the excitability peculiar to the corresponding region of the organ, and the inertia of these nervous elements under the action of the brain closes the avenues by which the motor impulse is transmitted; as a necessary consequence of this state of things there results paralysis of all parts situated below the affected points." The following case of Echeveiria's, which the author and others after his example have given as a type of the so-called reflex paraplegia is, to my mind, an absolute demonstration of the theory just stated, — allowing the finger to be laid, as it were. olO PATHOLOGY OF PREGNANCY. upon the pathological mechanism of the paralytic affection. A woman who had miscarried three times, continued to suffer after the last one severe pain in the hypogastriutn accompanied by a slight metrorrhagia. Seventeen days after *hf abortion the uterus was found to be, anteverted ; it was soft and voluminous, rising an inch above the pubis; the neck was sensitive, bled easily, and admitted the finger; the anterior lip was covered by a painful ulcer of a violet-red color. Having determined these facts, Echeverria, with the double object of exciting the contraction of the uterus and hastening the cicatrization of the ulcer, had re- course to electricity by placing one pole of the apparatus upon the pubis, the other in the orifice of the cervix, and then transmitting a current of low power. In- stantly violent pain was experienced in the womb, loins, and lower extremities, which were seized with convulsive tremors. The current was immediately sus- pended, when it was found that in place of the convulsion there was complete paraplegia which lasted for fourteen hours (Jaccoud). Is it not evident that we have here a case in which extreme excitement exhausted the irritability of the spinal cord? Loss of motion resulting and continuing until the functions of the nervous centre had been restored by adequate repose. The causes of paraplegia may be various and combined, of which the following case is an example. A young primiparous lady, of extremely lymphatic tempera- ment and affected with general oedema, had a tedious labor requiring the use of the forceps. Extensive laceration of the perineum occurred, and profuse hemor- rhage attended the delivery of the placenta. The lying-in was also complicated by a double phlegmasia alba dolens, pleuritic effusion, and ascites. I attended this patient with my friend Dr. Siredey, now hospital physician, and we assured our- selves at various times that the urine contained no albumen. When convalescence was established, it was found on getting the patient up that she had paraplegia. For several months she was unable to stand, but the power of motion gradually returned until at length walking was possible with the assistance of a cane. Whilst this improvement was in progress the paraplegia suddenly became complete, the aggravation being afterward found to have coincided with the time of her becoming again pregnant; and throughout the gestation no improvement took place. During labor the limbs were thrown wildly about in a way which the patient would have been incapable of doing by any exertion of her will. After delivery the power of motion was again wanting. The paraplegia continued for several months with- out much amelioration, but finally disappeared under the use of strychnine and electricity, the recovery having been now for a long time perfect. In this case, thus briefly related, it would be reasonable to refer the beginning of the paralysis either to pressure by the head of the child during the first labor, or to the hemor- rhage attending the delivery of the placenta ; but how shall we explain the recur- rence of the affection during the next pregnancy? In my opinion, the cause of the new phase of the disease must be regarded as an instance of reflex action.] § 5. Intellectual Disorders. Insanity. Those physicians who may be willing to admit the truth of the analogy which we have endeavored to establish between the sympathetic disorders of pregnancy, and those observed in young girls suffering from difficult or irregular menstruation (p. 462), will readily understand the functional aber- rntions of the intellectual and sensorial faculties so often observed in preg- nant women. The pre-existing alterations of certain organs of the senses are sometimes very happily modified by the occurrence of pregnancy. A young woman, whose imperfect vision bad obliged her to use specta< les from childhood, found her sight so much improved immediately after the beginning of preg- DISEASES OF PREGNANCY. 511 nancy as no longer to have need of glasses. (Obs. de Salmat, Cent. III. Obs. 27.) At other times there is greater or less disturbance of the affective and intellectual faculties. I knew a young lady pregnant for the first time, whose former love for her husband was replaced by an antipathy which she was barely able to overcome. Another young woman, when five months gone, was suddenly seized with such an aversion for her apartment, that after many fruitless efforts, and notwithstanding all the force of her reason, she had to be left in the country for the remainder of her pregnancy. Some exhibit a peculiar tendency to sadness, which is mentioned bv Burns, and of which I have observed two cases. Certain individuals, who are usually of a gay disposition, suddenly become sad and morose; refuse all the enjoyments tendered to them, and entertain the belief that they will not survive their labor, with a tenacity that nothing can overcome. A young American lady, recommended to my care by M. Rayer, exhibited a profound melancholy for the last six weeks of her pregnancy. Although surrounded by her family, she declined all the pleasures of the capital. She wept unceasingly over her inevitable end, which was so near at hand, and was constantly expressing her distress at being obliged to leave all whom she loved. She had a happy labor, and from the next day her usual gayety was resumed. [Disorders of intelligence may proceed even to insanity; although this form is more common with newly-delivered females than with pregnant women. Marce's excellent book, which shall be our guide in the preparation of this article, gives as the result of several collections of statistics, that of 310 cases of puerperal insanity 27 came on during pregnancy, 180 after delivery, and 103 during lactation. Puerperal insanity may date from the time of conception, or may appear during the course of gestation. In 19 of Marce's cases it commenced with conception eight times, and in the remaining eleven during pregnancy. It began three times in the third month, once in the fourth month, three times in the sixth month, twice in the seventh month, and twice at times which could not be clearly ascertained. Melancholy seems to be the most common form of this insanity. Analysis of the above-mentioned 19 cases shows that the duration of the disease is very variable. Seven times the recovery dated from delivery ; twice only did it occur during the course of gestation ; nine times the disease continued, or else did not subside until long after delivery ; finally, in one ca>e, the delirium was exasperated by deliverv. and death occurred shortly after. The physician ought, therefore, to be very guarded in his statements when questioned in regard to the probable result. It is well also to know that when a woman becomes insane during gestation, there is reason to fear a recurrence, should she again become pregnant. Montgomery mentions the case of a woman who became insane at the com- mencement of three successive pregnancies. In another case, the derangement recurred in eight pregnancies, and ceased only after delivery. By a curious anomaly, however, it happens that some women suffer from this affection in one of their pregnancies only. Hitherto we have studied the influence of pregnancy as productive of mental alienation; but there remains another question, the discussion of which will not be devoid of interest, to wit: What are the effects of pregnancy occurring in a woman who is already insane? In regard to this, Esquirol says, "Pregnancy, labor, and lactation are sometimes used by nature as a means of curing insanity, though, in my opinion, this result is rare." Almost always, indeed, pregnancy 512 PATHOLOGY OF PREGNANCY. gives to mental alienation a character of extreme gravity, either as regards its form or its duration. It is evident, therefore, that the practice of some physicians who recommend pregnancy for insane women cannot be too strongly censured. Labor itself, in its last stages, ''specially when the pains are extremely severe, may occasion disorder of the intellectual faculties. All accoucheurs, indeed, have described the excitement of mind which occurs under these circumstances, arid which in some rare cases assumes the form of maniacal delirium. To the examples already noted on page 300, we add the following. A woman in the hospital of the Clinique was suddenly, when near the termination of her labor, afflicted with a complete hallucination ; she saw a spectre at the foot of her bed, endeavoring to injure her, and which she made strong efforts to drive away. The illusion lasted hardly two minutes before her mind became perfectly sane. The transitory in sanity occurring thus during labor is doubtless caused by the excessive pain. Notwithstanding its apparent gravity, it is rarely followed by serious consequences if care be taken, by sufficient watchfulness, to prevent the lamentable acts to which the patients might be impelled. It subsides spontaneously, and very rarely passes into long-continued mania. The part of the physician, in these cases, is easily pointed out. Generally every- thing will be left to nature ; but should the labor last too long, delivery should be effected by the forceps. Blood-letting at a later period, should it be indicated by the signs of plethora, antispasmodics and judicious expectant conduct, will suffice for the successful management of an occurrence which in itself presents but little gravity. There remain a few observations to be made upon the subject of the insanity of lying-in women and nurses, known as puerperal insanity. As predisposing causes of this affection may be mentioned inheritance, numerous pregnancies, advanced age of the subjects, previous attacks of insanity, eclampsia, and the return of menstrua- tion. Sometimes the disease commences suddenly, but is often preceded by an accelerated pulse, heat of skin, dryness of tongue, thirst, and the entire assemblage of pyretic symptoms. The various forms of mental alienation are far from occurring with equal fre- quency under these circumstances, but may be represented in the following order: first, mania; secondly, melancholia and partial insanity. The mania of lying-in women ends in recovery, incurability, and, in some rare instances, death. Of these, recovery is by far the most frequent termination, and may be said to include about two-thirds of the entire number of cases. Cases are mentioned in which the affection subsided in less than three days, though it more commonly terminates within the first month following the commencement of the attack. Again, recovery may be postponed as late as the sixth month, or not take place until after one, two, or more years. The prognosis is most favorable in mel- ancholia and monomania. A great variety of remedies have been recommended in the treatment of puerperal mania. Warm baths, purgatives, and narcotics are the most available at the out- set. It is of the greatest importance to watch the patients, and not lose sight of them for a moment. The children should be taken away (Marc6) ] ARTICLE VI. diseases of the skin. § 1. Itciiin<;. The skin, during pregnancy, is sometimes affected with extreme itching without any appreciable lesion. M. Maslieurat-Lagemart has published a remarkable case of a lady who, in eight successive pregnancies, was afflicted DISEASES OF PREGNANCY. 513 ■with itchings so violent as to produce premature labors. On four occasions, they began in the sixth month, twice at eight months and a half, and twice in the seventh month. They appeared almost instantly over the entire cutaueous surface ; the legs, thighs, genital parts, the whole trunk, the neck, face, scalp, were all affected; nothing escaped but the palms of the hands, and even they were invaded at a later period. So severe were tliey , that the violent rubbings of the poor sufferer excoriated the skin. Hardly was she delivered when they vanished entirely. The skin retained its natural transparency, color, and brightness throughout. Simple and alkaline baths, ammoniacal and camphorated frictions to the spine, preparations of opium, bismuth, valerian, hyoscyamus, belladonna, and bleeding, were all employed without advantage. Three cases of general itching which I have had occasion to treat, yielded quite promptly to alkaline baths. (Five ounces of carbonate of potash to an entire bath. ) Lotions of carbolic acid, glycerine, and water seldom fail to relieve this condition. \l 2. Pigmentary Spots. Pityriasis. The skin during pregnancy often becomes affected -with yellowish spots known as ephelidae, chloasma, and pityriasis versicolor. When they appear on the forehead, cheeks, and chin, they receive the common name of mask. These spots affect by preference the face, especially the forehead ; they vary in size, are almost symmet- rical in form, and never extend to the roots of the hair, from which they always are separated by a border of healthy skin. It would seem that the action of light is one of the principal conditions of their formation, and that the shadow of the hair is sufficient to arrest their progress. M. Hardy, physician of the Hospital St. Louis, classifies them as ephelides and pityriasis. The ephelides make no projection from the surface, and are attended by neither itching nor desquamation ; their examination would almost lead one to say that the pigmentary matter had left the healthy parts and collected in the spots, on account of the apparent bleaching of the skin around them. They are the result, simply, of an accumulation of pigment within a circumscribed space. Ephelides often ap- pear in women at the menstrual period, and more especially during pregnancy : they usually vanish after delivery, though, much to the chagrin of those affected, this does not always happen. When they continue, a special treatment, having for its object the production of a superficial inflammation of the skin, will often prove successful. To effect this, M. Hardy recommends frictions to be made twice a day with the following lotion: R.— AVater, . . . f^iv. Corros. Sublim., .... gr. v. Sulph. Zinc, ..... 3 SS - Acetate of Lead, .... 3ss. Alcohol, . . . . . q. s. to dissolve the corrosive sublimate. Slioald the lotion fail, sulphurous douches, especially with the mineral waters of Luchon and Bar6ges, applied to the affected parts, may be used with advantage. Pityriasis versicolor, also termed hepatic spots and chloasma of pregnant women, appear in the form of spots bearing strong resemblance to the ephelides. In pity- riasis, however, the spots project slightly from the surface of the skin, and the epi- dermis becomes detached in the form of little scales, either spontaneously or by scratching. They are always accompanied by itching, which is generally slight. The characters just mentioned will suffice to distinguish pityriasis versicolor from 33 514 PATHOLOGY OF PREGNANCY. cpnelides, in which there are neither elevation, desquamation, nor itching. Pityri- asis versicolor is a parasitic disease, so that the microscope affords another means of diagnosis by exhibiting the spores and numerous ramifications amidst the epithe- lial Bcales. The pityriasis of pregnancy usually declines after delivery, though in some ca*cs it remains and offers great resistance to the treatment employed. The therapeutic measures are very simple. Sulphurous waters, by lotion or douche, and ointments containing sulphur, are often effectual. The above lotion (see formula) and nitric acid ointment produce similar results.] ARTICLE VII. lesions of the pelvic articulations. § 1. Relaxation of the Pelvic Articulations. The question has long been agitated whether the ligaments which unite the bones of tbe pelvis are ever softened, and whether the articulations are movable. Ambrose Pare himself, that great surgical luminary, did not adopt the opinion of Hippocrates until alter Severin Pineau made a dissec- tion, in 1569, of a woman recently delivered, in his presence. But, at the present day, this question is determined by a very great number of cases, and it is now generally admitted that a ramollissement of the symphyses actually occurs in most females during gestation. This softening may be and generally is slight; though it may be carried to so great an extent as to admit of considerable separation between the articular surfaces, constituting then a true pathological alteration. Hunter, Morgagni, and some others, cite instances wdiere the relaxation was such that t he pubes could be drawn more than an inch apart. With our present knowledge on the subject, it is impossible to explain the cause of this softening; for, when trifling, it generally escapes the notice both of the woman and her physician; but if well marked, a separation of the bones takes place as just stated. Authors do not agree as to the manner in which the separation is pro- duced; since, according to some, the cartilages are softened and thickened by the liquids that penetrate them, acting like a piece of prepared sponge placed between two bones to absorb the effused fluids; whilst others imagine them to resemble the roots of the ivy, which insinuate themselves into the little crevices between the stones of a wall, and finally overturn it. Louis thinks they act more like dry and porous wooden wedges placed in the fissures of a rock, which, by imbibing moisture, swell up and ultimately split the rock, — or like polypi in the nasal fossae and frontal or maxillary sinuses. M. Lenoir supposes that a slight degree of this relaxation is due simply to infiltration of the pelvic ligaments resulting from the pregnant con- dition ; the articular surfaces are, therefore, not separated, though separation is possible under the influence of actions tending to produce it. In the more advanced stages, he adds to this softening a hypersecretion of synovia, which distends the articular cavities, and separates the bones that constitute them. Mobility in these cases is great, and if the joints be opened in the dead body, a viscid fluid is discharged abundantly, as was once observed by JNIorgagni. DISEASES OF PREGNANCY. 515 This relaxation may, according to Baudelocque, oppose the spontaneous termination of the labor, by destroying the point d'appui which the abdo- minal muscles derive from the bones of the pelvis; and perhaps, also, the distress produced by the engagement of the head, forces the woman tc re- strain the pains as much as possible; though, on the other hand, from the observations of Desormeaux, Smellie, &c, we learn that this circumstance, so far from being a cause of dystocia, has actually permitted a spontaneous de- livery in some cases where the disproportion between the size of the head and the dimensions of the pelvis would have otherwise rendered it impossible. [The attention of physicians has, of late years, been again called to the study sf the relaxation of the pelvic symphyses by a work of M. Ferdinand" Martin, which was soon followed by M. Danyau's report. A special article was devoted to the subject in the previous editions of this work, so that M. Trousseau was wrong in supposing that it had been omitted. (Legons Cliniques sur le Relachement des Symphyses du Bassin, May, 1865.) Nevertheless, as the affection is still badly understood, frequent errors in diagnosis are the consequence. The pains in the back which many pregnant women suffer, are due simply to relaxation of the symphyses. To be convinced of the fact it will be sufficient to examine the lumbar region by pressure over the sacro-iliac articulations when, if they be diseased, decided pain will follow. The same remark applies to the sym- physis pubis, which is often the seat of the vague pains complained of in the lower part of the abdomen. In all these cases it is the more easy to be deceived, as the patients, on being questioned, are rarely able to define clearly the seat of their suffering, and the real affection is overlooked if care be not taken to make a direct examination. How often is the uterus regarded as the source of the pain, when the lesion is precisely located in the pelvic articulations! The spontaneous pains produced by relaxation of the pelvic symphyses are more particularly awakened by motion of the lower extremities, as in walking and stand- ing, and usually subside upon lying down. In slight cases walking is difficult, the patients are soon fatigued, drag their limbs, and are unable to stand upon one foot. In a more advanced stage, walking becomes increasingly difficult, painful, and finally, impossible. When the patient would stand, the sensation is as though the sacrum descended between the iliac bones, or as though the body would drop be- tween the thighs. It is then quite possible by moving the lower extremities to perceive the motion of the ilia, and sometimes even a very sensible crackling or clicking can be detected. In one of M. Trousseau's patients the end of the fore- finger could be readily inserted between the two pubic bones and a softened con- dition of the interarticular cartilage perfectly detected. Relaxation of the pelvic symphyses is often greater after delivery than during gestation, and though more evident during the lying-in, is still often overlooked, and the pains which it occasions attributed to metritis or uterine displacement. In all these cases, however, the symptoms are the same and require similar treatment. ^ The prognosis is variable ; in slight cases no treatment is required and the affec- tion disappears after delivery. In a more advanced stage, rest in bed is insuffi- cient, and an appropriate treatment becomes necessary. Sometimes three, six, or eight months, or several years, are required for the consolidation to take place. In one of M. Martin's patients the cure was postponed until after another labor. There are facts, indeed, which go to prove that relaxation of the symphyses may continue through life in spite of the best treatment. Finally, in the following article we shall speak of Inflammation and suppuration of the symphyses, which may also occur and lend fresh gravity to the affection. 516 PATHOLOGY OF PREGNANCY. As soon as the relaxation is discovered, the patient should le put to bed aid kepi strictly at rest, with the pelvis held motionless by means of a compressory bandage. For this purpose a towel passed around the pelvis and drawn very tight, may answer in the simplest eases. The procedure is at once a rational treatment and a means of diagnosis, inasmuch as relief is generally immediate, and if successful, leaves no doubt as to the nature of the disease. Bandages of linen or ticking are, however, liable to stretch and loosen in a very short time, in which case a good substitute is found, according to Boycr, in a leather belt quilted internally and caused to surround the pelvis between the great trochanter and crest of the ilium and buckled in front. The best apparatus, however, is the one recommended and used by M. Martin. It is composed of a strong circular piece of metal two inches wide, open in front, and large enough to embrace the entire circumference of the pelvis. It is padded and quilted like the spring of a truss and provided at one end with a strung strap and with a buckle at the other, whereby the ends are brought together and held firmly. This apparatus has the advantage of being applicable during pregnancy without interfering with the development of the abdomen, and is even more useful after delivery. Although its weight is consider- able, the patients soon become accustomed to its use. It secures immobility of the bones so fully that absolute quietness is no longer necessary, and the patients may walk every day without the recovery being interfered with. "We owe," says M. Danyau, "the acknowledgment to M. Martin, that his belt fulfils all the indications, and that none other does so more effectually. Not only is it, like layer's, narrow enough to clasp the pelvis where the pressure can produce neither interference nor injury and be at the same time really effective, that is to say, between the crests of the ilia and the great trochanters, but what is not less important, it is so strong and stiff that when once applied and the bones brought in contact by it, separation afterward becomes impossible."] When to relaxation of the pelvic articulations, inflammatory symptoms are added, they should be met by the appropriate means; in their absence, we may apply gentle pressure around the pelvis, and make use of some topical applications, general and local tonics., and astringent and resolvent lotions. After the total disappearance of the lochia, Desormeaux highly extols the employment of douches, sea-bathing, a good diet of nutritive articles, the Spa and Seltzer waters, wearing flannel next to the skin, and dry frictions. We cannot recommend too highly the use, in these cases, of the steel girdle of M. Martin, which, when tightly drawn around the pelvis, immediately restores a portion of its normal solidity, and facilitates the cure wonderfully. These measures should be continued for a long time, and even when con- valescence is fully established, the greatest possible care must be exercised in rising, walking, &c. § 2. Inflammation of the Pelvic Articulations. Inflammation of the pelvic articulations, which is sometimes observed after labor, may also occur, though more rarely, during pregnancy. Drs. Hiller, Monod, Danyau, and Professor Hayn, of Konigsberg, have men- tioned instances of it. The disease generally begins without appreciable cause with sudden, acute, sometimes lancinating, though usually heavy pain, in one or several of the pelvic articulations. The pain is increased by pressure, standing, and i specially by attempts at walking, which i-s sometimes altogether impossible. DISEASES OF PREGNANCY. 517 These pains often extend into the lower extremities, and especially into the thighs. Swelling can sometimes be detected over the inflamed articula- tions These articular pains are sometimes attended by a febrile movement, which is o. casionally severe, though generally quite moderate. In some cases, indeed, there is almost no general reaction. The inflammation, when moderate, usually yields promptly to proper treatment ; the cure is almost perfect after twelve or fifteen days, and the delivery and lying-in seem to experience no unfavorable effect from it. In some cases, however, whether in consequence of the intensity of the inflam- mation, or because the proper means were not employed with sufficient- energy, the disease ended in suppuration, and in two instances proved fatal. In these cases, the articular surfaces were found denuded of cartilage. MM. Hiller and Monod mention two cases which proved fatal in this manner. If the pains are very acute, and the general reaction decided, general and local bleeding may be employed at the outset. But when there is no fever, and the local symptoms are moderate, we may be content, with resol- vent applications, restricted diet, and absolute repose in the horizontal pos- ture. Narcotics may be added to the resolvent applications, if the pains are too severe. ARTICLE VIII. DISEASES OF THE VULVA AND VAGINA. [Various lesions of the vulva and vagina impede delivery, and are therefore dis- cussed in the article on Dystocia. At present we shall describe only pruritus of the vulva, leucorrhcea, and vegetations, as they occur in pregnant women. \ 1. Pruritus op the Vulva. Pruritus of the vulva, though not peculiar to, often occurs during pregnancy. It is characterized by intense itching of the external genital parts, the labia majora and minora, and often extends even into the vagina. The itching is irresistible, obliging the patients to scratch themselves, and thus, in consequence of tne relief afforded, leads to a sort of masturbation. Examination of the affected parts discovers no appreciable alteration : sometimes there is redness, at others some exudation of serum with superficial liberations reminding one of eczema. (Hardy.)] The itching was so insupportable in a young married lady under Aiy care, that she could not refrain from continual scratching, and the gen^ai irrita- tion resulting therefrom almost threw her into convulsions. In another instance, a young girl, who wished to conceal her preguancy, was so tormented by this disease, that it was absolutely impossible to hide her distress from the observation of her family; and when I examined her, I found the internal face of the labia externa, and the nymphse, both swollen and inflamed from the constant scratching; the nympha on the right side had been so long, and so strongly dragged upon, that it had acquired twice the usual length at least. Generally speaking, the frequent use of bathing, and of the vegeto-mineral lotions applied live or six times a day, will calm the itching; and as it is often greatly aggravated by walking, perfecl rest is 518 PATHOLOGY OF PREGNANCY. of course indicated. Some advantage is often to be derived from a fine compress dipped in oil of sweet almonds, and then placed in the vulvar fissure; or still better, if the compress be soaked in lead-water. Dewecs states that he examined a young lady who complained of this excessive itching in the genital parts, and he found the internal face of the vulva, as also the inferior part of the vagina, covered by numerous aphthae; and that the application of a strong solution of borax, four or five times a dav, caused them all to disappear in the course of twenty-four hours. Dr. Meigs has always found the following preparation useful: — R— Borax 3'j- Sulph. of morphia, ....... gr. ivss. Dist. rose water, fo y iii. Apply three times a day to the affected parts, by means of a sponge or piece of linen, taking care to wash the parts beforehand with soap and water, and to dry them well afterwards. The following solution of bichloride of mercury may also be used with advantage : Add a drachm and a half of corrosive sublimate to four ounces of distilled water, and of this solution let the patient add a dessert-spoonful to a pint of very warm water, and use for injections and lotions. Hot water alone will answer in many cases. (Trous- seau and Pidoux.) [Pruritus of the vulva is often very obstinate. In the rebellious cases mentioned, M. Dubois adviscs'that the entire mucous surface of the vulva be cauterized with the solid nitrate of silver. A great objection to it however is, that it is extremely painful anil almost always produces but temporary alleviation. We have generally succeeded with a solution of corrosive sublimate, as follows: R. — Bichloride of mercury, gr. xxxi. Alcohol, f3iij- Rose water, f^iss. Distilled water, f5 xv > This is used as a wash, undiluted, morning and even'ng, as follows: After using warm water for the purpose of removing mucous secretions from the vulva, and (Irving the parta well with a piece of fine linen, a small sponge saturated with tho Uuid is passml rapidly over the entire itching surface, so as to moisten it thoroughly. A smart burning sensation is the first effect of the application, which is alleviated by a few minutes washing with cold water. Subsequent applications are less and less painful, and the cure is generally rapid. AVe prefer this treatment to all others J § 2. Leucorrhcea. "We shall limit ourselves to a short notice of the profuse leucorrhoea with which women are very often affected during pregnancy. This discharge, which is sometimes white and sometimes of a yellowish-green color, usually makes its appearance during the second half of gestation, though I have Been some persons affected with it from the early months. It is generally coincident with the development of numerous granulations, which, as we have already said, sometimes cover the vaginal mucous membrane, and constitute what has been described of late as granular vaginitis. When it is very profuse, an examination by the speculum frequently discovers numerous ulcerations of the ueck of the uterus. We shall have occasion DISEASES OF PREGNANCY. 51^ to speak of these ulcerations hereafter. I am convinced that the vaginal granulations and ulcerations of the cervix are very rarely as serious during gestation as they appear to be under some other circumstances since they generally disappear with the pregnancy, during which they are developed. Sometimes the discharge is so abundant as to react upon the functions of the stomach, and I have seen several patients with symptoms of gastralgia, evidently connected with the leucorrhcea, inasmuch as they increased or diminished according as the latter was more or less profuse. _ This affection often produces, in addition, great irritation, a burning heat, and sometimes an almost insupportable itching of the lower part of tha vagina and external genitals. A profusion of small vesicles appear upon the internal surface of the greater and lesser labia, which, by constantly rubbing against each other, finally give rise to excoriation, and render walking very painful. Frequent baths, lotions, and injections of cold water, to each quart of which a dessertspoonful of subacetate of lead has been added, repeated several times daily, according to the degree of pain, are the best remedies. It will also be found advantageous to separate the parts, by introducing a piece of fine linen between the labia, so as to prevent friction whilst walking. It is unnecessary to say that the introduction of the speculum during preg- nancy requires that especial care be taken not to press it too far. Though the patient's sufferings may easily be alleviated in this manner, it is more than probable that the granulations will continue, and that the discharge will not cease entirely ; in spite of all that can be done, it gener- ally lasts until the end of pregnancy, and in the great majority of cases only terminates after delivery. Would any disadvantage attend the insertion in the vagina of tampons formed of carded cotton and alum? Would they be likely to occasion abortion or pre- mature delivery ? During my present temporary service at the Lourcme hospital, I have found quite a number of pregnant women affected with vaginitis and profuse ieucorrhoea, and in all such cases it is the practice there to use the above-named tampons, notwithstanding the fact of pregnancy. I continue them as they have been used heretofore, though not without apprehension; still no accident hat occurred as yet. I should desire, however, a longer experience, before I could feel willing to advise them. . „ . Vaginal injections, especially if used indiscreetly, may excite contraction of the uterus and abortion, if the fluid be thrown upon the os tincaa. \ 3. Vegetations. The external parts of generation, particularly in women affected with blennorrhea, vaginitis, or uterine catarrh, often become covered with vegetations, which were long supposed to be of a syphilitic character. They seem always to be connected with the presence of a discharge in non-pregnant females; that their production may also be favored by pregnancy, is a fact established, as I think, by the treatise of M. Thibierge. . , . . . „ The vegetations may appear in pregnant women at any period of gestation. They consist of tufts of a rosy hue, attached by a pedicle, and spreading out like a cauliflower. In respect to number and size they vary greatly. They may he either scattered or so grouped as to form large masses. A patient in the Hosnital of the Clinic had them in the form of a tumor as large us the list- 520 PATHOLOGY OF PREGNANCY. Thev affect more especially the mucous membrane of the vulva, though they also form on the external surface of the labia major a, in the furrow between the but- tocks, about the region of the anus and the genito-crural folds: sometimes, even, they sprout from the walls of the vagina or the os tincae, though in these situations they are generally small. They are attended with itching, considerable pain, and a discharge. They also exhale a very unpleasant odor, but are really devoid of danger, and occasion no obstruction to delivery, even when of large size. In the majority of cases the} disappear spontaneously after delivery; the pedicle dries up, and they fall like a ripe fruit. This favorable termination is not, however, universal. One of their peculiarities is that of continuing to sprout during gestation in spite of all kinds of treatment. Still. M. Thibierge thinks that the use of local appli- cations during pregnancy may dissipate them when small and few in number. Under other circumstances they are almost certain to return. In regard to treatment during pregnancy, an attempt may, in the first place, be made to destroy them by local applications, as of alum, nitric acid, or the acid nitrate of mercury applied drop by drop. Excision, and even crushing, are liable to occasion obstinate hemorrhage, so that radical operations ought not to be per- formed. After delivery, should the trouble persist, any of the methods of treat- ment used in such cases become applicable.] ARTICLE IX. ABDOMINAL AND UTERINE PAINS. Beside the numerous functional disorders just studied, some pregnant women suffer, in various parts of the body, pains whose intimate cause is imperfectly understood, and to which they sometimes call the attention of the physician. Some of these pains appear to be seated in the abdominal parietes, the lumbar region, the groins, and the internal part of the thighs ; others, again, appear to affect more especially the walls of the uterus, or the annexes of that organ. § 1. Abdominal, lumbar, and Inguinal Pains. T hcse pains, which are sometimes confined to a quite limited space of the abdominal parietes, do not often appear before the latter months of gesta- tion. They are frequently felt at the lower part of the breast, near the upper insertions of the abdominal muscles, or, less often, in the inguinal folds near their inferior attachments. The pains are much increased by motion, the least pressure, and sometimes, also, by the movements of the child, if violent. As already stated, they are generally limited in extent, sometimes not affecting a space larger than a silver dollar, the parts sur- rounding being entirely free from pain. Since lumbar and inguinal pains, occurring in the first half of gestation, may be the preludes of an abortion near at hand, they claim special atten- tion. At this early period they are almost uniformly the sympathetic ex- pression of uterine disorder, itself due to a local congestion, though perhaps .-till oftener to a special irritability of the womb. They then resemble pre- cisely the lumbar and inguinal pains which are so often experienced by young girls affected with dysmenorrhea or amenorrhoea, and are effectually overcome by opiates, small revulsive bleedings, and sometimes, also, in very DISEASES OF PREGNANCY. 521 nervous women, by warm bathing. If, as is often the case, the pains seem to be increased by sexual intercourse, too long a walk, or riding in a carriage, it were useless to say that abstinence from all these causes, and repose in the horizontal posture, are the first indications to be fulfilled. These pains most commonly appear toward the end of pregnancy, but their cause, that especially of the lumbar pains, is very obscure. Some- times, however, it can be ascertained that they are seated in the pelvic articulations (see page 515). Dragging upon the broad ligaments, com- pression of the lumbar nerves, extreme distention of the uterus, and engorgement of the pelvic and uterine vessels, have been successively ad- duced in explanation ; but though the relief obtained from bleeding, in some cases, would seem to show that they might sometimes be caused by local plethora, there is no evidence of any such influence as is attributed to the other causes mentioned. The inguinal pains have generally been referred to traction upon the round ligaments. I do not say that this traction may not produce them, but I am convinced that toward the end of pregnancy they are oftener due to the pressure of the uterus upon that region, in the vertical as well as in the sitting posture. They generally disappear, indeed, in the hori- zontal position, and the best means of relieving the patients is to support the abdomen, and at the same time raise it a little by means of a well-made corset, or of a large abdominal belt, the central portion of which embraces the sub-umbilical region, and whose two ends are attached to the back part, of the corset. [Having for some time made a special study of these abdominal, inguinal, and lumbar pains, we are convinced that very often they are due to neuralgia of the cutaneous nerves from the collateral branches of the lumbar plexus. To be assured that such is the case, it is only necessary to test carefully the sensibility of the skin in these regions, either by rubbing it rudely with the end of a pencil, or by raising it in the form of a fold which is to be gradually pinched between the fingers. Pressure ought also to be made all along the crest of the ilium in the direction of the genito-crural nerve. Should we be satisfied with merely question- ing the patients, or depressing the walls of the abdomen by the hand, we would incur the risk of obtaining very little information, or of suspecting the existence of a deep-seated visceral pain when the skin only is affected. This mistake, which we see committed every day, would be avoided by taking the trouble to make the above-mentioned examination, and we cannot recommend it too highly. The principal parts affected by this neuralgia are the lumbar, iliac, hypogastric, and inguinal points, though the pain may appear in some other portion of greater or less extent of the skin of the abdomen. Sometimes confined to a circumscribed point, it occasionally invades an entire half of the abdominal walls. It very rarely affects both sides at the same time with equal intensity. The local application of narcotics constitutes the treatment par excellence, of these neuralgic pains. We have almost always succeeded with very small blisters sprinkled with one of the salts of morphia. Subcutaneous injections are also clearly indicated, and none of these methods are liable to effect unfavorably the couise of the pregnancy. What we have just written applies especially to the abdominal neuralgia of pregnanl women; but before leaving the subject, we desire to say thai the same affection is also extremely common after delivery. In t J i * - latter case, however, 522 PATHOLOGY OF PREGNANCY. instead of being ihe chief pathological element, it is almost always symptomatic of a lesion of some one of the pelvic organs. Its investigation is not, on this account, less important, because, generally, the intensity of an inflammation is estimated by the acuteness of the pain which it produces. Under these circum stances, if the skin be raised carefully between two fingers, and the fold thus formed be pinched, it is often found that the pain is seated partly in the skin and not in the uterus or its appendages. The physician is thus better informed, since a slight metro-ovaritis may be attended by a violent cutaneous neu llgia more alarming by far than dangerous. The lumbo-abdominal neuralgia which is symptomatic of a metro-ovaritis or of a metro-peritonitis, also enables us to understand certain facts which would be inexplicable without it. Suppose a newly delivered female to be attacked by metritis; the uterus is examined by depressing the walls of the abdomen by the hand, and several examinations carefully conducted assure us that pain is produced about the fundus of the organ. The usual treatment in such a case consists in the application of leeches directly over the seat of pain, and, we must say, almost alwavs affords relief. Is it not surprising that such a result should be produced? How could we suppose that an abstraction of blood from the skin of the abdomen near the umbilicus would act directly upon the fundus of the uterus when all vascular communication between the two parts is prevented by the interposition of the peritoneum ? We bow before the facts, yet believe that the bites of the leeches, when they afford relief, do so by acting directly upon the cutaneous neuralgia which is symptomatic of the metritis, and have no effect upon the vascular engorgement of the uterus. The same result would follow the applica tion of a blister dressed with a salt of morphia. As soon as time shall permit, we intend publishing several cases which go to prove what we have just said respecting the part played by lumbo-abdominal neuralgia during pregnancy and in the diseases of lying-in women.] The pains in the internal parts of the thighs, the numbness and cramps of both legs, though more commonly of one only, are usually attributed to pressure of the head on the lumbar and sacral nerves. But, as Tyler Smith remarks, since they mostly occur at night, when the women are in the hori- zontal posture, or whilst they are sitting, in both which positions the pressure should be much less than whilst standing, it seems very probable that com- pression of the nerves is not the cause. Perhaps we may accept the idea of the English accoucheur, that, like the corresponding affections in cholera, they are connected with some irritation or difficulty of the large intestine, or with a morbid condition of the uterus. It would not be the only instance of visceral irritation producing spasmodic contraction of the muscles of animal life by reflex action. According to this hypothesis, the best means of preventing the recurrence of the cramp is to keep the bowels free, and allay the irritability of the womb a3 much as possible by baths, opiates, &c. The surest means of cc interact- ing it is to contract voluntarily, the very moment it appears, the antagonistic muscle of the affected one ; thus the thigh should be strongly extended when the flexor muscles are contracted, and the foot should be flexed on the leg when the cramp affects the muscles of the calf. § 2. Uterine Pains. 1. Beside the uterine pains which sometimes accompany the outset of a disordered pregnancy, also beside those which seem to herald the approach DISEASES OF PREGNANCY. 523 of labor in the latter weeks of gestation, females experience, at variable periods and intervals, pains which are sometimes very acute, anl evidently seated in the walls of the uterus itself. It is impossible to determine the cause and nature of these pains ; for though they may be attributed, in some rare instances, to partial spasm of the muscles of the uterus, or to a more or less extensive inflammation, most frequently nothing of the kind is to be discovered. Sometimes they are limited to a single circumscribed point, whilst at others they affect the entire womb. In the first case they are con- tinuous ; in the second, they are irregularly intermittent, and their recur- rence, or rather their paroxysm, appears to coincide with a motion of the female, pressure upon the abdomen, an attack of coughing, or sudden move- ments of the child. At the same time the uterine tumor may almost always be felt to become denser and harder: in short, a true contraction takes place, which continues as long as the paroxysm lasts. If, struck with this condition of the body of the womb, an examination be made pervaginam, the cervix will be found unchanged, having undergone no alteration which could excite solicitude on account of the long-continued previous contrac- tions. Usually, there is very slight general reaction, and little or no fever. When the pain is both circumscribed and moderate, emollient and nar- cotic applications may be found sufficient ; but when more severe, it will be necessary to prescribe the most absolute repose, injections with camphor and laudanum, baths, maniluvia, and even bleeding from the arm. It generally yields to these measures when properly employed, though, unfortunately, it returns with some individuals very frequently. I have, at this moment, a young lady under care, who is at the eighth month of her pregnancy, and who has had five attacks within three months, two of them lasting for twenty-four hours. The first time she was bled ; but as her general condi- tion seemed to contraindicate a repetition of this measure, and she was very averse to bathing, I was obliged to content myself with prescribing rest and opiate injections. Now, there is every prospect of her reaching her full term. 2. The sensibility of the uterus is sometimes singularly increased by con- stant and violent motions of the foetus. Some children, indeed, seem en- dowed with such activity that they are hardly ever quiet, and their con- tinual movement becomes a cause of irritation to the womb, which, by re- acting upon the whole economy, may produce insomnia, general excitement, and nervous and sometimes even convulsive movements. I have seen two instances of these disordered motions of the child; especially was it marked in the case of the wife of one of my professional brethren. This poor lady was delivered at term, notwithstanding she had been almost entirely deprived of sleep during the eighth and ninth months. Burns says, that patients under these circumstances are delivered rather before the ninth month. The bleeding and opiates which he recommends may indeed lessen the irritability of the uterus, but evidently can have no power to diminish the activity of the motions of the child, which is the first cause of the uterine pains. 1 » Dr. Tyler Smith endeavors to show, in a very interesting memoir, thai the active motions of the child amount to almost nothing, and that the sensations perceived by 524 PATHOLOGY OF PREGNANCY. 3. Some authors state that metritis, or metro-peritonitis, are possible during pregnancy, but they are so rare that it has never fallen to my lot to see them. Besides, they seem to me to belong to the same category as all the acute affections which may arise during pregnancy ; and though the usual gravity of the prognosis be heightened by the condition of the female, the treatment would be the same as after delivery. § 3. Rheumatism of the Uterus. Rheumatism of the uterus, although studied for a long time in Germany, was scarcely known in France, until M. Dezeimeris published in his journal (J Experience) a series of facts that were previously known to, and put forth by, the German authors. About the same time, M. Stoltz, who was ac- quainted with the works of our neighbors &n the subject, devoted particular attention to this affection at the Clinical Hospital of Strasbourg, and com- municated the result of his observations to his pupils. One of them, Dr. Salathe, has quite recently defended a thesis on this subject ; and from his work, as also from the bibliographical researches of M. Dezeimeris, I extract the following account of this disease, which is unknown to French nosologists. According to Radamel, rheumatism may attack the uterus in the non- gravid state ; but we have only to study it here as occurring in pregnant females, in whom it may appear at all stages of the puerperal condition. Therefore, after some general remarks on the disease itself, it will be neces- sary to point out the influence that it may have over the gestation, the par- turition, and the lying-in. Causes. — Every circumstance calculated to favor the development of the rheumatic affections in general, may likewise prove a source of rheumatism of the uterus: thus, a momentary or a prolonged exposure to cold and moisture, inadequate clothing, or sudden changes from a very high to a very low temperature, and all those other atmospheric constitutions which have been enumerated by medical authors, either as predisposing or as determin- ing causes of rheumatism, may likewise produce that of the womb. But, besides these general causes, there is one peculiar to the disease under con- sideration ; that is, the susceptibility of this organ to the impression of cold under the attenuated integuments of the abdomen during the latter months of gestation ; for the belly is only covered at that particular point by very light clothing, which is far from fitting closely, and the lumbo-sacral region is often but imperfectly protected by the short jackets worn by the patient. Symptoms. — Rheumatism of the uterus very often occurs in persons who are constitutionally predisposed to the rheumatic affections ; and it may co- exist with a general disorder of the same nature, though in the majority of cases the womb, together with its appendages and the adjacent parts, is alone affected. Again, it has oftentimes resulted from a sudden cessation the mother and accoucheur, hitherto attributed to the muscular contractions of the child, result simply from partial contraction of the muscular fibres of the uterus. Not- withstanding the seductive character of the reasons adduced by Dr. Smith, we hold tc the generally received opinions, though entirely disposed to think that the views of the English accoucheur may be applicable to the exceptional cases of which we are speaking. DISEASES OF PREGNANCY. 525 of a rheumatic pain at some other point, which is speedily transferred to the uterus. But, whatever may Have been the mode of* its attack, this disease exhibits some well-marked peculiarities, by which it can easily be recognized. The principal symptom is pain, or a distressing sensation, which involves the whole, or a part of the womb, without any violence having been exerted on the organ ; its intensity varies from a simple feeling of heaviness to the most painful dragging sensation ; and it may occupy either the entire womb, or only one of its parts, such as the body, the fundus, or the inferior segment. When the rheumatism is fixed in the fundus uteri, the pain is particularly apt to be felt in the sub-umbilical region ; it is augmented by pressure, by the contraction of the abdominal muscles, and sometimes even by the simple weight of the bedclothes ; and in many cases the patient is unable to bear auy movement whatever. If seated somewhat lower, she suffers from acute dragging sensations, that run from the loins toward the pelvis, the thighs, the°external genital organs, and the sacral region, along the uterine liga- ments. Finally, when the inferior segment participates in the affection, the seat of it can be detected by the vaginal exploration, which gives rise to the most acute sufferings. But, of all the causes that may exasperate these pains, there are none more distressing than the incessant movements of the child.' Like all rheumatic pains, those of the uterus are metastatic, and they occasionally pass rapidly from one point of the organ to another ; often, indeed, they disappear at once, and pass off to some other organ. This is particularly apt to occur when the pain was originally located at some other point, and measures have been employed to recall the affection to the part primitively attacked. They present frequent and variable exacerbations in their duration and intensity, according to the stage of the disease ; sometimes they are followed by remissions, during which the patient experiences only a vague sensation of weight in the part. The uterine pains are usually accompanied by a recto- vesical tenesmus, which is the more distressing as the former are the more energetic, and are seated near the inferior segment. The patient is then tormented by a continual desire to empty her bladder ; the emission of urine is attended by a smarting sensation, and sometimes by acute sufferings, while at others it is even wholly impossible; and in many cases the attempts to move the bowels prove equally ineffectual. Most of the German authors attribute this double recto-vesical tenesmus to a rheumatic affection that is not always exclusively limited to the womb, but which also invades the neighboring organs. But M. Stoltz appears disposed to believe that it is rather the result of the close sympathy existing between these adjacent parts ; for, if these new pains were occasioned by a rheumatism of the rectum or bladder, those of the uterus ought to disappear altogether, or at least should be diminished. (Salatke's Thesis.) Analogy would lead us to suppose that an unusual heat and tumefaction must exist in the affected parts ; but the difficulties in detecting these char- acters are self-evident, although their existence is quite probable. Such acute pains, seated in so important an organ, would naturally pro- duct' considerable general reaction; and it is found that this disease, like 02G PATHOLOGY OF PREGNANCY. the greater number of the inflammatory affections, most usually commences by a slight chill, which lasts for a quarter of an hour or twenty minutes; the fever that follows it diminishes, and sometimes disappears altogether, during the interval between the paroxysms; but, pending their duration, it is usually quite intense, the pulse is frequent and hard, the face excited and flushed, and the tongue is red and dry ; the patient complains of thirst, the 1 t PATHOLOGY OF PREGNANCY. my hand, says the author, so as to avoid laceration of the membranes. I examined it with the greatest care, and discovered, besides the opening made by the head in the centre of the membranes, a second opening, of cirenlar form, near the edge of the placenta. It was doubtless through the latter that the fluid escaped from time to time. It is proved, by many observations, that amniotic dropsy frequently recu is in the subsequent pregnancies of the same female. A remarkable circumstance, pointed out by MM. Bunsen and Kill, and one instance of which has Come under my own notice, is a dropsical condition of the foetus, it being sometimes affected with hydrocephalus, and at others with ascites. The same authors also mention having observed that in these cases the placenta was often remarkably large. Thus, in a case reported by M. Kill, in which the extreme distention of the uterus produced abortion at the sixth month, the circumference of the placenta was a third larger, and its thick- ness double that of ordinary placentas. It was pale, and its tissue spongy, and, when divided, the vessels traversing its substance were found to have almost the size of the arteries and umbilical vein. The abdomen of the fcetus contained a large amount of fluid. The liver was voluminous, occupying almost the whole abdominal cavity. Its structure was normal, without any indication of swelling, but its vessels were highly developed. This great size of the liver is supposed by the authors quoted to be con- nected with the extreme development of the placenta, whose enlarged vessels would of course supply a great quantity of blood to the umbilical vein. (Churchill, page 50.) When the malady is once established, it is exceeding difficult to find the proper remedies, — I will not say to cure, but even to impede its course; — for instance, diuretics have usually proved of little value. Some authors, indeed, Beein to have observed good effects from dry diet ; and Burns specially recommends cold bathing. But, in spite of all we can do, the affection ordinarily goes on increasing until the commencement of labor; and in the greater number of cases there is nothing to be done except to await this event. However, if the uterine tumor be of excessive size, more especially should the dropsy of the amnion be complicated with ascites and a general infiltration, and the patient's life be endangered by the obstructions to the haematosis, an evacuation of the waters should be determined upon by rupturing the membranes. The puncture is usually effected by the use of a male or female catheter, or a stylet, which is introduced through the neck, and the membranes per- forated with its extremity. When the cervix is sufficiently dilated, the rupture maybe performed with the finger. When not obliged to act quickly, contractions may be previously solicited by introducing and leaving a piece of prepared sponge in the cavity of the cervix, or by practising some douches upon the inferior segment of the uterus. (See Premature Artificial Delivery.) But should the gravity of the symptoms demand immediate intervention, there would, I think, be some advantage in following the advice of M. Guillemot, and to glide the catheter between the ovum and the uterus, so a? DISEASES OF THE OVUM. 545 to pierce the membrane far above the neck ; this process would permit the discharge of the fluid to be controlled, and only the superabundance, so t< speak, to be withdrawn. The pregnancy may afterward be left to itself. In case of complete obliteration or' the neck, paracentesis by the vagina and in the vicinity of the uterine orifice must be performed. Scarpa aaJ Camper recommend puncturing between the umbilicus and pubis. In one of the observations of Evrat, Sen., the operation was practised in the place, so called, of election, for paracentesis. The patient was delivered eight days afterward of two living children, and recovered perfectly. The details given by the author do not inform us whether the case was one of ascites, or really of amniotic dropsy, as he thought. The vaginal puncture seems to me likely to subject both mother and child to the fewest risks, whenever the neck is inaccessible. § 2. Hydrorrhea, (Hydrorrhoea gravidarum:) The Germans have given this name to those discharges of water that occur in the course of the gestation, but which, in general, are neither preceded nor followed by any uterine contractions ; their nature is such as to interfere but slightly with the pregnancy, the latter advancing as usual to term, and at the accouchement the bag of waters is regularly formed. This affection is quite common in the latter months, but very rare at the beginning of gestation. I observed it once between the third and fourth month, and it reappeared but once during the remainder of the pregnancy, which terminated happily. (See Abortion, article Diagnosis.) The frequency of such discharges, and the quantity of water lost each time, are exceedingly variable in different cases. Sometimes the liquid comes away in gushes, at others drop by drop ; but the amount may increase in an incredible manner, and the loss may occur but once, or be renewed frequently. Further, the intervals of its appearance are very irregular, and lasting a long time when it does come on, during which any mental emotions or bodily excitement singularly influence the profuseness of the discharge. On the other hand, it augments in quantity during the most perfect quietude, as, for instance, at night during sleep; its cause can rarely be ascertained. Most generally, the female enjoys her usual health before the discharge comes on, when she unexpectedly finds herself wet, the fluid escaping drop after drop, or else she hears the peculiar sound caused by the sudden irrup- tion of a considerable quantity of the waters. In most cases, she suffers no pain either pending or after this discharge; though it may happen thai a too rapid depletion of the uterus, and the consequent parietal retraction, may bring on some slight uterine contractions; but if the patient then keeps perfectly still, they soon disappear, and everything resumes its natural order. In color, the discharged water is usually a little yellowish, very limpid, and at times tinged with blood, leaving stains upon the linen, and having a well- marked spermatic odor. Should the hydrorrhoea be attended with the uterine pains, it would be an evidence of an approaching abortion ; and some accoucheurs, supposing the membranes had been ruptured, have been known, under such circum- stances, to use every effort to accelerate and to terminate a laboi *hicfo 35 546 PATHOLOGY OF PREGNANCY. really had not commenced, and which, without their interference, would not have occurred before the ordinary period. [We saw a case of hydrorrhea during the sixth month of gestation, in which uterine contractions had come on and almost completely effaced the neck of the womb which was opened to the size of about a franc-piece. Rest in bed and opiate injections quieted the threatening of abortion, and the patient was delivered at term.] This error may be avoided by attending to the fact, that, notwithstanding so considerable a flow of liquid, the size of the uterus, its consistency and elasticity, are such as it generally presents at that period. These remarks will at least be sufficient to excite a doubt as to the true source of the waters; and from the moment that there is a doubt, every effort should be made to prevent and not to hasten abortion. These fluids, although having no relation in their seat to the liquor amnii, have, however, been called the false water?, so as to distinguish them from those which escape after the membranes are ruptured in labor. Various opinions have been advanced as to the nature and seat of these false waters; thus, certain accoucheurs have supposed that they were con- tained between the chorion and the amnion, and that their escape is due to a laceration of the chorion ; others, that they are owing to the rupture of an livdatid, lodged either in the cavity or the neck of the uterus (Koehmer, Roederer). Again, Baudelocque was of the opinion that it resulted from the transudation of the liquor amnii through the membranes. Some others explain it by invoking an ©edematous condition and an infiltration of the uterine cellular tissue. It is an easy matter to refute all these opinions by recalling the fact of the frequency and abundance of the discharges', which often come away in large quantities. Mauriceau, Camper, and Capuron supposed that these waters proceed from the interior of the amnion; for, in certain cases, they say, the membranes may yield at a point quite distant from the neck, and the superabundance of this fluid will then gradually drain away, though still an abortion may not occur. This explanation is not applicable to the greater number of cases of hydrorrhea, for observation does not show that when water came away several times during pregnancy the amount lost during labor was less than usual: beside which, careful examinations of the membranes after delivery have very rarely detected traces of old rupture. Some well observed cases, however, prove that Mauriceau's opinion may be exceptionally true. (See page 543.) It is much more probabk that the fluid which thus escapes in the course of gestation, sometimes a few days only before term, had accumulated be- tween the internal uterine surface and some portion of the membranes (variable in extent) that were detached. This is the view advocated by Na:gele, and it has been lately reproduced by one of his pupils in a thesis sustained at Heidelberg, from which I have derived most of these details. That is to say, the fluid secreted by the internal surface of the organ gradu- ally detaches the membranes, thereby forming a pouch for itself until its constantly-increasing quantity succeeds in separating them as far as the neck, when an irruption of the liquid takes place. DISEASES OF THE OVUM. 517 This theory was confirmed by the autopsy of a pregnant woman affected with hydrorrhcea. Dr. Duclos, of Toulouse, who relates the case, found the membranes partly detached and from that point the fluid escaped. Else- where the membranes were raised by an accumulation of fluid between them and the uterine wall, being thus ready, so to speak, to give rise to a fresh attack of hydrorrhcea whenever the detachment should extend to the cervix. Now, if we admit with Professor Burdach, that an exhalation takes place from the internal surface of the uterus, which, by transuding through the membranes, reaches the amniotic cavity, and thereby contributes to the nutrition of the foetus during the greater part of the intra-uterine life, it would be easy to explain this abnormal accumulation of fluids, either by an excess of secretion or an arrest of transudation. It may also be explained by supposing that the secretion continues beyond the ordinary term, and the liquid is obliged to create a cavity or a kind of reservoir for itself by detaching the membranes to a certain extent. Generally speaking, this is not a serious affection; nevertheless, if fre- quently repeated, it might bring on premature contractions. The treatment is very simple. The patient must maintain the most per- fect rest, avoiding all moral and physical excitement during the flow, and for seven or eight days after it has ceased. Should it be followed by slight contractions, enemata, containing laudanum, would arrest them; and if the discharge is accompanied by any evidences of general or local plethora, these symptoms must be promptly met by the appropriate measures. [I 3. Dropsy of the Villi of the Chorion. Hydatiform Mole. The villi of the chorion sometimes become distended by fluid which collects within them, causing them to swell and assume the form of rounded vesicles, com- parable to gooseberries or grapes, and having, consequently, some resemblance to hydatid vesicles. On account of this analogy, they were, for a long time, supposed to be true hydatids. M. Velpeau was the first to discover that the hydatiform mole has its origin in the chorion, and the microscopic examinations of Prof. Robin ex- hibited still more clearly the true nature of the disease by showing that the en- velope of the hydatiform vesicles have all the anatomical characteristics of the walls of the villi of the chorion. It is now regarded as certain that the disease known as hydatiform mole is nothing but a dropsical condition of the villi of the chorion. Though the affection is a rare one, we have a good account of it in Dr. Cayla's thesis, which we have found very useful in the preparation of this article. If an ovum, presenting the alteration in question, be examined, the villi are seen, as usual, detached from the surface of the chorion. In some cases, the pedicles will have undergone no change in size, whilst at others they will be dhghtly dilated. The dilatations, or vesicles, begin to appear where the ramifica- tion commences, the branches of the villi being found swollen at intervals. The dilatations vary in size from that of a walnut to that of a filbert, and so down until they become almost invisible to the naked eye. A whole villus is often almost completely metamorphosed into a bunch of vesicles almost as large as gooseberries. Upon the larger of these, s !le r ours are often inserted, and generally by a very fine pedicle, a portion of the undilated branch of the chorion. The pedicle varies from -039 to -078 inches in length. Sometimes it is extremely fine, but may reach a diametor of 039 inches; in which case it allows the fluid to flow through it from 548 PATHOLOGY OF PREGNANCY. one vesicle into the < ther. More frequently, it is obliterated through a greatei or less extent of its course. All the vesicles of the same group are, therefore, con- nected by pedicles, forming groups of the strangest appearance, but, nevertheless, recalling that of the villi in the normal condition. It is generally easy enough to separate the vesicles from each other, and to trace tin- pedicles down to the chorion ; sometimes, however, they are inextricable. The fluid contained in the vesicles is usually colorless, transparent, liquid as water, and containing albumen in solution. Occasionally, the contents are of a reddish color. Tli is dropsical condition may affect either the villi of the chorion, properly so nailed, or those of the placenta, and in both cases the life of the foetus is nearly always compromised. The dominant fact in the affection is, after all, the arrange- ment of the umbilical vessels. Should all the villi become dropsical, the death of the foetus would necessarily ensue, and, occurring at a period very near that of conception, it might undergo solution in the amniotic fluid, and thus disappear. Should the alteration of the villi be more recent or less complete, we should have an embryonic mole, in which the body of the foetus would present various grades of development. Sometimes even, though rarely, when the alteration affects a small number of villi, the foetus may be fully developed. Finally, a case of M. Brachet's proves that a few hydatiform vesicles occurring on the placenta do not prevent the birth, at term, of a healthy child of the usual size. It is certain that in twin pregnancies an alteration of one ovum may affect the other injuriously ; still, some cases, reported in the Dictionary, in thirty volumes, show that one ovum may be transformed into a hydatiform mole, whilst the other foetus undergoes regular development, and is born at term. By what symptoms may dropsy of the villi of the chorion be suspected or dis- covered ? If the alteration be slight, none of the usual signs of pregnancy will be wanting, and then a diagnosis will be almost impossible. If, on the contrary, the change is so great as to completely alter the ovum, the affection may be suspected and occasionally discovered. All writers admit that attacks of hemorrhage are common in such cases, and they almost always coincide with an unusual develop- ment of the uterus, whose size is no longer in conformity with the presumed period of gestation. These two symptoms are found conjoined in a case of M. Depaul's, already published by M. Cayla. The most important sign, however, is a too rapid increase in the size of the uterus, and by it was a positive diagnosis made in the following case, which we owe to the kindness of M. Pajot, from whom we received it. The account will be read with interest: "I saw a case () f so-called uterine hydatids in connection with Dr. Gocherand (of Ivry), and although it was the third one of the kind which has fallen under my notice, the circumstances attending it were very different from my own two first cases, and afforded the opportunity of studying a much greater alteration of the.villi of the chorion." The patient was a young woman who had given birth to a child about a year previously, and who now supposed herself to be about three months pregnant. On making an examination I was astonished to find the uterus as large as at the eighth month of gestation. A very marked sense of fluctuation made me at first suppose; that there might be a collection of fluid or a rapidly developed cyst of the ovary. However, I soon became satisfied that there was an accumulation of fluid in the rjavity of the uterus itself. By vaginal examination I found that the lower segment of the uterus was considerably developed. The neck was as soft as at the eighth month of gestation, and presented the indications of a previous labor. The finger could be inserted as far as to the internal orifice, which was closed hermetically. By passing the finger around the cul-de-sac, the left hand at the same time being applied upon the fundus if the uterus, the sense of fluctuation already perceived so clearly by palpation, DISEASES OF THE OVUM. 549 was again evident. There was no solidity at any point of the abd)men. The patient's general health was bad ; she had a dry, hot skin, and pulse at 120. It was the only one of the three cases in which a diagnosis could be established. I advised the insert on of a gum-ehistic catheter through the internal orifice, and the administration of ergot. The advice was followed the next day, and the patient expelled, together with a large quantity of fluid, a multitude of hydatiform vesicles, either in a detached state or in clusters of five or six together. The entire collec- tion would have filled a man's hat. The vesicles were taken to Paul Dubois, who showed them to his class, and made them the subject of a lecture. The evacuation was followed by no improvement in the general symptoms; the patient continued to lose strength, and died a few days after the operation. Unfor- tunately, an autopsy could not be obtained. (Pajot.) Although the uterus, in these cases, is generally too large for the stage of the pregnancy, it is sometimes in the opposite condition. (Thesis of Dr. Louvet- Lamarre.) The pregnancy usually terminates earlier than in normal cases, expulsion of the ovum generally taking place before the sixth month, and in the usual manner; all the symptoms which precede, attend, or follow it resembling precisely those of abortion, though the accompanying hemorrhage is commonly profuse. The formation of an hydatiform mole rarely appears to have any effect upon the general health of the patient, or upon subsequent pregnancies. Madame Boivin, however, mentions some cases of women who wel'e so unfortunate as to suffer repeatedly from the affection. ARTICLE II. LESIONS OF THE VILLI OF THE PLACENTA. Although changes in the structure of the placenta are quite common, our knowl- edge of them is as yet so limited, that in a work like the present we shall be able to notice only the most important of them. A clear statement of what may be said of the pathology of the placenta, makes it necessary to revert to some details respecting the chorion and its villi. The two latter are composed of the same substance, that is to say, of a membrane formed of polyhedral cells, which are easily distinguished up to the sixth week. At a later period their nucleolus disappears, the nucleus loses its transparency, and the cell itself becomes filled with granules. In this way the chorion soon assumes the appearance of a continuous membrane, which is more or less granular and sprinkled with nuclei. In its beginning the chorion has the form of a regular hollow sphere, with smooth outlines; soon, however, its surface becomes covered with multitudinous prolonga- tions, to which the term villi has been applied. Almost all these prolongations are traversed by a canal, which terminates in a cul-de-sac at the free extremity of the villus, but opens freely at the internal surface of the chorion. This internal surface is, therefore, covered with minute perforations, each communicating with the canal of its respective villus. AVhen the allantoic! is formed, it becomes applied against the internal surface of the chorion, and quickly sends vascular prolongations into most of the villi. Some of these villi then continue to grow, so as to form the placenta; the rest become atrophied in a way which has been well described by Robin (Archives Generates de Me'decine, 1848, et Gazette Medicate, 1854), and which affords the key to some of the lesions of the placenta. Prof. Robin's investigations may be recapitulated ati fi Hows : — 1. During the formation of the villi the development of some of them is arrested, so that they contain no central canal, and consequently can have no participation j>50 PATHOLOGY OF PREGNANCY in the allantoid circulation. They appear as solid cyli ders, having imledded in their tissue an abundance of grayish granules. 2. Although most of the villi are provided each with .1 canal, some of them fail to receive a prolongation of the allantoid ; these, consequently, remain tubular, and are distinguished by the abundance of fatty molecular granules, with which then parietes are sprinkled. 3. Although nearly all the villi become vascular at a certain stage in the devel- opment of the ovum, most of them have become atrophied by the time the placenta is distinct. In following up this process of atrophy, the allantoid vessels traversing the villus are first observed to disappear, and the canal is quickly obliterated, beinc filled with a tissue resembling the reticulated magma. The walls of the villus itself bee >me charged with fat in the shape of fatty granules and real oil- drops, sometimes scattered and sometimes in collections of various forms. 4. The placental villi occasionally present the same indications of atrophy as are constant in the other villi in the chorion; in other words, the placental villi may undergo atrophy, cease to be vascular, and exhibit an abundant fatty deposit in their walls. We shall soon explain the mode by which the normal atrophy of the villi of the chorion gives rise to important lesions when it happens to extend to those villi which go to form the placenta. FIBROUS OBLITERATION OF THE PLACENTAL VILLI WITH OR WITHOUT FATTY DEGENERATION. The lesion in question has been described as induration of the placenta, encepha- loid, scirrhous, cancerous, tuberculous, and fatty degeneration: still oftener has it been mistaken for a fibrinous deposit, the remains of a placental apoplexy. (See Placental Apoplexy.) The degeneration appears in the form of grayish or whitish masses, which are always less red and moist than the rest of the placenta, and of a tissue which is hard, compart, friable, and but slightly stringy. This appearance has caused them to be mistaken for concrete pus, masses of crude tubercle or scirrhous formations. When, however, they are examined under the microscope, it is soon seen that all the parts of the tissue thus altered are composed of obliterated villi of the chorion with their tissue charged with fatty granules. All the ramifications, however, are not thus supplied with fat, since in the parts apparently the most diseased and distinguished by their whitish color, the villi contain no trace of fat granules, or have them only at long intervals. In a word, the lesion which we are describing is characterized by obliteration of the placental villi, precisely similar to the atrophy which invades the villi of the chorion after the formation of the placenta, and which we have described above. This alteration is more especially met with at the circumference of the placenta, the cotyledons in that situation being the ones chiefly affected. It may always be found in the cotyledons of the periphery, or, at least, in a small portion of some of them: in this cum', however, the affected ramifications of the chorion are lost, as it were, in the midst of those which remain pervious, and in this degree the disease is of no interest to the clinical observer. In certain placentas, however, there will be one or several portions of cotyledons, or even one or several entire cotyledons, which have undergone fibro-fatty degen- eration ; and sometimes even the greater part of the placenta is thus transformed into a morbid tissue which is impervious to blood. A placenta examined by MM. Laboulbene and Iliffelsheim had six of its cotyle- dons entirely obliterated, beside whicb there were discovered eleven other small, yellowish masses, presenting the same external characters and structure as the diseased cotyledons. The altered cotyledons are sometimes scattered through the DISEASES OF THE OVUM. 55] placental mass, at other times they touch by their edges, but are ilways definitely separated by deep furrows. The change is generally more evident upon the uterinfl surface of the cotyledons than upon the side of the chorion, for, there the tissue resumes gradually its softness, humidity, ami reddish hue. " If the placenta be emptied of blood," says M. Robin, from -whom we borrow almost the whole of this article, " the diseased cotyledons will project more than the healthy ones ; but if the placenta be injected, the former will be depressed in comparison with the latter. This result is due to the fact that the ramifications which remained vascular in the emptied placenta, subside in consequence of the discharge of their blood; but as the obliterated ones do not collapse, their bulk remains greater than that of the others. When, on the contrary, the healthy ai d vascular cotyledons are distended by injection, they form a larger mass than those whose subdivisions are obliterated, and appear in relief beside them." The alterations just described are independent of hemorrhage or placental apo- plexy. Whenever the two affections have been confounded, the observers were, doubtless, deceived by their coincidence. It is, indeed, by no means rare to find an apoplectic space in the centre of the diseased cotyledons, large enough to contain a pea, a bean, or only a millet-seed, and the fibro-fatty degeneration of the villi has often been mistaken for a bleached clot. This confusion is now impossible, thanks to the microscope, which discovers in the mass of diseased cotyledons not a collection of fibrin, but a network of atrophied villi of the chorion. A single argument remains in favor of the view which attributes them to apo- plexy, to wit, that the hemorrhage which takes place causes the obliteration of the cotyledons. To us it seems impossible thus to make the obliteration subordinate to the apoplexy, and M. Robin's researches tend to prove that the fibro-fatty altera- tion may become a cause of hemorrhage as regards the neighboring villi which continue pervious. Moreover, as a matter of fact, placental apoplexy is met with, without obliteration of the cotyledons, and it is very often impossible to discover a trace of apoplexy in cotyledons which are completely obliterated. The two lesions are, therefore, mostly independent of each other. Obliteration of the placental cotyledons is without importance as regards the mother, but, as will be readily understood, may be highly injurious to the foetus. It is, indeed, proved that an almost constant relation exists between the weight of the foetus and that of the placenta. Now in the case before us, any obliteration of the villi cuts off by so much the active portion of the placenta ; if but a few villi be obliterated, the child experiences no bad effect from it, but if several cotyledons bo altered, its development will be imperfect, and should half of the organ be invaded, its life will incur the greatest danger. In a still more advanced stage, its death is almost certain. All our knowledge of the fibro-fatty degeneration of the placenta is, so to speak, condensed into the anatomo-pathological statement just given, and we are obliged to confess, as does Dr. Millet, whose excellent work may be consulted with advan- tage, that there is nothing to give us light upon the etiology of this lesion, no sign which enables us to fix its symptomatology upon a certain foundation. Sometimes, however, there have been evidences of uterine congestion in eases in which the patients had complained of weight or pain in the loins. These symptoms then resemble those observed in cases of placental apoplexy, and, we would observe, are really so vague or even insignificant that it would seem to us almost impossible to diagnose the fibro-fatty degeneration in a case of first pregnancy. As, however, the affection is liable to recur and sometimes adheres tenaciously to tin' same woman in all her pregnancies, the accoucheur may take warning and let the least trouble occurring either to the mother or foetus during gestation have its weight in his estimate of the situation. M. P. Dubois says, in reference to these matters, that, if a sense of dull pain and fulness is connected with a slight diminution of the motions of the foetus, there is reason to fear that it is in serious danger. 552 PATHOLOGY OF PREGNANCY. It is possible, then, to suspect or even to foresee the fibre-fatty degeneration of the placenta; but how shall it be prevented? What course shall be pursued if the woman becomes pregnant again? M. Dubois' advice to his pupils, under these circumstances, is thus briefly stated by Dr. .Miller : Ad vise the patient to avoid all kinds of fatigue; insist upon her lying down, and prescribe a light diet fur the purpose of moderating the circulation. At the same time practise a revulsive bleeding to the extent of from one to two ounces. followed the day after by a similar one. In connection with this apparently reducing treatment, M. Dubois, without fear of being taxed with inconsistency, adds the use of iron, inasmuch as it has appeared to him that women are predisposed to the affection by a certain degree of impoverishment of the blood. The iron would, at any rate, seem in several instances to have benefited the patients. AETICLE III. EFFUSION OF BLOOD IN THE PLACENTA. Utero-placental hemorrhage will be studied in all its connections when treating of abortion or the hemorrhages accompanying delivery (see Abortion, and Dystocia) ; we are, however, to speak in this place of certain effusions of blood in the substance of the placenta which present peculiarities deserving of special attention. These effusions differ considerably both in situation and form, the variety being due, for the most part, to the more or less advanced stage of the development of the placenta. Thus, if the blood occupy circumscribed cavities formed in the tissue of the organ, it takes the name of placental apoplexy given to it by M. Cruveilhier, and will be described in the next paragraph. Up to the third month, however, not only may the blood be effused into the placenta itself, but may even extend beyond its limits and spread over the entire external surface of the chorion. This last variety will be the first to engage our attention. As utero-placental hemorrhage has been so well treated of by M. Jacquemier, we can do no better than borrow several passages of his description. Up to the third month, as stated, the blood effused into the placenta has a great tendency to spread itself over the surface of the chorion ; in fact, it could hardly be otherwise, for at the outset the placental villi are not yet connected by the amorphous tissue which at a later period forms of them compact lobes, and the circumference of the pla- centa is not yet well defined, there being no distinct limit between the villi of the placenta and those of the chorion, which latter are destined soon to disappear. The entire surface of the chorion is, in fact, at this time covered with prolongations which separate to a certain extent its external surface from that of the decidua reflexa until both membranes are brought into contact through the atrophy of the villi. Should a rupture now occur of some of the utero-placental vessels either in process of development or but recently perfected, the blood therefrom would soon reach all the vascular tufts of the placenta ami villi of the chorion by spreading itself in a layer between the ovular decidua and the chorion. The aborted ovum under these circumstances often has a fleshy appearance, its surface being more or less bluish or Idackish, whilst its walls form an envelope of variable solidity and thickness. If it be entire, a careful examination will often detect on the external surface of the placenta minute ruptures opening into cavities and closed or not by coagulated blood. Frequently, also, there is no rupture, although the placenta may contain deep-seated, circumscribed cavities or extensive diffused infiltrations. If the layers of the decidua be Btripped from the ovum, the entire surface of the chorion, the portion occupied by the placenta included, will be found covered by coagulated blood which is firmly held by the vascular ramifications of the placenta and the villi of the chorion imprisoned in its substance. Both chorion and amnion are intact, the amnii tic fluid having a slightly red color by imbibition. If the embryo DISEASES OF THE OVUM. 553 be very young, it may sometimes be found to be entirely dissolved, the Mily trace left of its existence being a very small bit of the cord still attached to the placenta by a few fragments of a very soft tissue. At other times the amniotic liuid may merely seem to be a little thicker than usual, resembling in this respect a mucilage of gum. Should the structure of the embryo be firmer, it will be found in its normal condition, only more or less withered and macerated according to whether the date of its death be more or less remote. The blood covering the entire surface of the chorion sometimes forms a firm and hard coagulum, which, occasionally, in some parts has lost its color and resembles the huffy coat of blood from venesection ; at other times it is soft and presents the appearance of a black-, thick, and granular fluid. The amount of blood effused varies greatly, and the layer formed by it may be only from , 068 to - 136 inches, or from '78 to *.1'17 inches iu thickness. In the latter case, the euds of the villi will have lost their relation with the reflected and inter- utero-placental deciduas, thus producing an unnatural widening of the interstice which, in the normal state, is very small. The layer of blood is not of equal thickness at all points; in some places it collects in larger quantity, and that most generally where the placenta would have been formed. Ova thus affected have, sometimes, another appearance ; thus, if during their expulsion the decidua has been removed, as often happens, they look like a clot of blood, but dissection and washing soon discover in their tissue the vascular ramifications of the placenta and villi of the chorion, showing that the seat of the effusion is the same as in the preceding case, and that they are not merely ova wrapped in their deciduas and enclosed in a clot of blood. At a rather later period of gestation, say the third or fourth month, the effusion spreads much less over the surface of the chorion and shows a tendency to be con- fined to the placenta ; still, it will sometimes extend beyond the edges of the latter in the form of streaks, projecting iu various directions to a greater or less distance. The limitation of the effusion is due to the approximation and somewhat firm adherence between the chorion and the decidua reflexa, due to the atrophy of the villi of the chorion, so that a space no longer exists between the two membranes except for a variable distance near the border of the placenta. Even should we suppose that these effusions exert a considerable force, it is not generally sufficient to rupture the membranous envelopes which restrain them. Still it is not so very rare for the decidua reflexa to give way and allow the blood to pass into the cavity of the decidua and even reach the internal surface of the uterus. As an excep- tional occurrence it is sometimes found to have ruptured the chorion and amnion, ^8 in the cases observed by M. Gendrin, who found blood effused between the ihorion and amnion, and even in the cavity of the latter, where it enveloped the embryo completely. Within the periods of foetal life above mentioned, there can be no doubt that the effused blood proceeds from a rupture of the utero-placental vessels, even though it be impossible to detect any lesion upon the external surface >f the placenta. It is impossible to suppose that the blood comes from the umbil- ical vessels, for we have seen that in some cases the embryo is so slightly developed as soon to be dissolved, whilst in others the amount of blood effused generally far exceeds the entire bulk of the embryo. If the umbilical vessels are ever ruptured, they could only be so consecutively to rupture of the utero-placental vessels, in which case the foetal and maternal blood would mingle together. An occurrence of this kind happening to the extent just imagined, would, gener- ally, be fatal to the foetus, though the ovum would nut be expelled until later. Aa the effused blood is not in contact, with the walls of the uterus, it does not stimu- late tin; organ immediately to contraction, and it very often happens thai when abortion takes place, tin; blood is found to have already begun to lose its color, as also to present Other changes indicating thai the hemorrhage must have taken place some time previously. Should the effusion be moderate] it would nut seem im- possible I'ui- gestation to continue. (Jacquemier.) 554 PATHOLOGY OF PREGNANCY. PLACENTAL APOPLEXY. Mr. Jacquemier's book again guides us in describing placental apoplexy. From the middle of intra-uterine life the placenta continues to be quite frequently the seat of effusions of blood, which effusions are peculiar from the fact that they no Longer extend beyond its edges between the now firmly united chorion and decid'ia. Instead of being diffused and occupying the greater part or even the whole of the placenta, these effusions are more fully circumscribed and confined to the lobes in which the ruptured vessels are situated, although they always show a strong ten- dency to extend toward the foetal surface of the placenta. They also present varieties which may be described under three principal heads. In the first variety there is no cavity, properly so called, produced, but the blood infiltrates the tissues of one or more lobes of the placenta, apparently diminishing its density. In some places it accumulates sufficiently to form little vacuoles filled with a very dark-colored fluid which in some cases has the appearance of a very thin jelly. (Jacquemier.) In the second variety the effused blood forms a very irregular cavity, having prolongations in various directions, and the parts adjacent are infiltrated and stained of a reddish hue for a very considerable distance. The foci are usually quite large and mostly communicate with the external surface of the placenta through a rupture of greater or less size, with detachment of the parts correspond- ing; they are irregular in form and more liable to be found near the edge of the placenta in proximity to the coronary vein, which is sometimes ruptured, and communicating with the cavity. When the effusion takes place near the centre of the placenta it easily reaches the external surface of the chorion ; and should it be near the point where the principal branches of the cord traverse the latter, a little blood will sometimes be found to have penetrated to a greater or less extent the tissues which surround the umbilical arteries and vein at the root of the cord. This condition has already been described in several cases, of which one published by M. Gendrin is very interesting ; the cord, for the distance of two or three inches from the cavity in the placenta was infiltrated with blood, and yet there was no evidence of rupture of either of the umbilical arteries or of the vein. These irregular cavities in the substance of the placenta may be numerous, or there may be but one; and in case there are several, they may have been formed at the same period or at different times. The third variety is the most remarkable of all ; the cavities are here well defined and regular in form, even when the effusion seems to have occurred but very re- cently. Usually there are several of them, and judging from the appearance of the blood which they contain, they are produced successively. It is not uncommon to find seven or eight of them in the same placenta, and sometimes there are twenty or more. Simpson mentions a four months' placenta in which they were so numer- ous us to give the impression, upon dividing it, of a collection of innumerable, small, rounded, and distinct clots, closely compacted together. (Dlctionnaire en 30 volumes.) It is rare for the clots to be larger than a pigeon's egg; some are as small as millet or hemp seeds, whilst others are of intermediate size. They are also situated at various depths in the substance of the placenta, some extending to the internal surface, and others approaching the uterine surface, upon which some of them open by a small and irregular orifice. The surrounding tissue of the organ is in its normal condition, and the appearance of extravasation of blood extends for but a few lines beyond the boundaries of the cavities. These regularly formed clots begin to lose their color at the circumference, so that at a certain period the cavity exhibits a white, thin pellicle, which detaches more easily from the clot than from the placental tissue. (Jacquemier.) We have hitherto said that the placental tissue surrounding the javities is in a uealthy condition ; but this is not always the case. It will be remembered, indeed. DISEASES OF THE OVUM. 555 that it is not uncommon to find apoplectic collections in the centre of coty .edons affected with fibrous obliteration of the villi. (See page 551.) In such placentas occur very small, regularly formed cavities, enclosing clots of blood of an appear- ance compared by M. Jacquemier to black grape-seeds. The blood effused in the tissue of the placenta, when the ovum is not expelled, separates into two portions, one solid, the other liquid. The serum disappears by infiltration, whilst the solid part forming a clot contracts, becomes denser and somewhat smaller, and gradually loses its color. The importance of the consecu- tive changes in the effused blood has, however, been greatly exaggerated; thus it was supposed that the transformation might be so complete as to produce whitish and homogeneous masses resembling concrete pus or tuberculous matter, but it is evident that in such cases effects have been attributed to placental apoplexy which were really caused by fibrous obliteration of the villi. (See page 550.) We have said that when utero-placental hemorrhage occurs in the first half of pregnancy, it is occasioned by the rupture of some of the maternal vessels, gener- ally the veins, and that it very rarely proceeds from the umbilical vessels. We think that the same observation applies to placental apoplexy. The various kinds of apoplectic formations in the placenta may coincide with the lesion met with in uterine hemorrhages, whether internal or external ; that is to say, with a partial or complete detachment of the placenta and the presence of a clot of greater or less size in the artificial cavity thus formed, together with streaks of coagulated blood stretching away to the cervix, and situated between the internal surface of the uterus and the uterine decidua. The ovum is then expelled prema- turely, with the symptoms of an ordinary uterine hemorrhage. Effusions within the placenta, however, rarely occasion such extensive lesions, but are almost always limited and compatible with the continuance of gestation. The effect of placental apoplexy, moreover, varies with the period of gestation at which it occurs, as also with the number and extent of the effusions and the more or less frequeut occur- rence of the accidents. If the points of effusion are small and few in number, a considerable part of the placenta retains its natural structure and capacity for the fulfilment of its functions ; in this case not only will the foetus continue to live, but its nutrition will suffer little or not at all. Under opposite circumstances, if it should not die, it will be born feeble, puny, and emaciated. Should the apoplectic attacks recur at short intervals, they will often produce, in spite of all that can be done, gradual diminution of the motions of the child and of the pulsations of its heart, and the final cessation of both. In these unfortunate cases, it is not uncom- mon for both the mother and the accoucheur to be obliged to witness, as it were. the sufferings and death of the child. [Dictionnaire en 30 volumes.) Apoplectic effusions in the placenta are rarely betrayed by any symptoms, pro- vided the hemorrhage is limited in amount. In some cases, most of the indications of moderate internal hemorrhage are observed, though its occurrence will be rather a matter of suspicion than of certainty, unless the patient has sufl'ered from the affection several times previously; for it is by no means rare for the same woman to miscarry several times consecutively, and always from the same cause; and if she should be delivered at term, a number of effusions, both old and recent, will be found in the placenta. (Jacquemier.) Supposing there is reason to fear the occurrence of placental apoplexy, and especially if the woman is predisposed to the affection, the prophylactic treatment had recourse to in cases of uterine hemorrhage during pregnancy, will be indi- cated (see Abortion). As measures offering the greatest chance of success, we would mention absolute rest and small bleedings, to be repeated at longer or shorter intervals. 556 PATHOLOGY OF PREGNANCY. CHAPTER IV. DISEASES AND DEATH OF THE FCETUS. \ 1. Diseases of the Fan >. Although the diseases of the embryo and foetus during intra-uterine life are numerous, they are very little known. As it does not enter into the plan of this work to treat fully of subjects coming under this head, the history of monstrosities and whatever else belongs to teratology will be laid aside, and we will merely pre- sent succinctly such diseases as are most interesting to the accoucheur on account of their endangering or destroying the life of the child. As we even think it best to defer the account of such as might obstruct natural delivery, until we come to treat of dystocia, our task for the present will be quite a limited one. 1. Inflammation. — Traces of inflammation have been detected in various organs of the foetus. As the most important we would mention peritonitis, which was made the subject of a special treatise by our colleague and friend Dr. Lorain. It was most frequently observed in lying-in hospitals during the prevalence of puer- peral fever. The pleura and lungs are sometimes attacked with inflammation, though less frequently. But although rare in the human species, it is very common in ani- mals affected with epizootic pneumonia, — a fact to which I called attention in my paper on puerperal fever. 2. Fevers. — It would seem that the eruptive fevers may be communicated by the mother to the child. There can be no doubt of the fact as regards variola, and we have nothing to add here to what has been said elsewhere (see pages 446 and 447) on the subject; and the same remark applies to intermittent fever. (See page 445.) 3. Icterus. — Several observers have reported cases of women having icterus giving birth to children affected with the same disease, the waters also being of a yellow color. These are, however, exceptional cases, as it is far more common for children born of jaundiced mothers to be free from any abnormal color. (See page 451.) 4. Syphilis. — We have already said that syphilis may be inherited. The foetus thus affected usually undergoes a very regular development; and not until some weeks or months have elapsed after its birth, do the accidents appear which, there- fore, it does not fall within our province to describe. This, however, is not always the case, for it is by no means rare for the syphilitic foetus to be born prematurely or even to die before birth. These children, like the former, when examined im- mediately after delivery, generally exhibit no lesion which can be attributed to syphilis, though in some, traces of the disease are evident, the most common being pemphigus of the palms of the hands and soles of the feet. When the bullae are perfect, the eruption is easily recognized, but they are almost always ruptured and their place occupied by rounded erosions with elevated epidermis. Still, they have a characteristic look. Pemphigus is more difficult to recognize when the eruption is beginning: it then appears in the form of small, red, and barely pro- jecting spots, marked in the centre with a whitish point, due, doubtless, to a slight elevation of the epidermis. I have met with two cases of this kind, which are represented in wax models deposited in the hospital of the Clinique, and the re- ports of which were published by Dr. Bernardot [Theses de Strasbourg). Autopsies of the children sometimes reveal visceral lesions due to syphilis, such as certain alterations of the thymus gland, lungs, and liver. Prof. Dubois was the first to call attention to syphilitic alteration of the thymus gland. Externally the affected organ seems healthy, but if cut open and squeezed, a whitish fluid resembling pus exudes from it. When the lung is the seat of the lesions, these DISEASES AND DEATH OF THE FOETUS 657 consist of indurated nodules varying in number and size, and of abjut th = c msist- ence of the liver, as stated in a detailed account of the affection by Prof. Depaul. Some of these indurated masses project beneath the pleura, under which circum- stances they present quite a deep-yellow hue. At a later period they undergo softening and have at their centre a cavity containing a fluid of a sero-puruleiu appearance. The lesions of the liver have been well studied by M. Gubler, whc describes them as being sometimes general, sometimes partial, and characterized by spaces of indurated yellowish hepatic tissue, whose normal structure is infil- trated with fibro-plastic elements and an albuminous fluid resembling the serum of the blood. The indurations are distinguished from the healthy tissue of the organ by their contour, hardness, and resistance to the finest injections. 5. Dropsies. — Hydrocephalus, hydrorachis, ascites, and cysts are affections to which the foetus is quite liable; but as they often cause difficulty during labor, they will be treated of under the head of dystocia. (See Dystocia.) 6. Spontaneous Fractures. — Cases have been reported of spontaneous fractures, almost aiways multiple upon the same foetus. Chaussier mentions a child born at the Maternity Hospital, in 1803, after a rapid and easy labor, during which no force had been applied to it, which had forty-three fractures, involving the cranium as well as other bones. Some of the fractures were recent, in some callus was forming, and others were thoroughly consolidated. Another case, cited by the same observer, is still more extraordinary. The child in question, which was born after an extremely short and easy labor, in a state of debility and of a bluish color, ex- pired in a short time. Attention was attracted to it by its extreme shortness and an unusual mobility in the continuity of its bones. One hundred and thirteen fractures were counted by Chaussier, involving the different bones of the cranium, chest, and limbs (Jacquemier). The causes of this singular lesion are unknown; it is most probably due rather to arrested development of the bony tissue than to fracture properly so called. 7. Complete or Incomplete Amputation of the Limbs. — Cases not less curious than the preceding are those in which the children are born with limbs amputated at various heights, and having a cicatrix at the centre of the stump. Chaussier saw three deprived of the hand and a portion of the forearm. In one of these cases, a small bony cylinder found on the foetal surface of the placenta was recognized as a portion of the radius. The stump, undergoing cicatrization, was covered at its centre with granulations. Watkinson, in 1824, attended a woman in her first labor who had experienced nothing unusual during her pregnancy. The child was born prematurely, and lived but twenty minutes. Its left leg appeared to have been amputated just above the malleoli. The foot, smaller than the other, was found in the vagina, but presented no appearance of gangrene or alteration of color or consistency. The two divided surfaces (of the foot and of the limb) were almost entirely cicatrized, and both presented small projections formed by the ends of the bones. Montgomery, in a work on this subject, relates two cases very similar to the preceding, in which the detached feet were expelled before the child. Cicatri- zation was complete in one, and far advanced in the other. (Jacquemier.) It would be easy, though I think useless, to mention other examples of this species of deformity. Spontaneous amputation is sometimes incomplete; that is to say, grooves of greater or less depth, occasionally extending to the bones, are observed upon the limits. What is the cause of this singular lesion ? Some have supposed it due to circulai turns of the cord around the limbs, acting as does a ligature around the pedicle of a tumor ; but it is very difficult to suppose that the cord could be drawn tight enough to amputate a limb without arresting the placental circulation ai the same time. Montgomery's explanation is much more probable; be supposes the amputation to 558 PATHOLOGY OF PREGNANCY. be effected by constricting materials other than the cord. In several cases were found fibrous bands, whose origin it is difficult to determine, which constricted the limbs as would real cords, and which would have occasioned complete or incomplete amputation according to the degree of constriction. It must, however, be said that these bands are not always to be found, so that the etiology of spontaneous ampu- tation is very uncertain. It cannot be affirmed, says M. Jacquemier, that they are always the mechanical effect of a constricting agent; they may possibly be due to a deep-seated local lesion and to the constriction induced in the skin by an exten- sive cicatricial action. \ -. Death of the Fcetus. The causes which destroy the life of the embryo and foetus are numerous, but we shall not attempt to recapitulate them here, referring the reader to the chapters which treat respectively of the diseases of the mother and of the ovum and foetus, as also to the article on abortion. It must, however, be confessed that it is often impossible to determine the cause of death or to discover anything which can explain it in a satisfactory manner. Some of these unknown causes have attracted attention by the persistence with which they continue to act in the same woman through several successive pregnancies. I myself knew a woman in good health, who, on thirteen consecutive occasions, and without any discoverable reason, lost her child during the last month of gestation. Since Denman's time, it has been supposed that in these cases recourse might be had successfully to the induction of premature labor. We would also revert to the fact (see page 271) that in twin pregnancies one foetus sometimes dies and assumes a mummy-like condition, whilst the other undergoes its regular development. This occurrence can only be known after delivery. It is not always easy to assure ourselves that the fcetus is dead ; it will sometimes be suspected when it ceases to move, especially after having been unusually active. At other times, the spontaneous motions gradually grow less frequent and weaker, and finally cease. Too much importance ought not, however, to be attributed to this sign, because the fcetal motions present numerous anomalies, even in the midst of the most perfect health. The surest indications are derived from auscultation of the foetal heart. "In regarding the subject from this point of view/' says M. Depaul, "we must set aside the three first months of gestation, during which the sounds of the heart cannot be heard, and also remember that in many cases it is impossible to perceive them before the expiration of the fourth month. During the last half of gestation, the conditions are altogether different, success in the stetho- scopic examination being the rule, whilst failure should be regarded as a very rare exception. Inasmuch, however, as this exception may exist, it is impossible to attribute an absolute value to auscultation of the foetal heart as a means of deter- mining whether the child be living or dead. It would be a great mistake, however, not to regard it as an extremely valuable means, since, in the immense majority of cases, it leads to probabilities which amount almost to certainty, and consequently allows questions of the highest practical interest to be solved." (Depaul, Traite d' Auscultation.) Out of 67 women, more than five months pregnant, in whom M. Depaul was unable to hear the pulsations of the heart, but three were delivered of living children.] Further, the phenomena experienced by the mother after the deatli of the foetus are very singular in these cases : the abdomen collapses instead of increasing in size; the breasts, which had become developed, shrink ; the woman suffers from a sensation of weight in the loins, and an unusual pressure in the lower part of the abdomen ; an inert body in the uterus obeys the laws of gravity and fails to whichever side the woman turns in bed. DISEASES AND DEATH OF THE FCETUS. 559 OLher symptoms are soon added to the foregoing. If the gestation is somewhat advanced, everything passes off absolutely as if the expulsion of the embryo had occurred, only excepting the discharge of the lochia: thus, in the course of forty-eight to sixty hours after its death, the breasts swell up, the phenomena of milk fever are manifested, and the lacteal secre- tion is fully established, after which the breasts again subside, and the usual order is resumed. As a general rule, the prolonged retention of a dead infant does not produce any disastrous result to the mother, and I suspect that writers have greatly exaggerated on this point : they say, indeed, that the woman becomes depressed, uneasy, and of a fretful temper ; that she experiences lassitude, alternations of heat and cold, oppression at the epigastrium, headache, syncope, palpitations of the heart; her face is pale, the eyes dull and surrounded by a livid circle, the breath fetid, pulse frequent and irregular: in a word, all these general phenomena of a slow fever have been considered by them as so many rational signs of the child's death. But these symptoms are certainly absent in the majority of cases ; for most women, after we have succeeded in calming their fears, experience nothing of the kind, and I have known many of them to carry a dead child for several months without even suspecting it, and some even to congrat- ulate themselves upon the amelioration of their general condition, in con- sequence of the sudden disappearance of the sympathetic disorders of preg- nancy. At an indeterminate period labor comes on, and the abortion is effected. By examining the dead foetus, we may learn why its prolonged sojourn in the uterine cavity has been wholly innoxious to the mother. In fact, the infant is not putrefied, as is proved by its having no bad odor ; the solid parts undergo a peculiar transformation, and the body is somewhat analo- gous in appearance to one that has been soaked for a long time in water. When the foetus remains in the uterus thoroughly protected from the air, it does not putrefy, but undergoes maceration. M. Martin (of Lyons) judi- ciously remarks : " The kind of alteration which a dead child undergoes in the womb, will also vary according to the period of pregnancy at which it ceased to live. Thus, in the early stage of its formation, when its organi- zation has but little consistence, and approaches the mucilaginous state, it dissolves in the waters of the amnios, which then become thicker and assume the characters of a gummy solution, and no further trace of the embryo is found in the amniotic cavity. But at a period somewhat later, that is, from the second to the fifth month, it withers away, becomes shrivelled and dried up, and looks like a little mummy of a yellow color, or like a foetus pre- served for a long time in alcohol. Not unfrequently, the placenta likewise participates in this state of desiccation, the liquor amnii disappearing and being replaced by a thick and apparently an earthy humor, which incrusts the fetus." (Memoires de Med. et de Chir. Prat, page ( J6.) After the fifth month, a child putrefied in the womb presents so different an aspect from one that has undergone the same process in the open air, that it is only necessary to observe this particular condition once or twice, never to mistake it afterwards. Imagine the little defunct stretched on a table: the flaccidity of it? soft 560 PATHOLOGY OF PREGNANCY. parts is then so very striking, that the head becomes flattened under tht influence of its own weight, whatever position may lie given to it; the soft parts on the thorax exhibit the form of the ribs; the front of the chest is very much flattened, the abdomen sunken and nearly hollow about the navel, and forming two large rounded projections on the flanks; even the extremities exhibit the same state of collapse. The discoloration of the skin is particularly remarkable, although often confined to the abdomen, at least when the sojourn of the foetus in the womb has not been very long. The skin of this part has a brownish-red shade, without the least appear- ance of a greenish hue. This tint is less marked on the chest, neck, head, and limbs; nevertheless, it exists there also. But this is not the brownish hue that often succeeds a green putrefaction ; it is a much clearer reddish- brown. The cord is no longer twisted, but it forms a true fleshy cylinder, of a reddish color, soft, and saturated with a brown fluid. The epidermis is detached from a considerable part of the surface, and may be easily sepa- rated from those places where it is still adherent, thus leaving the humid dermis exposed, which is as glutinous as if it were lubricated by a mucous fluid ; and then the true skin has a bright rose color. The epidermis on the feet and hands is white and thick, and looks as if it had been corrugated by cataplasms. The subcutaneous cellular tissue is infiltrated with a reddish serosity, which is also seen between the muscles, and sometimes in the sub- stance of the muscular tissue itself. The bones of the head are feebly held together, their periosteum may be readily detached, and they are movable on each other. The cellular tissue underneath the hairy scalp is infiltrated with a thick serosity, resembling currant-jelly in appearance. Finally, whenever we attempt to move or raise the foetus, it slips through the hands just like a fish that lives for some time out of water, in consequence of the fluid mucus covering its surface. (Devergie, Med Legale.} A dead foetus is merely a foreign body in the uterus, which will soon have to be discharged. The time at which the expulsion will take place varies greatly ; sometimes after a few days only, sometimes weeks will elapse, and occasionally a month or more. The symptoms which arise will be those of abortion or labor, according to the age of the foetus at the time of its death. (See Abortion.) CHAPTER y. OF ABORTION. The term abortion has been applied to the expulsion of the foetus from the womb, where this occurs at a period of pregnancy when the product of con- ception is not yet viable: that is to say, an abortion may take place at any time between the commencement of pregnancy and the end of the sixth month. The ancients applied the term effluxio to this accident, if it hap- pened before the seventh day. 1 The term premature labor is usually applied to expulsion occurring after the sixth or seventh month. \\ e place i lie period of viability at the seventh month, though well aware that some reported where foetuses born at six, or five, or even four months, have lived ; but such instances, besides not having all the authenticity desirable, are too rare to invalidate the general law. OF ABORTION. 561 In a recent and very remarkable article by M. Guilkmot, this author admits three varieties of abortion, founded on the period of its occurrence : thus, ovular abortion is the title he gives when it takes place before the twentieth day; embryonic, if prior to the third month; and/ceto/, from the latter date up to the sixth month of gestation. Persons out of the profession, further, designate abortion under the title of miscarriage (fausse couche). Abortions are much more frequent in the first two or three months than at any other 1 period. The great vascularity of the uterine mucous mem- brane, become the decidua, and the ease with which effusions of blood may take place into the space which originally exists between the chorion and the reflected portion of the decidua (see page 552), sufficiently ex- plain the frequency of hemorrhage, and consequently of abortion in the early months. In making this remark, I am not ignorant that Madame Lachapelle has given a different view, but it was because her position at the Maternity rarely furnished her with opportunities of observing abortions prior to the fourth or fifth month, for females do not usually go to the hos- pitals on account of the miscarriages of the first five or six weeks of gesta- tion ; and though other persons have since adopted her opinion, it is doubt- less owing to the difficulty of diagnosis, and to the errors of females them- selves, who, supposing they have only a simple retardation of the menses, allow an abortion to pass away in the early stages unperceived. Morgagni and Desormeaux supposed that abortion of foetuses belonging to the female sex are more numerous than of males, and I do not know whether the vulgar opinion opposed to this is true or false ; but certain it is, that at term the boys exceed the girls in the proportion of sixteen to fifteen, which would seem to prove that female abortions are the most numerous ; and besides, it is possible that the difficulty of distinguishing the sex in the earlier periods of intra-uterine life may have had some influence in creating the popular error. The history of abortion evidently includes the study of the causes produc- ing it, the symptoms and consequences which may arise, the signs by which it may be detected, and the more suitable indications for preventing or opposing it. ARTICLE I. CAUSES. Considered in relation to its determining causes, abortion may be divided into the spontaneous and accidental. The term provoked has also been used, where the abortion has resulted either from criminal efforts, or from the measures adopted by the scientific physician with a laudable object. We shall retain this division for etio- logical purposes. § 1. Causes of Spontaneous Abortion. [The causes of spontaneous abortion may be sought for either: 1. In the father. 2. In the genera] health and habits of the mother. .">. In the state of the womb and its appendages. 1. En diseases of the ovum. o. [n diseases of the foetus. 80 562 PATHOLOGY OF PREGNANCY. 1. Causes due to the father. — At first thought, says M. Ferdut, coosidering the tran- sitory pari taken by the lather, it would not seem probable that be could be the cause of a miscarriage which should not take place until after two or three months. Such, however, is the fact, as is proven by the experience of women who invariably miscar- ried during the life of a first husband, but who were several times delivered safely at term after a second marriage. The influence of the father in causing abortion may be exerted in two ways — by his constitution and by his diseases. Ova, fecundated by men who are either too old or too young, rarely become, it is said, fully developed, and the same remark applies to those whose constitution is exhausted by debauchery or excesses of any kind. From M. Devillier's article in the new Dictionary, it would seem, however, that he thinks the idea of an influence exerted by the father in the causation of abortion should be received with considerable reserve. We would remark, says this author, that the procreative power is entirely distinct from that of develop- ment. If a man, under the conditions mentioned, has been able to fecundate a robust and healthy woman, the generative influence once having been communi- cated by him, the development of the product of conception would thenceforth be almost wholly under the influence of the vitality of the woman ; so that it is prob- able that the influence of the father would at least be very limited. (Devilliers.) It will also be understood that diseases of the father may, to a certain extent, be transmitted to the foetus and produce abortion. Of all these morbid conditions, syphilis exerts a more deleterious influence upon the duration of pregnancy than any other, though, it should be stated, all authors do not agree upon the subject. We believe, at any rate, that we would be correct in saying that, in some cases, the father, and not the mother, ought to be subjected to a prophylactic treatment.] 2. General Condition of the Mother. — "Women of a plethoric habit, and having copious menstrual discharges, are greatly exposed to abortion during the early months of gestation; in fact, we have already alluded to those hemorrhagic molimens that appear! in them at every monthly period. Again, nervous, or very irritable women, those who are strongly affected by moral impressions, such as anger, chagrin, &c. ; females of a sedentary habit, who are always shut up in the shops, as well as those that follow an indolent life, passing their time at balls or soirees, and in light reading, also abort very frequently. The surrounding atmo- spheric conditions are not wholly without influence in the production of abortion ; in fact, we may refer to this cause those epidemic miscarriages spoken of by most authors. Mountainous countries, where the air is bleak, are considered as being favorable to their production ; for, according to the report of Saucerotte, the women inhabiting the summit of the Vosges are very subject to abortion, and they are in the constant habit of descending into the adjacent plains to avoid this accident. Acute diseases, especially the eruptive fevers, and small-pox most par- ticularly, occurring in the course of pregnancy, abdominal or thoracic affections, and recent cutaneous diseases, often give rise to miscarriage. Syphilis in the mother has the most disastrous influence upon the progress of gestation, and even the mercurial treatment does not always secure from abortion. Some writers think thai the administration of mercury endan- gers the life of the foetus. Their opinion is, however, rejected by most modem writers upon syphilis, almost all of whom regard the antivenereal treatment begun at the outset of pregnancy, as the besl means of preventing OF ABORTION. 563 abortion. The numerous facta which have come under our own observa- tion, have changed our opinion upon this point, and we now think it most prudent to begin the treatment as soon as possible. It often happens, indeed, that, notwithstanding the existence of constitu- tional syphilis, when the mother has been treated properly and sufficiently long, the pregnancy continues to the full period, and the child escapes the infection to which it seemed fated. (Duval.) According to the author just quoted, it would seem that much depends upon the length of time which the disease has lasted. " Numerous observa- tions," he says, "show that syphilis at its commencement does not usually endanger the product of conception, but that, at a more advanced period, it involves the greatest peril." It should also be remembered that Dr. Paul's researches have shown that lead-poisoning may likewise produce abortion. The convulsive diseases may occasion miscarriage either by provoking uterine contractions, or by directly destroying the child. (See Eclampsia.) 3. Diseases of the Womb and its Appendages. — The causes dependent on the uterus are referable either to a particular state of that organ, or to a peculiar habit of the body, the influence of which is reflected back on the womb. The following are given as causes of abortion dependent on this source: An excessive rigidity of the uterine fibres, and their consequent resistance to dilatation ; an unusual contractility and sensi- bility of the organ, and too great a laxity and weakness in the uterine neck. I willingly admit that, in certain females, the excessive sensibility of the uterine fibre will scarcely support, without reaction, the strange modifications it must undergo during gestation ; but I do not equally com- prehend that species of opposition, which some authors seem desirous of establishing, between the resistance on the part of the uterine walls and the expansive force of the ovum. What, indeed, can an ovule, a few lines in diameter, effect against the thick walls of the womb ? or, what action can it possibly have on the uterine neck, that will explain the influence which has been accorded to this pretended laxity of the cervix, on the frequency of abortions ? The truth is, the ovum and the uterus are developed simulta- neously, but by forces peculiar to each. Therefore, although abortions are more frequent in primiparse, where the females have been married too young or too old ; and although certain women abort in all their pregnancies at nearly the same period, we must not on that account attribute these accidents to too great a resistance of the body, or to an extreme laxity of the neck ; for these repeated miscarriages, when not owing to the hemorrhagic tendency before alluded to, are far more naturally explained by the excessive irrita- bility of the womb. The organ has to habituate itself, as it were, to its new functions ; a proof of which is, that, in many females, the accident is repeated a number of times, but each time at a more advanced period ; so that, about the fourth or fifth pregnancy, they go on till full term. Hence, those uterine congestions, which are so often produced in plethoric women by the men- strual periodicity, and that excess of sensibility as well as of irritability observed in nervous females, are the only two predisposing causes that I consider as belonging to the uterus proper, and even they are mere exagger- 5 1 1 1 P A THOLOGY OF P RE( ; X A N CY. ations, as will be Been, of the physiological condition. Where abortions are often produced by the influence of either of these, they are designated as periodical. But, independently of these two causes, we must evidently take into account all the diseases of the uterus, whether acute or chronic, whose action is discernible : thus, the various tumors which may grow in the substance of it< walls, or may contract adhesions with them and the foreign bodies devel- oped in its cavity, also ulcerations, whether syphilitic or otherwise, which are so frequently found upon the cervix, are so many predisposing causes, which may both hinder and oppose its free enlargement ; and lastly, let us add the various displacements of the uterus, such as prolapsus, lateral obli- quities, or anteversion and retroversion, as acting in the same manner. On the part of the appendages, all the chronic diseases to which they are subject ; the adhesions, deformities, displacements, and their divers degenera- tions ; the organic alterations of the tubes, fibrous, polypous, or other produc- tions seated in the uterine tissue or neighboring parts ; unnatural adhesions of the broad or the round ligaments, tubes, or ovaries : in a word, everything that can impede the easy and free development of the womb, must be re- garded as occasional causes of abortion. (Madame Boivin, Recherches sur une cause peu conmie d'avortement.) Finally, an inflammation of the adjacent organs, particularly the bladder, rectum, &c, may, through the irritation thereby communicated to the uterus, bring on its contractions. Moreover, the existence of any voluminous tumor in the abdomen must necessarily incommode the development of this organ ; also the compression of the hypogastrium, that some women produce by the use of corsets, may have the same effect. , According to Peu, we must add to these various sources of inconvenience, contraction of the pelvis opposing the distention of the womb, and sometimes its elevation above the superior strait ; more especially when the narrow- ness of the latter coincides with the regular, or even an increased size of the excavation. 4. Diseases of the Ovum. — Any of the diseases of the ovum may give rise to abortion, and we shall not repeat what we have said concerning them. (See Diseases of the Ovum). It will suffice to mention here that the most impor- tant of these diseases are, dropsy of the amnion, hydrorrhcea, the hydatiform mole, placental apoplexy, and fibro-fatty degeneration of the placenta. As regards the insertion of the placenta over the neck, I can scarcely believe that it could produce an abortion, and hence I imagine that the cases cited in support of that view have been misinterpreted; the insertion has been considered as the cause of the accident in those instances, when it cer- tainly was nothing more than a simple coincidence. M. D'Outrepont has advanced the torsion of the umbilical cord as a cause of determining the death of the foetus ; for the state of compression, says he, resulting therefrom, may impede the circulation. The embryos had been dead for a long time, in all the cases of that kind observed by him. Again, it may be asked, if the umbilical cord is too short, could it drag off or detach the placenta, or even be ruptured itself? Now, to the facts bearing on this point, reported by Mauriceau, Stein, &c, M. Guillemot adds OF ABORTION. 565 the following: The foetus was about three months old, the umbilical cord was tightly stretched and even half separated near its origin at the navel ; two folds of it encirlced the neck, and some deep marks were left on this part from their pressure. The circulation, he continues, was therefore inter- rupted in the cord by the tension and compression it sustained ; and the strangling: of the child's neck also contributed to its death. M. Deneux has furnished a case of a rupture of the umbilical vein, and effusion of its blood into the tissue of the cord itself; he found there a clot, equalling a small nut i'q volume, which had interrupted the circulation in the umbilical vessels by its pressure. Lastly, the disease of the membranes, and of the umbilical vesicle, also prove a frequent cause of abortion, especially in the early stages of embryonic life ; for in more than two hundred products of conception, that had not passed beyond the third month, M. Velpeau generally found an alteration of some part of the ovum. 5. Diseases and Death of the Foetus. — Circumstances, which are often unknown to us, may arrest the development of the foetus : for instance, it may be affected in the mother's body, by those acute diseases which at times beset it after birth ; and such affections, though not always fatal to the new-born infant, are the most disastrous to the intra-uterine foetus as they occur the nearer to the period of fecundation. (See Diseases of the Foetus.) We may add, the presence of several children as a cause dependent on the child ; in fact, we have elsewhere seen that the excessive distention pro- duced by a twin pregnancy, frequently brings on premature contractions. However, the uterus is rarely developed enough prior to the sixth month to provoke such an accident, for this seldom happens until a more advanced stage, and then it no longer appertains to abortion properly so called. Some diseases of the parents may affect the child ; for example, a vitiated spermatic fluid communicates to the new being a principle which does not fail sooner or later to destroy it. M. Guillemot attributed the numerous miscarriages of a young lady who consulted him to this cause ; for her hus- band, although of a suitable age, exhibited all the characters of premature decrepitude. Having become a widow, she remarried, was several times pregnant, and was always delivered happily at full term. The mother, also, may transmit her diseases to the child. Nothing, indeed, is more common than to find children presenting, a few weeks after birth, evident traces of the venereal infection received from the mother during intra-uterine life, and hence we may conceive that this hereditary taint may prove fatal to the foetus whilst still within the womb. Small-pox is also sometimes communicated from the mother to the foetus, and causes its death. It is remarkable that several circumstances seem to prove, that the infection frequently does not take place until after the mother's recovery. (See page 447.) In some cases, the body of the mother is but the conductor of a conta- gious principle of small-pox. We might here add examples in addition to those already cited (page 447). Some years ago, a woman, in the wards of Professor Fouquier, was deliv- ered of a dead child affected with small-pox, although she had herself been 566 PATHOLOGY OF PREGNANCY. vaccinated. Finally, the illustrious Mauriceau relates that his mother when in the last stage of her pregnancy, had the misfortune to lose the eldest of her three sons by small-pox, to whom, notwithstanding her condi- tion, she was unceasing in her attentions ; and that at his birth, which occurred the day after the death of his eldest brother, he presented four or five pustules of small-pox. In short, all the diseases to which the foetus is subject may be followed by abortion. Its death always produces it. § 2. Causes of Accidental Abortion. Besides the causes just enumerated, that have been designated by most writers as the predisposing ones, but which, perhaps, would be more appro- priately called slow-acting causes, there are yet some others that might be termed accidental causes : such as those which operate from without, and make their influence more promptly felt. The latter are very numerous ; indeed, on reading the published cases, we find that authors have considered all the moral and physical excitements that women are subject to, as so many causes of abortion. In most of the recorded instances, we can readily 6atisfy ourselves that the observers have attached too much importance to these occasional causes of its production ; for, generally speaking, it would have occurred without them, only, perhaps, a little later ; and even here the expulsion of the foetus is, in truth, owing to the slow and gradual action ;>f the predisposing cause. However, there are some accidental causes whose influence is indisputable. For instance, falls, excessive fatigue, too frequent coition, and severe contusions, have, in some instances, produced immediately a loss of blood, followed by abortion. Falls and contusions may act in two ways : either by bruising or violently irritating the mother's organs, or by wounding the foetus, and determining its death. The latter has been denied by some persons : but to the instances now known to science, I will add the following from my own observation : A young woman, six months pregnant, struck her abdomen violently against a table while walking in the dark in her chamber ; during the night, the motions of the child were for a time quite tumultuous, then they diminished, and on the following morning could not be perceived at all. Two days afterwards she was delivered of a dead child, which presented an ecchymosis on its back as large as the palm of my hand. Burdach speaks of a woman who received a blow upon the lower part of the abdomen, when in the sixth month of her pregnancy, and who was delivered of a child, the bones of one of whose legs and of a forearm had been fractured, and united at an acute angle. The jarring attendant upon travelling by rail, or too great use of a sewing-machine, are also capable of giving rise to abortion. I shall not enumerate here the various circumstances that have been considered as occasional causes ; but, by way of showing how their importance has been overrated, I will merely remark that, although certain women, who are constitutionally predisposed to miscarriages, may abort in consequence of a trifling fright, or the odor of a badly snuffed candle, yet there are others, on the contrary, who will suffer the most acute moral im- OF ABORTION. 567 pressions, and the most violent physical shocks, without any accident what- ever resulting therefrom; and nothing would be more easy than to bring forward numbers of cases in support of this proposition ; the following, however, may be sufficient : I had an opportunity of observing, at the Hotel Dieu, when acting as an "interne" in the obstetrical wards, a young girl in the fifth month of pregnancy, who, being rendered desperate by the desertion of her lover, cast herself into the Seine, from the Pont Neuf, yet, notwithstanding so violent a shock, the gestation pursued its regular course. Again, M. Gendrin speaks of a young lady who was thrown from a chaise over the horse's head by the animal falling in his career. This lady was then five months pregnant, but the accident did not prevent her from reach- ing her full term. I met with a case precisely similar in the wife of a notary living near Paris. I was consulted, in Sept., 1845, by a young lady, who was evidently six or seven months advanced. Her physician had suspected an inflammatory engorgement of the womb, and during the third or the fourth month this gentleman had applied fifteen leeches on the neck of the uterus itself; and, strange to say, not only was this application unattended by any accident, but the patient seemed relieved of the distress and pain in the hypogas- trium. And, lastly, is it necessary to refer here to all the manipulations, and all the violent remedies, that some distracted women make use of in vain to procure an abortion ? § 3. Causes on Account of which Abortion is artificially produced. The third order of cases still remaining for our examination are the means of producing abortion. These must be distinguished according to the pro- posed object : that is, whether, in producing an abortion, the indication be to relieve the woman as well as the infant, if the latter is well developed, from the dangers that threaten them (and we shall treat of the means to be em- ployed in such cases when we speak of the indications presented by the mother's vices of conformation), or whether, contrary to all the laws of morality, the design is to destroy the foetus in the body of its mother, for the sole purpose of concealing the traces of an illegitimate pregnancy. But sve have nothing whatever to say concerning the measures resorted to by criminal hands in such cases, for, unfortunately, they are too well known. ARTICLE II. SYMPTOMS OF ABORTION. The signs of abortion vary with the period of its occurrence, and alsu with its determining cause. Thus, when it happens in the early (lavs of gestation, it is attended by but very few remarkable phenomena; and, in general, the pain is so trifling that the patient scarcely suffers more than from a difficult menstruation. The first uterine contractions are sufficient to produce the complete separation of the ovum, the adhesions of which arc still very feeble ; and it escapes either in mass or in shreds, usually sur- rounded by fluid or half-coagulated blood, and, being mistaken for a clot, it oi'ten passes away unnoticed, most women then supposing that they have 568 PATHOLOGY i>F PREGNANCY. only had a slight postponement of their menses, followed by a more difficult and abundant flow than usual. At a more advanced stage, the symptoms are much better marked, but still vary with the cause of the abortion. For instance, when this accident has been produced under the influence of bad health in the mother, or of chronic diseases, or those causes that operate slowly, by altering the genital organs, or the ovum and its membranes, the following symptoms are ordi- narily observed, namely: shiverings succeeded by heat, anorexia, nausea, thirst, spontaneous lassitude, palpitations, cold extremities, pallor, sadness, depression of spirits, tumefaction and lividity of the eyelids, want of bril- liancy in the eyes, a sense of sinking at the epigastrium, of cold about the pubis, of weight near the anus and vulva, pain in the loins, vesical tenesmus, frequent ineffectual desires to urinate, and a weakness and flaccidity of the breasts, from which a serous fluid sometimes exudes. These phenomena may be considered as the precursors of an abortion ; for, when they have lasted for some time, the pains in the loins become more and more acute, extend round to the hypogastrium, and are renewed at short intervals, finally assuming all the characteristics of the regular uterine contractions. During these pains, if the uterus is sufficiently high up to be easily dis- tinguished above the pubis, it will be felt to harden sensibly, whilst at the same time a sanious discharge takes place from the vagina, afterwards becoming sanguinolent, and eventually replaced by liquid or grumous blood. If the woman be then examined per vaginam, the neck will be found partly dilated, the dilatation advancing progressively with the fre- quency of the pains ; the membi-anes begin to protrude, then engage, and ultimately rupture; the waters escape, and the foetus and placenta are suc- cessively expelled. Usually in those cases in which the cause has operated slowly, whether dependent on diseases of the mother or affections of the ovum, the foetus dies before the labor, or at least during the first pains. When the abortion is a consequence of the occasional violent causes, it usually has quite another course. Thus, in some instances, the expulsion of the ovum closely follows the accident ; a woman slips in descending a staircase, and falls violently on her seat; when she rises, her clothes are flooded with blood, for an ovum of six weeks has been driven out, together « ith a large quantity of fluid blood. This, however, is more apt to occur in the beginning of pregnancy; for, at a more advanced period, some inter- val always elapses between the accident and the consequent abortion. The phenomena then observed vary, according to whether the cause has affected the mother's organs, or has directly influenced the foetus itself. In the former case, the mother experiences, at the time of the accident, a sharp pain, either about the loins, or else in some part of the abdomen ; after the lapse of a few days, during which the pain has diminished, or even entirely ceased, it is violently renewed, and followed almost immediately by uterine pains and contractions, a slight dilatation of the neck, some dis- charges of serosity from the vagina, at first reddish, then sanguinolent, and lastly pure blood. Finally, if the travail continue, the foetus is expelled as usual, and often living. OF ABORTION. 569 'Hie expulsion is almost always effected very slowly, and the pi ogress of the lahor is far from being as regular as at term. The resistance occasioned by the length and hardness of the cervix at this period sufficiently explain the extreme slowness of its dilatation ; and even when the latter is sufficient, the contractile powers of the uterus are yet so feeble that the ovum may remain engaged in the orifice for several days, and even project into the upper part of the vagina, before being expelled completely. When the cause has acted directly upon the foetus, either mechanically, as by a violent blow or concussion, or physiologically, by destroying to a greater or less extent its vascular connections with the uterus, the subse- quent course of affairs is different ; for here the phenomena which announce the death of the product of conception are the first to be manifested. After the few hours necessary to dissipate the agitation and fears caused by the commotion she has experienced, the woman feels no pain nor inconvenience ; everything is calm, and seems to resume its natural order ; but, after the lapse of a few days, sometimes only eight or ten, the movements of the foetus, which had up to this time maintained their usual force and frequency, become weaker, are separated by longer intervals, and finally become imperceptible. From this moment, the uncomfortable sensations and diges- tive disorders, which had annoyed the patient from the outset of pregnancy, disappear as though by magic ; the swelling of the breasts and prickling sensations which had affected them, also diminish or cease entirely. A miscarriage is then inevitable, for the ovum is a foreign body in the uterine cavity, and soon irritates the walls of the organ by its presence ; the latter contracts, and the expulsion is generally effected about eight to nine days after the accident. In this case, the process advances in a more regular manner, because the womb has had time to prepare itself for the act. However, this term is not uniform, it being not at all uncommon for the dead foetus to remain much longer in the womb : two or three weeks, or a month, for example. I saw a woman at the Clinique, in whom the child's death was clearly ascertained, though she did not abort until six weeks afterwards. Cases are also recorded of the embryo remaining in the womb until the ninth month. The development of the contractions is solicited by the derangement which this condition of death gradually produces in the placental circu- lation; indeed, the quantity of blood arriving in the placenta often dimin- ishes by degrees, and ultimately becomes almost nul; but this is not always the case, since, in some instances, the circulation continues, and the placenta enlarges, — attains even to double the volume of that at term, and after its expulsion exhibits the same degree of integrity. Lastly, in other cases, says M. Guillemot, the placenta retains its vitality and grows; but, at the same time, assumes unusual forms, and a singular structure, exhibiting a cavity in which remains of the foetus are hardly to be found. Where a long time thus ensues between the period of the child's death and that of its expulsion, there is, in general, less danger from hemorrhage than if the premature labor had taken place immediately. In these abor- tions, less blood is usually lost than in the labors which come on naturally, after tin most favorable gestations; which is probably owing to the fact 570 PATHOLOGY OF PREGNANCY. that the child's death diminishes the activity of the uterine circulation, especially that of the utero-placental vessels, which must then become obliterated in a great measure, and consequently can furnish but little blood at the time when the placenta is separated. We have seen (page 558) that the general phenomena experienced by the mother after the death of the foetus are very singular in these cases, but abortion does not always follow immediately, a variable interval, sometimes a long one, intervening before labor begins. The child born under these circumstances has a peculiar macerated appearance, but no evidence of putrefaction. But it happens otherwise when, the foetus being dead, the membranes are ruptured, and the expulsion is delayed; for then a rapid putrefaction sets in, as a consequence of the contact of the child with the external air. A high fever, characterized by the symptoms of a veritable infection, develops itself; a dark fetid liquid oozes from the genital parts, mixed with shreds, in a state of putrefaction ; and if the uterine contractions do not speedily relieve the organism from this source of infection, the patient may rapidly succumb under its deleterious influence. Finally, when the abortion is brought on by the existence of two children, the twins are nearly always expelled simultaneously; although we have occasionally known the women to abort of one child in a multiple pregnancy, whilst the other continued to grow. Hemorrhage is one of the most common symptoms. It may precede, accompany, or follow the expulsion of the foetus, and is of such frequent occurrence that most authors make it the principal disordei In some cases it is certainly the cause of the abortion, though often merely a con- sequence. Sometimes, indeed, the miscarriage is accompanied with but slight hemorrhage. The latter circumstance is, however, rare, especially in the false labors that take place before the end of the fourth month ; because a more or less abundant discharge of blood nearly always show 7 s itself during the first expulsive pains, and persists until the uterus is completely emptied; but, as we all know, nothing of this kind is observed in labor at term. M. Jacquemier has happily explained the difference between the two in the following manner: He states that, towards the end of gestation, the placenta spreads out from the centre towards the circumference, in order to conform itself to the uterine enlargement at its greater extent; and this is accom- plished in such a way that its different lobes, by separating from one another, have a considerable space left between them. 1 From this it follows, that, within certain limits, the uterine contractions have no tendency to detach it; for the placenta accommodates itself wonderfully to the retraction of the organ until it reaches its own proper limits; and even then its great flexibility permits a further reduction, so as to follow the uterus as it becomes less, before the detachment commences, and this latter phenomenon only takes place when the entire foetus is nearly expelled. But, prior to the fourth 1 To convince one's self of the truth of this fact, it is only necessary to see the pla- centa still adherent to a uterus which has been developed but is not yet retracted, or even the uterine surface this mass occupied ; for the latter is nearly one-third larger than the surface of the placenta which covered it. [Jacquemkr.) OP ABORTION. 571 month, the after-birth is far from offering the same conditions ; since the thickness of the uteroplacental decidua and the large amount of plastic matter interposed between the lobes at that time, confer upon it a much greater density; and therefore it can only yield within very narrow limits, either in the way of extension or retraction towards its centre. Hence, the facility of its separation during the early contractions, the rupture of a certain number of vessels, and the incessant hemorrhage throughout the whole duration of the labor. ARTICLE III. DIAGNOSIS. Judging from the numerous signs just given, the diagnosis of an abortion ought to be very easy ; but, unfortunately, these signs are not very clearly marked until the accident is inevitable, and consequently, when it is a matter of indifference to the patient whether the physician makes oui. a clear diagnosis or not. It is, therefore, in the beginning of such symptoms, especially, that we should endeavor to recognize their true nature, because then only can our art succeed in arresting their progress ; but this is exceedingly difficult. The diagnosis of abortion involves the solution of several questions. Is the woman pregnant ? And, supposing the pregnancy to be determined, are the symptoms those of a simple uterine congestion, or of a commencing abortion ? Lastly, is the abortion inevitable ? 1. Is the Woman Pregnant? — This first question is quite readily resolved after the fourth month of gestation, though before that period it is almost always unanswerable. All practitioners of obstetrical experience are aware of the difficulties which often involve it. Thus, a woman in good health has her courses suddenly suppressed for several months without *vny appre- ciable cause, the breasts swell, and the body increases in size : in a word, she experiences several of the phenomena properly regarded as rational signs of pregnancy ; then, all at once, at the return of the third or fourth menstrual period, some symptoms of congestion of the uterus appear, last for several days, and are soon followed by a slight flow of blood. How, then, shall we determine whether the pains felt by the patient, and the dis- charge of blood from the vulva, are owing to a return of the interrupted menses, or to an approaching abortion ? The pains attendant on difficult menstruation, especially after a suspension of several months, resemble greatly, both in situation and intermittence, those of abortion. According to Madame Lachapelle, in abortion the uterine orifice is open, the hemor- rhage precedes the pains, and the latter persist notwithstanding the abun- dance of the discharge ; whilst in difficult menstruation the orifice is closed, the pains are felt before the hemorrhage appears, and they diminish or even cease entirely when the discharge is well established. The contrary, how- ever, not unfrequently occurs. Doubtless a strict investigation of the circumstances which accompanied and followed the suppression of the menses, and an examination of the uterus, might lead to an opinion as to the probable state of the case ; but 672 PATHOLOGY OF PREGNANCY. what experienced physician does not know how deceptive are all these rational signs, when we take into consideration the tendency to exaggerations of the females, who so readily believe what they wish or what they fear, as also how nearly the congestion, which precedes and accompanies the sus- pended menstruation, places the uterus in the same physical conditions as in a commencing pregnancy? Does the blood escape from the genital parts as a clot? It has been hoped that the shape of the latter might furnish a reliable sign. It has been stated that the clot driven from the unimpregnated womb exhibits a triangular form, corresponding to that of the cavity where the blood coagulated, which never happens when a product of conception is present ; but this may fail, as the clot is mostly changed in its shape by traversing the neck ; and, on the other hand, in abortion, the blood may collect and coagulate in the vagina, and the coagulum exhibit the indi- cated character. But, if the coagulum be still in the cervix uteri, and supposing the finger is able to reach this point, how can we distinguish whether the foreign body felt there is a clot or ovum ? For this purpose, Holl has laid down the fol- lowing signs : If the finger introduced into the orifice perceives the mass to become tense during the contraction, to augment in volume and advance towards the vulva, it is an ovum engaged in the os uteri ; and if it were a clot, it might be recognized by its fibrinous structure ; besides, during the pain, its exterior surface would not be more tense, nor more smooth, and it would not appear forced down, but rather compressed ; finally, as the ovum resembles a soft bladder, its inferior extremity is rather rounded than pointed, while the coagulated mass is more resistant and solid, is less com- pressible, and has, in general, the form of a cone, the enlarged extremity of which is above and the apex below. Finally, if we should then attempt to move the uterus in its totality by pressing on this mass, it might be easily effected if there were a clot con- cerned, whilst the parietes of the ovum would yield, and would not transmit the motion to the organ which envelops it, and with which it is then but feebly adherent. The question is therefore by no means simple, yet it is important to know whether pregnancy really exists; for as the appearance of the menses is then of very rare occurrence, especially when they are absent in the early months, a flow of blood should be treated as a serious accident, which, on the contrary, would be promoted, if attributable to a return of the courses. Notwithstanding these uncertainties, there may be a union of circumstances Buch as to allow of at least a probable diagnosis. Thus, if a woman, who has been habitually regular, finds her catamenia to stop suddenly and unac- countably; if this suppression is followed by other rational signs of preg- nancy; if the pains continue notwithstanding the discharge of blood; if they appear as an effect of any violence whatsoever, or if they present any thing unusual as respects either intensity or duration, it may be concluded that abortion is imminent. The diagnosis becomes more certain if the blood Hows more profusely than in ordinary menstruation, if it is accompanied with sharper pains in the hypogastrium than is usual, if coagula are OF ABORTION. '"'' expelled, and if the orifice is sufficiently dilated to admit the extremity of the finger. . , 2 Pregnancy existing, may the symptoms be attributed to simple con- gestion of the uterus, or should they be regarded as the first tokens ot a Threatened abortion? Though it is very difficult to decide this question within the first three or four months, and at the beginning of the accident, its solution is happily of little importance as regards the treatment, the measures indicated by simple congestion being equally applicable to the prevention of miscarriage. When symptoms, which in all appearance were due to simple congestion, have yielded to proper treatment, the physician is often required to answer a question whose rigorous solution is always impossible : namely, the abdom- inal and lumbar pains being allayed, and all the other alarming symptoms removed, is the patient therefore out of danger of miscarriage? In the majority of cases we can tell nothing about it, for it is impossible to know whether the congestion has been arrested in time to prevent a rupture of blood-vessels, and an effusion between the placenta and uterus, or whether the separation of the placenta is extensive enough to have destroyed the foetus immediately ; even supposing the child to be still living, we canno ascertain the degree of separation of the placenta, nor foresee the effect which a partial destruction of its maternal attachments may have upon the foetus. Very frequently, indeed, the latter, by being cut off from a con- siderable part of its means of respiration, is placed in the condition of an adult whose lungs are in great measure destroyed, and whose respiration and nutrition being insufficient, gradually wastes away, so the child often does not perish until after the lapse of eight days, two weeks, and frequently even not until the next menstrual period ; this, too, without the appearance of any new symptoms to explain its unlooked-for death. The physician cannot therefore be too reserved in his diagnosis, as regards the possible consequences of such accidents. 3. Finally, supposing the abortion begun, can we hope to arrest the symptoms? The intensity of the pains, their constant direction from the umbilicus towards the coccyx, the previous duration of the discharge and the amount of blood already lost, softening and dilatation of a most the entire neck, and even of the internal orifice, and projection of the mem- branes during the contraction, doubtless indicate a very unfavorable prog- nosis, though they should not destroy all hope. All these symptoms con- jointly have in fact been known to yield to appropriate treatment, every- thing to resume the natural state, and the pregnancy to go on as usual. Some authors even state that the rupture of the membranes and discharge of the amniotic fluid does not render abortion inevitable, lhis Last asser- tion, however, seems to me to be at least very contestable, lor it ,s infinitely probable, not to say certain, that in the cases alluded to there has been a mistake in reference to the true origin of the waters lost by the patient. It appears to me that a rupture of the ovum must inevitably give rise to abortion; and Desormeaux has certainly confounded cases of hydrorrhea with the true discharge of the amniotic fluid. _ _ A young lady, who had already been so unfortunate as to miscarry in her 574 PATHOLOGY OF PREGNANCY. first pregnancy, to be delivered of a dead child in the second, and finally to have lost a little girl of six months, had advanced three months and a half in a fourth pregnancy. After returning from mass, in a church very near her dwelling, there was a sudden discharge of flnid from the genital organs, to an amount estimated by the patient at about a tumblerful. Ou first seeing her, I thought abortion inevitable. Then, upon a careful exami- nation of the uterus, it seemed to me, that, notwithstanding the loss which had occurred, the organ presented its usual size, a certain elasticity, a pecu- liar suppleness showing that some fluid must still remain within the amni- otic cavity ; there was nothing peculiar in the state of the cervix ; no flow of blood ; neither was there pain before, during, or after the discharge of water. In acquainting the patient with the fears which I entertained, I also assured her that all hope was not lost, and that the circumstances just mentioned presented collectively features which do not usually appertain to ruptures of the ovum itself. Absolute quiet, a small bleeding from the arm, opiate enemata, and hand-baths, to be repeated morning and evening, were directed. No new symptoms supervened, and the development of the uterus continued. For the first two days, there was still a very small dis- charge of water. At four months and a half, and also without appreciable cause, there was a sudden escape of five or six spoonfuls of a fluid similar to the preceding. After this, nothing of the kind occurred until the end of her pregnancy, which terminated very happily. (See Hydrorrhea.) Abortion is really inevitable only when the foetus has ceased to live, or when the separation of the placenta and the rupture of the utero-placental vessels are so extensive that the remaining utero-placental attachments are unequal to the support of the foetal respiration. In order to estimate the probable degree of disturbance of the utero- placental relations which has taken place, much more regard must be had to the amount of the discharge than to its duration. A simple exudation, or a moderate flow of blood, may continue for several days or weeks, since it may originate in the rupture of very few vessels ; I have known it to last for six weeks and two months, without compromising the pregnancy ; but that the patient should lose a considerable amount of fluid or coagulated blood in a short time, the placenta must be separated to a considerable extent, and abortion almost necessarily ensues. There is still another peculiarity not mentioned by authors, which appears to me of importance, inasmuch as it cuts off almost all hope of arresting the progress of the symptoms: I allude to a particular form of the neck. When the patient has been for a short time only pregnant, we know that it is always easy to distinguish the neck of the uterus from its body; in the irreat majority of cases, we may even feel the angle which separates them. Now, when the contractions have lasted for a certain time, they have grad- ually dilated the internal orifice; the cavity of the neck has become con- founded with that of the body, and when the finger in the vagina is passed over the entire lower Begment of the uterus, the neck can no longer be dis- tinguished from it; a well-defined limit between them is no more to be detected, and all that belongs to the neck of the womb has the shape of a peai, the larger part being continuous with the body of the organ, and the OF ABORTION. 575 lower extremity corresponding with the external orifice. "Whenever I have met with this condition of things, abortion has taken place. " The vagina itself," Dr. Coffin remarks, "is so far affected, that its upper extremity becomes rounded, the rugse are effaced, and the finger meets everywhere a smooth and regular surface like that of a polished vase." It is impossible to ascertain certainly in the early months, whether the foetus be living or dead. I must, however, mention a peculiarity which in my estimation is of great value in reference to this question : namely, the sudden cessation of the vomitings, salivation, or any other sympathetic functional disorder of pregnancy. When, after an accident, vomiting and salivation cease, there is cause to fear that the child is dead, the persistence of these discomforts being on the contrary a favorable sign. Happily, though the uncertainty upon this point makes an exact prognosis impossible, it in no wise affects the treatment. Whenever, indeed, a collective examination of the general and local symptoms leads to the supposition that the child \s living, and that we may hope to arrest the progress of the accident, we should act as though we were certain. We see, therefore, that in the first third of gestation the diagnosis, at the best, can be only probable. At a more advanced stage of gestation, the diagnosis is much more cer- tain. First, because we can then generally ascertain the development of the uterus without difficulty ; then, again, pains are more energetic : the blood flows in greater abundance, and the dilatation of the os uteri is more easily detected ; but it becomes still more certain when the death of the foetus can be verified in a positive manner. (See Signs of the Death of the Fcetus, page 558.) ARTICLE IV. DELIVERY OF THE AFTER-BIRTH. The spontaneous expulsion or the extraction of the placenta presents very different phenomena according to the period when the abortion takes place ; and, in this respect, it is highly important to distinguish the accident in the first two months from that of the third and fourth, as also from that of the fifth and sixth ; for the ovum is usually expelled entire iu the first and second months, but in the two latter the expulsion of the placenta is accomplished nearly in the same way as at term. But in the third and fourth months it is altogether different, because the placenta, which is already voluminous, has contracted at this period numerous and very inti- mate adhesions with the womb, which has not as yet acquired all the con- tractility of tissue that it possesses at term; consequently the premature contractions, although sufficiently energetic to rupture the ovum, are not adequate to the destruction of the utero-placental adhesions. Hence, under the influence of such contractions, the amniotic sac, being pressed on all sides, yields near the neck, the waters escape, the little foetus is expelled, And the very delicate umbilical cord breaks easily; at the same time a cer- tain quantity of liquid or coagulated blood is poured out, and very often the small fcetus is lost in the midst of the coagula that accompany its discharge, Then the uterus, being partially evacuated, retracts, the neck closes up 576 PATHOLOGY OF PREGNANCY. and the symptoms disappear; nevertheless, the placenta and membranes are still undelivered, and may remain in the womb for eight, ten, or twelve days, or even longer. Dr. Advena, of Labischin, reports an instance where the after-birth was not expelled till three months subsequent to the abortion this latter having occurred at the fifth month of pregnancy. {Journal de ( 'hirurgie, Aug. 1843.) The complete closure of the neck evidently makes the introduction of the finger impossible, so that every attempt made for this purpose would prove fruitless. Ergot may, indeed, be administered with the object of exciting contractions, though I have never seen it have any good effects when given under these circumstances. To wait, at the same time watching carefully, is all that can be done. The symptoms which may then result from retention of the placenta are very variable, and should be carefully studied. 1. Very frequently, nothing at all unusual is observed for a few days fol- lowing the miscarriage. The general health is good ; the patient, believing herself entirely cured, gradually resumes her ordinary occupations, when ali at once, and without any known cause, some intermittent pains are felt in the hypogastrium, and a little blood escapes from the vulva. The woman often neglects these primary symptoms, but they persist and augment in intensity, thereby constraining her attention to them; for the placenta has become a foreign body in the womb, and, irritating the uterine w r alls by its presence, excites their contractions; these break up the utero-placental adhesions, and the after-birth is almost free in the uterine cavity. This separation is always accompanied by hemorrhage, which is at times verv abundant, because the os uteri dilates with so much difficulty, to permit the foreign body to escape, that the latter, by remaining in the womb, encourages a hemorrhage by irritating the organ and preventing the complete contrac- tion of its walls ; insomuch that, if art does not seasonably interpose, life itself may lie endangered. What is still worse, if the physician was not pres- ent at the time of the miscarriage, and carefully examined all the clots him- self, tin 1 attendants will tell him that the after-birth and the child were expelled together, and he may possibly overlook the cause of the accident. Consequently, the accoucheur should rely exclusively on his own personal examination, lie must absolutely touch the female, when he will usually find the os uteri to be partially dilated, and a portion of Lhe placenta hang- ing in its orifice. It then is only necessary to seize this portion with the two fingers, for its extraction is, in general, quite easy. In case of necessity, Levret's abortion-forceps, Duges' placenta-crotchet, or Pajot's curette, might be used for this purpose. [It has always been my practice to remove the whole ovum — foetus, placenta, mem- branes, ami all — before leaving a patient who is aborting, provided, of course, the uterine canal was sufficiently patulous ami no injurious force was required to accomplish my object. To remove the placenta and membranes, 1 have used preferably my fingers, aided by pressure on the abdominal walls, and when I failed with this method, I have always succeeded in detaching the secundines with a large, blunt curette, and in re- moving them with the fingers or a long, broad forceps. My reason for this has been that no woman has seemed to me free from the danger of hemorrhage or sepsis, so long as a portion of the secundines remained in the uterus, and I have never had occasion to regret following this practice. (SeeAmer. Jour, of Obstetrics, Feb., 1881.)— P. F. M.l OF ABORTION. .",77 Sometimes the adhesions of the placenta are so numerous that it is im- possible to destroy them. It is then possible, by strong pressure upon the hypogastrium, to depress the womb, so that the forefinger of the other hand can be passed into its cavity, and glided between the placenta and the uterine walls. If this does not succeed, the tampon must be resorted to, and the ergol administered at once ; conjoint use of these measures rarely tails to arrest the hemorrhage, and bring on sufficient contraction to expel the secundines. 1 Such are the measures whenever the hemorrhage becomes dangerous either by its duration or abundance. When, however, it is arrested, espe- cially when the placenta is partially engaged beneath the orifice, and seems to prevent, by its presence there, further discharge, we should wait, and be very careful how we attempt to extract it immediately. The engagement of the placenta in the cavity of the neck maintains in the latter a degree of dilatation likely to facilitate its complete expulsion, and besides exciting, as a foreign body, the sensibility of that part, also excites, or at least keeps up, the contractions of the fundus of the womb. Tractions upon the engaged portions might tear the placental mass at the point of constriction by the retracted internal orifice. Now immediately after this partial ex- traction, the neck would resume its former condition, the internal orifice would close more or less completely, and render impossible the removal of the portion of placenta remaining in the cavity of the body of the uterus. 2. Sometimes the placenta remains in the uterine cavity after having been separated wholly, or in part, and soon undergoes decomposition, just as though it were exposed to the air ; the lochia become fetid ; the uterine walls, being in contact with the substances in course of putrefaction, absorb a portion thereof, and, as a consequence, fever is developed, together with all the symptoms of a putrid infection. In these cases, we should evidently relieve the womb from those foul materials that infect the whole economy ; unfortunately, the neck of the uterus is completely closed, and an intro- duction of the finger thereby rendered impossible. Often it is exceedingly difficult to make the extremity of a canula enter for the purpose of throw- ing detergent injections into the uterine cavity, and we are then compelled to await the complete expulsion of the sanious matters resulting from the , decomposition. In such cases, M. Velpeau speaks favorably of the use of ergot. This, indeed, is a remedy that might be used, but from which, nevertheless, we should not expect too much. 2 A lady, thirty-five years of age, whom I suspected to be pregnant, although she would not believe it, felt a discharge from the parts after a suspension yf the menses for two months and a half, which she at first mistook for a return of her courses, but which, after riding out in a carriage, was suddenly 'Full doses of the fluid extract of ergot, or subcutaneous injection of ergotine, should be given. It is strongly advised to soak the pledgets of col ion, wool, the sponge, or other material used for plugging the vagina, with glycerines or carbolic acid and water (2ss. to ()j.). The tampon should not be allowed to remain longer than from 6 to 12 hours without renewal. 2 If, after employing the tampon for twenty-four hours, the cervix remains closed, a tupelo tent should be resorted to, never a sponge, on account of the danger of septic infection. 37 OlS PATHOLOGY OF PREGNANCY. converted into a profuse flooding. Having been summoned immediately, I found the os uteri slightly dilated, and I forthwith employed various mea- sures adapted to the arrest of the discharge, and among others the ergot. The hemorrhage gradually diminished, and at ten o'clock p. M. (six hours subsequent to the invasion of the symptoms) it had entirely ceased. During the first five days the patient did very well, but on the sixth I thought I detected a slight odor in the lochia, and at three o'clock in the afternoon a violent chill came on, which lasted an hour. From this moment all the phenomena of absorption were manifested. I immediately administered forty grains of the ergot, but without effect, for nothing came away ; and notwithstanding the enlightened efforts of Messrs. Chomel and Moreau, who were several times called in consultation, this unfortunate lady died on the tenth day following the appearance of the first symptoms. At the post- mortem examination we found the uterine tissue softened, and its cavity filled by the putrefied and still adherent placenta, which we could not separate without tearing. 3. It may further happen that the placenta, maintaining its vascular adhesion with the internal surface of the organ, continues to be developed after the child's death, the cord and foetus become atrophied, and then com- pletely destroyed ; or, indeed, the ovum may rupture, and the little product escape, leaving the membranes behind. These envelopes may undergo various modifications, but the most common is the morbid product known as a fleshy mole. It has been generally conceded, since the researches of M. Velpeau on the subject, that moles which are expelled from the uterine cavity are merely the remains of an altered product of conception. 4. Lastly, there is yet another mode of termination, admitted by Nsegele, Osiander, &c. I allude to the absorption of the placenta retained in the cavity of the womb ; for although such an absorption has been observed even after delivery at term, yet most of the reported cases refer especially to miscarriages. (See Delivery of the After-birth.} ARTICLE V. PROGNOSIS. The prognosis of abortion is necessarily variable, according to the time of its occurrence and the cause which has produced it. As regards the foetus, it is always mortal, since the expulsion takes place before the pro- duct of conception is fitted for an extra-uterine life, though I am well aware that cases are reported of children, born prior to the period of viability fixed by law, which have lived ; but these examples, even were they authen- tic, are too rare to invalidate the general proposition just laid down. As regards the mother, the prognosis is said to be more grave than thai of labor at term; but this proposition, which has been advocated since the days of Hippocrates, requires explanation, and should not be received with- out some restriction ; for the prognosis, considered in relation to immediate consequences, is certainly less serious in a case of abortion than in a natural labor ; but the remote effects are undoubtedly more disastrous in the former case. Thus, the acute diseases which attack lying-in women are more ire- OF ABORTION. 5 i ! > quent after labor, whilst the chronic disorders of the genital organs which appear in advanced age are more common with females who have often aborted than with those who have always been delivered at term. 1 Again, it is highly important to notice the unfavorable influence that one abortion seems to have over subsequent pregnancies ; for whenever a woman has had a miscarriage, she is more predisposed than others to a similar accident, and hence great precautions should always be taken to prevent it. The period at which an abortion occurs also influences the prognosis, although we cannot exactly say, with Desormeaux, that it is more serious for the patient in the advanced stages of gestation. Doubtless, as before stated, it scarcely constitutes an indisposition in the first or even the second month ; but in the third or fourth, the expulsion of the foetus de- mands a certain dilatation of the os uteri, and tolerably energetic contrac- tions ; for the neck and body of the uterus have not as yet undergone the modifications necessary to such an effort, and the delivery of the after-birth often presents difficulties less frequently met with at a more advanced stage of gestation ; whence I conclude, that an abortion is then more grave and painful to the patient, as also more dangerous, than in the fifth or the sixth month. Lastly, the prognosis varies with the cause of the accident. Thus, the most serious of all is an abortion brought on either by medicines adminis- tered internally or by manipulations ; while a miscarriage determined by slow and gradual influences is usually attended with less danger than one caused by external violence or some powerful moral commotion. In this latter case, the hemorrhage which precedes, accompanies, or follows the abortion, is nearly always much more serious. Lastly, when it occurs in the course of an acute inflammation of an important organ, or during the existence of an acute disease of the skin, it is exceedingly dangerous. AKTICLE VI. TREATMENT OF ABORTION. The treatment of abortion consists in preventing it, in favoring the expul- sion of the ovum when this is inevitable, and in remedying the various acci- dents that may complicate it. 1. Preventive Measures. — When the miscarriage is dependent on the woman's bad constitution, or on a lesion of the genital organs, we must en- deavor to combat and destroy this pernicious predisposition, more especially in the intervals between the gestations. I shall say nothing at this time of the means of modifying the general vices of the constitution, since they necessarily vary with the nature of the affection. It is particularly impor- tant, however, to bear in mind the disastrous influence of syphilis, whether the father or the mother be infected with it, over the life of the foetus ; and we should persuade them to submit to a mercurial course. 1 Would it be unreasonable to suppose that, inasmuch as women who have had fre- quent miscarriages are particularly liable to chronic diseases, the tendency may be due to the fact that they have long borne the germ which occasioned their previous •abortions 1 Which was the caun and which the etfect? (Blot.) 580 PATHOLOGY OF PREGNANCY. When it happens that several abortions have resulted in consequence of some displacement of the uterus, the latter should be remedied by the appropriate measures : for instance, in the commencement of pregnancy, the woman should avoid all fatigue and every violent effort; and it is even advisable for her to remain in the recumbent position until the uterus rises above the superior strait. We award the proper value to the influence attributed by Desormeaux to the supposed rigidity and excess of sensibility or contractility in the uterine fibre, as well as to the excessive weakness or relaxation in the fibres of the neck. But, whilst interpreting the action of those causes in a differ- ent manner, we believe, with him, that bathing, general bleeding, opiate injections, and a regulated course of living, are the means best suited to moderate this great irritability of the organ ; and that a tonic and strength- ening regimen, aided by the ferruginous preparations, cold baths, and the chalybeate mineral waters, will be the most usefully employed in those cases w T here the general debility of the patient may have seemed to exercise some influence over her former abortions. Plethoric women, who usually have profuse menstrual discharges, and who may have previously suffered from abortion at the periods of menstrua- tion, all of which had been preceded by the symptoms of general or local plethora, and all followed by more or less copious discharges, should be subjected before fecundation to a restricted regimen ; and during gestation, they should avoid all moral and physical excitements, and should remain in bed eight, ten, or even twelve days at every monthly term ; besides, they ought to be bled several times during the earlier periods of pregnancy, more especially just before the time for the menses to appear. 1 These, more than other pregnant women, should renounce the use of cor- sets, which, independently of the restraint they make on the development of the breasts, oppose the free return of blood, by interfering more or less with the abdominal and thoracic circulation, and thereby favor congestion of the inferior organs. Feeble, cachectic females, who are impaired by former diseases, and those whose tissues are soft, and their circulation languid, or who, from being habitually irregular, are affected with chronic leucorrhcea, are often attacked by hemorrhages during pregnancy which ultimately lead to an abortion. In such patients the face is pale, the pulse soft, small, and irritable, the tongue white, digestion painful, the intestines torpid, and the extremities cold. The least exercise fatigues them, sometimes even exhausts their strength. The fatigue is often accompanied by a sensation of weight, of painful drag- gings in the groins and lumbar regions, and, should they remain standing for any length of time, the uterus seems to require some support, as it ap pears just on the point of escaping by the vagina or rectum. Even in the 1 The physician often meets with much opposition from persons out of the profession when In- j.rojMis.-s .-i [ireventive bleeding in the early stages of gestatioD. Particularly, should any accident happen shortly afterwards, they would not. fail to reproach him with it. This, however, is no just reason for not acting according to his convictions, or for yielding in cases where he believes it really useful. Now, experience has fully proved that, in such instances as those we have described, it is one of the best pre- ventive measures. OF ABORTION. 581 earliest stages, they feel something like a weight in the lesser pelvis, always pressing on the most dependent part. Now, the best mode of preventing such a condition, is to prescribe a tonic regimen, together with the ferruginous and bitter preparations. Canella, in powder, has been recommended ; and Sauter highly extols the use of pow- dered savine ; he asserts, that he has succeeded in correcting this pernicious predisposition in pregnant women, who had previously had several mis- carriages, by administering fifteen grains of the powder three times a day, continuing it for three or four months ; by this remedy he has arrested flood- ing and prevented abortion, and many patients can attribute the fact of having children born at full term to the employment of this precious drug. White, of Manchester, has particularly recommended cold bathing, espe- cially sea-bathing, to be often repeated, both before and during pregnancy. The accoucheur must therefore search in the history of former miscarriages for the indications to guide him in the use of preventive measures ; and it is likewise very important that he should make himself acquainted with all the accompanying circumstances. Pregnant women are very often constipated, and this constipation fre- quently becomes the cause of periodic abortions, by the irritation it pro- duces ; hence, it should be prevented by the use of some simple injections, with the addition of one or two tablespoonfuls of linseed-oil, regularly, every other day, for two weeks before the period when the abortion occurred last time, and they ought to be continued for two weeks after it. But whatever may have been the predisposing cause whose influence was exerted in the previous pregnancies, there is one very important precaution, the neglect of which might render all others useless. In all cases where abortion has occurred several times, it is indispensable that the organ should remain undisturbed, and the husband be recommended to allow from six to eight months, or even a year to elapse, without the wife being exposed to become pregnant. When this accident has already occurred a number of times in former pregnancies, it is always indispensable for the woman to abstain altogether from intercourse with her husband, for all sources of irritation must evi- dently be withdrawn from the womb. Again, if the foetus was expelled dead in the preceding gestations, and this death had been caused by some lesion of the ovum, it is almost impossible to recognize, and consequently to prevent, a similar alteration. The case is rather different when the previous abortions have been attri- buted to utero-placental or intra-placental effusions, for these are almost always the result of a congestion of the uterus, of sufficient intensity to j:>ro- duce a rupture of vessels. In another pregnancy, it might be possible to avoid such accidents. We would, however, call attention to the fact, that these local congestions may occur in chlorotic as well as in plethoric women, and consequently, that, although revulsives applied to the upper part of the body, or to the superior extremities, are useful in all, bleedings from the arm at the menstrual periods are very advantageous with the latter whilst the foimer are benefited by the preventive use of ferruginous pre- parations, administered from the commencement of gestation. 582 PATHOLOGY OF PREGNANCY. Under some unfortunate circumstances, nature seems to deride all ihe attempts of art, and abortion reoccurs. Still, we must not despair when the woman becomes again pregnant, for experience fully proves that, not- withstanding numerous former abortions, a fresh pregnancy has sometimes succeeded in reaching full term. Dr. Young (Eigby, 91) relates, in his lectures, the history of an unfortunate lady, who, after having had thirteen successive abortions, became pregnant for the fourteenth time, and was hap- pily delivered of a living infant at term. But, notwithstanding all these precautions, it sometimes happens that an abortion is threatened. The patients are affected with shiverings from the most trifling causes, pains in the hypogastrium, loins, &c. ; uterine con- tractions appear, the sexual parts become moist, and occasionally even the os uteri dilates; but even here we must not lose all hopes of arresting the accident, notwithstanding those symptoms. If the patient is robust, the pulse full and frequent, more especially if the development of the symptoms had been preceded by indications of plethora, bleeding in the arm should be at once resorted to, the woman be laid as horizontally as possible, and opiates immediately administered. The laudanum of Sydenham may be given in the dose of twenty, forty, or even sixty drops, diffused in a small quantity of some mucilaginous liquid as an injection, and repeated at intervals of an hour, until the contractions dis- appear. This remedy, of which we have before spoken, is one of the most efficacious in cases of this kind, and sometimes it alone has enabled us to arrest a labor whose termination seemed to be inevitable, and thus has per- mitted the gestation to pursue its regular course. I cannot refrain from citing the following instance in illustration. A woman, advanced to three months and a half, was taken with pains in the abdomen and loins, after a violent altercation with her husband ; on the following day the pains augmented, and a little bloody fluid escaped from the genital organs ; the pains still continuing, and the discharge having somewhat increased, on the third day the patient came on foot to the Clinique. I found on her arrival that the uterine contraction was very dis- tinct, the pains sharp, and renewed every eight or ten minutes ; pure blood was discharging from the vulva, and the orifice was sufficiently dilated to permit the finger to pass readily as far tip as the naked membranes. I ad- ministered sixty drops of laudanum, divided into three doses, which were given at intervals of three quarters of an hour, and by the end of this time the pains disappeared, everything resumed its natural order, and the gesta- tion went on till full term. I might multiply such citations almost ad infinitum, but the above is suf- ficient to show that, however inevitable the abortion may at first appear, we should never abandon all hopes of preventing it. I may add, that the administration of opium in the doses just indicated, or even carried to a hundred drops in the twenty-four hours, has never been followed by serious consequences. Sometimes, perhaps, a little somnolency or heaviness about the head, or a general torpor may result, but which a few glasses of lemonade will soon dissipate. For, after all, when even death of the foetus must have been either the cause or the effect of* the primary symptoms, what do we OF ABORTION". 583 risk in calming or arresting the uterine contractions ? because, as we have already seen, the dead child may remain long within the intact membranes without any unfavorable consequences resulting to the mother. And besides, as it is almost impossible to ascertain its death with any degree of certainty prior to the fifth month of gestation, we must act in such doubtful cases just as if it were living ; although there can be no question that, if the foetus were really dead, it would be better to permit the contractions to go on, and its expulsion to be effected. But, even supposing these are wholly suspended, the expulsion is somewhat retarded, and that is all ; for after the lapse of a certain time the foetus, acting like a foreign body in the uterine cavity, will irritate its walls, and a new labor sooner or later take place in consequence. To these remedies (the venesection and opiate treatment) we must add strict confinement to bed, absolute rest of mind and body, the use of demul- cent beverages, cold lemonade, veal-broth, chicken-water, and the applica- tion of cold compresses, frequently renewed, over the abdomen ; which com- presses are to be saturated with some fluid whose temperature is progressively lowered. " Local bleedings," says M. Gendrin, " are too much neglected, especially in the treatment of the utero-placental hemorrhages ; indeed, we have so often had occasion to congratulate ourselves for having advised them in those cases, that we now prescribe them with great confidence when- ever the general condition does not directly indicate a depletory venesection. We direct them : 1. When there are any sharp pains in the neighborhood of the uterus or groins, and we apply them to the latter, the anus, or even the vulva ; 2. In cases of a considerable turgescence of the hemorrhoidal tumors (if any such exist) ; and 3. In the phlegmasia of the adjacent organs, such as the large intestine, &c." In these two latter cases we fully coincide in the opinion of M. Gendrin ; but, in the first, we should much prefer having recourse to a general bleeding in the arm, or, as he himself advises, further on, to the application of leeches at a distance from the uterus : for instance, near the breasts, armpits, &c, &c. Finally, to the means already enumerated, we must further add the use of irritant revulsives, placed upon the upper part of the trunk and the thoracic extremities, and must also recommend in a more special manner the application of dry cups, the decidedly beneficial effects of which we have often witnessed in cases where uterine plethora seemed to be the cause of the symptoms, but where the general condition required some pre- caution in the use of blood-letting. 2. It has been already stated that a copious hemorrhage, intensity of the pain and of all the other phenomena, and more particularly a rupture of the membranes, render abortion thenceforth inevitable ; and hence, the only course in such cases is to facilitate the expulsion of the product of conception. But still, if the hemorrhage is not of such a character during the first three months of gestation as to compromise the woman's life, the physician should remain a simple spectator of the efforts of nature, and confine himself to superintending the progress ; for the expulsion of the ovum ought to be left entirely to the uterine forces. Sometimes it comes away whole, which is a very favorable circumstance. Moreover, according 584 PATHOLOGY OF PREGNANCY. to the recommendation of Baudelocque, he should be very careful not tc rupture the membranes, for that would only retard the delivery of the placenta, and render it still more dangerous. In fact, when the foetus* escapes alone, this latter might be attended with the difficulties pointed out in one of the preceding articles. We should here remember how slowly the expulsion of the ovum is effected in certain cases, even when the orifice is sufficiently dilated to oppose no obstruction to its exit. This great slowness is sufficiently ex- plained by the slight contractile power of the uterus. When no accident complicates the abortion, the physician has nothing to do but watch the progress of the labor, and expect the complete delivery to be effected by the uterine efforts. At a more advanced period, that is, towards the fifth or the sixth month, the course of the physician is very nearly the same as it would be at term. The size of the foetus, which has now become quite large, requires a greater dilatation of the os uteri ; and this, in consequence of the greater softening of the cervix, is accomplished with somewhat greater rapidity. Generally, it is necessary that the child should present one or the other extremity of its long diameter to the os uteri ; however, it some- times happens that some portion of its trunk presents there, and its delivery is neither much more difficult nor much slower than usual. It is in such cases especially that the mechanism of spontaneous evolution may be fre- quently observed. The delivery of the after-birth does not, as a general rule, exhibit those difficulties which it presented in the earlier months ; in truth, it closely resembles the same process in the labor at term. 3. Hemorrhage is not only one of the most common symptoms, but it may fol- low the expulsion of the foetus, and become the most serious feature of the case. Whenever, notwithstanding the use of general measures, such as the horizontal position, cold drinks, the application of refrigerants to the hypo- gastrium or thighs, and the administration of opiates, the discharge of blood continues so great as to endanger the mother's life, an abortion thence- forth becomes inevitable, and the primary object of the accoucheur should be to bring on the contractions and the evacuation of the organ. He should also administer general stimulants to sustain the woman's Btrength, and, at the same time, those medicines having an immediate action on the womb itself, such as the tincture of canella, &c, but above all the ergot. However, when the miscarriage comes on at an early stage of the gestation, these measures are often ineffectual, for it is then exceedingly diffi- cult to excite the contractions of a viscus whose muscular organization is etill so imperfect ; or at least, if they are aroused, they are frequently inadequate to dilate the neck sufficiently. The tampon is then the only resource ; this, when well applied, acts in two ways : 1st, by opposing the escape of the blood externally, thus forcing it to coagulate, and conse- quently to obliterate the bleeding vessels ; 2d, by irritating the womb by mere contact, thereby determining its retraction, and the expulsion of the product of conception. This circumstance, indeed, is one of the best- founded objections to the use of the tampon in the early months of gesta- tion. But, in truth, is it not rather an advantage than otherwise? because the cessation of the Hooding is always a necessary consequence of the OF EXTRA-UTERINE PREGNANCY. 585 uterine contractions; and is the mother's life bought too dear, when ii i.< saved by the expulsion of a foetus which, in most cases, is dead even before the application of the tampon ? Besides, this measure is not always necessarily followed by abortion. Again, i aere is no reason to fear the conversion of an open into a concealed hemorrhage by the employment of the tampon, before the sixth month ; for, notwithstanding the observation of Chevallier, the accumulation of a large quantity of blood in the womb would seem to be impossible at this early period, without supposing an ab- normal relaxation of its walls. Where, however, the pregnancy is advanced to the fifth month, the accoucheur should carefully watch the body of the uterus after the tampon is applied, and assure himself, every moment, that its volume is not increasing. We shall describe hereafter (see Operations) the mode of applying the tampon, but it should be remembered that its use is almost always followed by abortion, and that it should be had recourse to only when the latter seems to be inevitable. When the ovum remains intact, and the labor lasts too long, the contin- uation of the hemorrhage being at the same time such as to cause serious anxiety, some practitioners prefer rupturing the membranes to applying the tampon. This measure, to which I shall again allude in speaking of hem- orrhage during the last three months, does not seem to me applicable before the sixth month, except in a few occasional instances, and I should, in general, decidedly prefer the tampon to it. In fact, a rupture of the membranes is necessarily followed by miscar- riage ; but the tampon, when early applied, leaves some hope that the ges- tation may continue till term ; again, the tampon always arrests the bleed- ing, whereas, after rupturing the membranes, it may happen that the uterus, whose muscular fibres have not acquired the contractile power which they would have at a later period, might not retract, nor the hemorrhage cease, so that it might still be necessary to have recourse to the tampon. Finally, let us add that, in the first three months, the rupture is followed almost immediately by a discharge of the waters and the escape of the fcetus ; but the expulsion of the placenta and membranes is thereby rendered much more difficult. After the complete expulsion of the ovum, the patient must observe the same precautions as are required after ordinary labor. CHAPTER VI. OF EXTRA-UTERINE PREGNANCY.' The fecundation, as elsewhere stated, most frequently takes place in thi ovary, and the impregnated ovule is then received by the fimbriated extrem- ity of the tube, which applies itself on this organ, doubtless by a kind of spasmodic contraction. Having beei once deposited in the tubal canal, the ovule traverses its whole length, and falls into the uterine cavity, where it« 1 See page 1165. 586 PATHOLOGY OF PREGNANCY. development continues until term. Such is the course observed in normal or uterine pregnancy ; but it may happen that the ovule is arrested, or diverted, in the route it thus travels, and ingrafting itself, so to speak, upon the point of stoppage, is there developed ; in the latter case, the pregnancy is called an abnormal, or an extra-uterine one. This species of gestation has been subdivided into several varieties, which have received different names, according to the part of the passage where the ovule becomes fixed. Dezeimeris admitted the following divisions, namely : 1. Ovarian pregnancy. 2. Sub-peritoneo-pelvic pregnancy. 3. Tubo-ovarian pregnancy. 4. Tubo-abdominal pregnancy. 5. Tubal pregnancy. 6. Tubo-uterine interstitial pregnancy. 7. Utero-interstitial pregnancy. 8. Utero-tubal pregnancy. 9. Utero-tubo-abdominal pregnancy. 10. Abdominal pregnancy. Such was the classification which, in an anatomo-pathological view, was adopted in the six first editions of this work. We now think it would be better to make a more simple arrangement, and shall, accordingly, describe but five varieties of extra-uterine pregnancy : 1. Abdominal pregnancy. 2. Tubo-abdominal pregnancy. 3. Tubal pregnancy. 4. Interstitial tubo-uterine pregnancy. 5. Utero-tubal pregnancy. 1. Abdominal Pregnancy. — To render fecundation possible, it is necessary i hat there should be direct contact between the sperm and the ovule, and, consequently, that the Graafian vesicle should burst into the abdominal cavity of which it, for the moment, forms a portion. But, should the fecun- dated ovule, instead of engaging in the tube, remain in the just ruptured ovisac and be retained at the surface of the ovary, or fall into the peritoneal cavity, its development gives rise to an extra-uterine pregnancy which we shall designate under the general name of abdominal pregnancy. Three varieties of this class will be recognized : in the first, the fecundated ovule is still contained in the just ruptured ovisac, and is developed upon the spot : the pregnancy is then styled internal ovarian. In the second variety, the fecundated ovule, having escaped from the Graafian vesicle, adheres to the surface of the ovary, where it undergoes development : this is called external ovarian pregnancy. Finally, should the ovule, after leaving the ovary, attach itself to some part of the peritoneum, it receives the name of peritoneal pregnancy. In internal ovarian pregnancy, the ovum is developed within the ovary itself. This variety has given rise to numerous scientific discussions, inas- much as it was for a long time admitted that the ovule could be fecundated OF EXTRA-UTERINE PREGNANCY. 58 i without previous rupture of the Graafian vesicle. Amongst the observa- tions pleaded in favor of this hypothesis, one related by Bcehmer ought to be mentioned. He describes with much care both the membrane proper of the ovary itself and its peritoneal envelope. M. Velpeau, however, very justly observes that it is. often extremely difficult to determine precisely the point of departure of the tumor ; therefore we admit with him that, in this species of pregnancy, the ovisac is always ruptured. If the minute wound resulting from it be not evident when the dissection is made, it is because it has been obliterated by the process of cicatrization and the production of a newly-formed membrane. External ovarian pregnancy cannot be doubted. It is, relatively speak- ing, quite common, and the fecundated ovule retains its intimate connections with the ovary upon which it is applied whilst undergoing development in the abdominal cavity. Peritoneal pregnancy was for a long time contested, but is now supported by so great an array of facts, observed both in women and animals, that it is impossible to deny its occurrence. It has, doubtless, often been con- founded with the ovarian and other forms, but in several published cases there can be no question that the ovum had no connection with the internal generative organs. M. Dezeimeris makes two varieties of this form of pregnancy, viz. : primitive and secondary. In the former, the product of conception has never been located elsewhere than in the peritoneal cavity, into which it fell on quitting the ovarian vesicle ; in the latter, on the con- trary, the first development of the ovule took place in the ovary, the tube, or the walls of the uterus, but at a later period extreme distention or pathological alteration of the walls of the tumor caused their rupture, and the ovum being partly or wholly expelled from the containing cyst, became lodged in the cavity of the abdomen, where it was at last found. The sec- ondary abdominal pregnancy of M. Dezeimeris is, therefore, merely a tubal or interstitial pregnancy, ending in rupture of the primitive cyst. Whether, therefore, this rupture occurs at a very early period or at the regular term of gestation, it deserves to be regarded merely as an epiphenomenon, and can, in no case, constitute a distinct variety. We apply, therefore, the name peritoneal pregnancy to that form in which, from the very outset, the ovule has become adherent to some part entirely distinct from the internal generative organs. The points at which it may thus attach itself are ex- tremely numerous, so that the placenta has sometimes been found inserted upon the peritoneum, covering the right or left iliac fossa, sometimes to the mesentery, or to a part of the small and large intestine, and sometimes, finally, to the anterior wall of the abdomen. Most of the cases described by Dezeimeris as snb-peritoneo-pelvic preg- nancies belong, we think, to the peritoneal variety. The author applies the former name to cases in which the ovule was unable, after leaving the ovary, to engage in the external opening of the tube, but slipped between the two layers of the broad ligaments and was developed there. According to his view, the ovum here is outside of the peritoneum, and remains principally in the pelvic cavity. Cases of the kind, he thinks, are not rare, and, on account of the situation of the ovum, are to be reckoned amongst the least 588 PATHOLOGY OF PREGNANCY. dangsrous. The position is, indf.ed, remarkably favorable to the sponta- neous expulsion of the debris of the foetus, or makes them easily accessible in case it should be thought necessary to abstract them. Whilst accepting this prognosis, we think that Dezeimeris is in error as regards the slipping of the ovule between the two layers of the broad ligament ; it seems to me impossible that it should follow this route. The observers were, in these cases, deceived by the fact that upon opening the abdomen the peritoneum of the lesser pelvis seemed to be raised by a subjacent tumor. The appear- ance, however, misled them, for the tumor is not, really, covered by the peritoneum, but by a newly-formed false membrane, which soon acquires the shining and polished appearance of a serous membrane, and which blends, without a well-marked line of demarcation, with the surrounding peritoneum. If this pseudo-membrane be incised, a careful dissection will reveal the true peritoneum below the foetal cyst. The tumor, therefore, is not extra-peritoneal, but intra-peritoneal. In short, the same phenomenon occurs here which for a long time sustained the idea that retro-uterine hematocele was seated outside of the peritoneum. 2. Tubo-abdominal Pregnancy. — It is evident that, if the tube be obliter- ated near the enlarged extremity, the ovule which has scarcely entered its canal will be arrested ; and if the development occurs at this point, the tubal walls will necessarily be dilated, and one portion of the surface of the ovum be free in the abdominal cavity; to this variety the name of tubo-abdomiixil is applied. The placenta is attached in the interior of the tube, and the fcetus developed in the abdominal cavity, and both are surrounded by a cyst, the walls of which are partly made up by the parietes of the tube. We include in the tubo-abdominal pregnancies those cases which have been described under the name of tubo-ovarian. In this the cyst, which surrounds the fcetus, is formed partly by the ovary, and partly by the open- ing of the dilated tube, whose extremities have contracted some adhesions with the ovarian tunic. The following case of Dr. Jackson's is justly quoted by M. Dezeimeris as serving for a type. A woman, aged thirty-two years, was seized, in conse- quence of a violent blow on the epigastrium, with some inflammatory symp- toms, to which she speedily succumbed ; at the autopsy, a large quantity of blood was found diffused in the abdomen, and a foetus of about ten weeks was found enveloped in an enormous clot ; the fundus uteri rested against the pubis, and its cervix near the middle of the sacrum. This change from its natural position had been produced by a tumor situated on the left side of the womb, which tumor was formed by the ovary, the Fallopian tube, and the broad ligament, that had become considerably thickened and modi- lied in their structure ; the fringed extremity of the tube adhered intimately to the ovarian envelope, and a cyst was formed by these two organs, whose distention by the body contained therein had produced the rupture. In another case, related by Bussieres, which seems to me equally conclu- sive, the tube on the right side was extremely dilated at the extremity ; and this dilatation, which was an inch in its largest diameter, extended for rather more than an inch and a half in length, gradually diminishing as it approached the womb. The portion of the tube thus dilated was curved OF EXTRA-UTERIXE PREGNANCY". 589 jn itself, and en. braced nearly the whole ovary, to the menbrane of which it^as so adherent that it could not be separated without rupturing the attachments. An unctuous, limpid fluid escaped as soon as it was opened, and then the ovum appeared, which was about the size of a hazlenut, and was surrounded by the liquid ; three-fourths of it had already escaped from the hole made in the ovary, so that it no longer seemed to rest there ; yet, on attempting its removal, it was found attached by a hard pedicle covered with blood-vessels. 3. Tubal Pregnancy. — This is the most frequent of all the varieties of extra-uterine pregnancy ; which fact is readily accounted for by the length and narrowness of the canal, and by the adhesions and morbid obliterations presented by its walls. Under such circumstances, the ovule is arrested and developed at some point between its abdominal extremity and the spot where it enters the uterine parietes ; and by its continual growth distends enor- mously the fibres of the tube which constitute the envelope of the foetal cyst. To the numerous cases of this kind reported by Velpeau and Dezei- meris, I might add another, already published by me in the Bulletin de la SocttU Anatomique, but so many examples are everywhere met with that it seems useless to reiterate their details. Dr. Lesouef's thesis may be advan- tageously consulted on this point. 4. Interstitial Tubo-uterine Pregnancy. — In this case the ovum is arrested in that part of the tube which traverses the thickness of the uterine walls ; and although this is its principal characteristic, two varieties have been made of it, of which we shall say a few words. In the first variety the walls of the tube, yielding to the distention occa- sioned by the development of the ovum, press back the surrounding tissue proper of the uterus, but always form the most internal layer of the cyst in which the product of conception is enclosed. In the second variety the ovule reaches that part of the tube which tra- verses the uterine walls ; but having arrived there, it opens a way through the tubal parietes, penetrates into the midst of the fibres of the womb, and thenceforth has no further relation with the tube ; hence, the surrounding cyst is formed by the muscular fibres of the womb alone. After having been once located among the uterine fibres, the ovum may either take an inward or an outward direction, and consequently may become seated near the mucous layer, or else to the peritoneal coat. In a prepara- tion belonging to M. Pinel Grandchamp, the volume of the uterus was about the same as at six weeks or two months of pregnancy ; at its left angle, a small tumor, slightly ruptured behind, constituted the cyst containing the product of conception. The tube, which passed behind it, communicated with it by an almost microscopic orifice, and presented nowhere any increase of calibre. The cyst was about large enough to contain an almond. 5. Utero-tubal Pregnancy. — Notwithstanding the free communication existing between the tube and uterine cavity, there is no absurdity in the supposition that the ovule may become deposited in a little depression of the mucous membrane, and there stop and ingraft itself, just at the internal orifice of the canal. In this case, phenomena similar to those of the tubo- abdominal gestations will arise: that is, the ovule, which may have con- t>90 PATHOLOGY OF PREGNANCY. tracted some intimate adhesions with this extremity, may, by its de\elop- ment, encroach upon the uterine cavity itself; and I do not hesitate, there- fore, to consider this variety of gestation as possible. It is probable that certain singular cases described by Dezeimeris under the name of utero-tubo-abdominal pregnancies belong properly to tubo- uterine pregnancies. In this variety, examples of which have been furnished by Patuna, Hunter, and Hoffmeister, the foetus is found in the abdominal cavity ; the cord leaving the umbilicus enters the Fallopian tube, traverses its whole length, and is inserted in the placenta, which itself is attached to the internal surface of the uterus. We explain them by supposing the existence of a tubo-uterine pregnancy ending in rupture of the tube with passage of the foetus into the peritoneum whilst, the placenta remains in the uterus. The cord traverses the tube in its passage from the foetus to its placenta. We have not been able, from the restricted limits of this chapter, to bring forward a larger number of cases, but sufficient has been said to furnish an idea of the importance that ought to be attached to the different varieties of extra-uterine pregnancy admitted by us. The reader may consult with benefit the article of Professor Velpeau, in the fourteenth volume of the Diciionnaire de Medecine, the learned memoir published by M. Dezeimeris, in the fourth year of the Journal des Connais- sances Medico- Chirurgicales, and the able articles of Messrs. Breschet, Me- niere, and Guillemot. Other writers have made fewer divisions in the classification, and the sub- ject lias been more recently and thoroughly studied. Playfair makes four classts (if extra-uterine gestation : 1st, tubal ; 2d, abdominal ; 3d, ovarian ; and 4th, two varieties in which an ovum is developed either in the supple- mental^' horn of a bi-lobed uterus or in a hernial sac. Prof. T. G. Thomas, of New York, whose successful operations are well known, believes that " in the commencement of its development the impreg- nated ovum never attaches itself to, nor draws its nourishment from, any other parts than those lined by the mucous membrane of the uterus or tubes. Knowing, as we do, the delicate and subtle connections which the chorion establishes with the maternal tissues, it is certainly difficult to believe that an impregnated ovum, falling free into the peritoneal cavity, or detained within the Graafian vesicle, can, with parts so unlike the lining of the uterus, establish relations almost identical with those which are normal." Puech, Annal de Gyncec, July, 1878, gives two varieties of ovarian preg- nancy. In one the fetus has developed in a vesicle which has remained open after fecundation, the other in which the vesicle had closed. Most of the cases he regards as either dermoid cysts, ovario-tubal pregnancies, or abdominal pregnancies with placenta attached to the' ovary. The besl contribution that has yet been made to the subject is unquestion- ably the work of Parry, in a volume published in 1.' According to this author, there are three species of extra-uterine pregnancy — tubal, ovarian, and ventral or abdominal — with varieties of each, as expressed in the fol- lowing schedule ( loc. '•/., page 49) : 1 Extra uterine Pregnancy; Its Causes, Species, Pathological Anatomy, Clinical History, etc., etc., by John S. Parry, M. D. Philadelphia: 1870. OF EXTRA-UTERINE PREGNANCY. 591 Tubal pregnancy. Species. Varieties. Tubo-ovarian (the germ being arrested in the pavilion, which con- tracts adhesions with the ovary i. Tubo-abdominal (germ arrested in the same locality. The tube may contract adhesions with neighboring organs. If it does not, the chorion may project into the abdominal cavity, with a part of its surface bare). Tubalproper (germ arrested between the pavilion and thai por- tion of the oviduct which traverses the uterine wall). Tubo-uterine (germ arrested in that portion of the tube which passes through the uterus). Ovarian proper (germ contained in the ovary; that organ remain- ing free from adhesions). Ovarian pregnancy. ■{ Q var i . tuoa i (g er m contained in the ovary, which contracts adhe- sions with the pavilion of the tube). f Primary (ovum developed from the outset in the perloneal cavity). Secondary (development commences in the tube or ovary, the cyst ruptures, ovum escapes, and continues to live and develop in the peritoneal cavity). From an analysis of 500 cases, he gives the following classification : " After excluding all cases of recovery by discharge through the abdominal wall, the alimentary canal, or genito-urinary tract ; many cases of recovery after gastrotomy, in which the variety of the gestation was supposed to have been determined, during the hurry and dread of a critical operation ; all cases of vaginal section which were not fatal, and all cases in which the appearances discovered at the autopsy were not described with sufficient care to warrant the deduction of correct conclusions :" f The ovum being developed in the tube proper .... 149 j The ovum being developed in the pavilion : the tubo-ovarian and Tubal, -j tubo-abdominal varieties 34 The ovum developed in uterine portion of tube: "interstitial" or (_ tubo-uterine pregnancy 31 Ventral or Abdomi nal pregnancy. 214 Ovarian . Abdominal Doubtful 27 29 230 § 1. Pathological Changes. a. Product of Conception. — In these pregnancies the ovule lias its proper membranes, the chorion and the amnion. I may state that I was utterly astonished to hear several honorable members contend, in a recent discus- sion before the Academy of Medicine-, that the envelope of the ovule, in ab- dominal gestations, was only composed of the amnios, and that no chorion existed; for although, in certain very old pregnancies, the most exterior fetal membrane is confounded with the walls of the cyst, it is not fair to conclude from thence that it did not exist at the commencement. The absence of the chorion supposes that of the allantois, and withoul the latter no circulatory relations can be established between the embryo and its mother. 592 PATHOLOGY OF PREGNANCY. In the so-called sub-peritoneo -pelvic gestation, or whenever the ovule, that was originally located in the ovary, tube, or even the uterus, is trans- ferred, after the rupture of the cyst which inclosed it, to some part of the abdominal cavity, there is besides a pseudo-membranous cyst, representing the uterine decidua, produced by the inflammation which the presence of the ovule determines around it. But this enveloping membrane, the cyst, does not exist in primitive peritoneal pregnancies. M. Dezeimeris thus explains the latter circumstance : When a fecundated ovule gets into the abdominal cavity immediately after quitting the ovary, we can readily be- lieve that a corpuscle so minute, soft, and fragile could only produce a very slight irritation at the point of arrestation, and that the extent of this excita- tion will not pass beyond the limits of contact with the little foreign body; in a word, it cannot produce an acute inflammation, or extensive adhesions, nor an exudation of plastic lymph sufficient to form an enveloping cyst. Now, if it has not primarily caused all these derangements, the neighboring organs will not be injured by its ulterior development, because they become gradually habituated thereto; and the ovule, having obtained a right of possession, lives, grows, and presents to the smooth, polished surfaces which touch it, a surface equally smooth, polished, and moistened at their expense : and not having occasion for any other protecting envelope, no cyst is formed. But when a voluminous product of conception suddenly bursts, and its con- tents, placed at first like it in the tube or ovary, are transported to the peri- toneal cavity, the ovule becomes there a foreign body, wounding and irri- tating the abdominal organs which are unaccustomed to its vicinity, and determining an acute inflammation around it, which results in the exudation of plastic lymph ; this, by coagulating, forms a cyst, and completely isolates the foreign body. If, under these circumstances, the displacement of the foetus is such that it completely escapes from the amniotic cavity, and sud- denly locates itself with its surrounding liquid in the midst of the intestinal mass, an inflammation occurs, and the cyst we have just described forms around it ; the new cyst then completely environs the foetus. But in some cases the displacement is not so complete — the largest part of the trunk may still remain in the amniotic cavity after the rupture, \ portion only being displaced, and the latter alone first determines an vnflammation around it, and then the exudation, which is transformed into a false mem- brane ; this, by uniting with the lacerated margins, forms only a part of the foetal cyst, the remainder being constituted by the old foetal envelope, the walls of the Fallopian tube, for instance, in the case of a tubal pregnancy. The same relations may be established with the membranes of the ovule when the chorion and amnion are ruptured at an advanced period in a case of primitive abdominal pregnancy. For instance, in a case cited by M. Dubois, the cyst that inclosed the foetus was formed of a membrane which was not altogether uniform in its structure and appearance: thus, for the greater part of its extent, the internal surface was of a light-brown color, owing perhaps to the imbibition of the adjacent liquids, and simulating, both to the touch and sight, the aspect of the mucous membrane of the small intestines, or, still better, the accidental membranes that occasionally line fistulous canals ; while at other points, those for instance which were OF EXTRA-UTERINE PREGNANCY. 5Hi^ near the circumference of the placenta, and on the largest part of this sur- face, the cyst was more smooth and polished ; presenting, in fact, the ordi- nary appearance of the amnion. The cyst was simple, and about a fourth of a line in thickness at the part where it exhibited the brown and villous character above alluded to; but on the contrary, where the surface was smooth and polished, it evidently consisted of two membranes (the chorion and the amnion.) In all cases, numerous and large vessels form in the walls of the cyst whose rupture it is evident must give rise to hemorrhage, which very often proves fatal to the mother. When an extra-uterine pregnancy is somewhat prolonged, these envelopes are sometimes destroyed, being perforated with fistulous canals, communi eating directly with the intestinal canal, vagina, bladder, uterus, or an ex ternal abscess. At times, the destruction of the cyst is partial, at others complete ; so much so, indeed, as to leave in certain cases no vestiges of its former existence; on the other hand, the envelopes sometimes undergo osseous or cretaceous transformations, which may convert them into solid shells. As a general rule, the foetus exhibits nothing peculiar in its devel- opment : for example, in several cases studied anatomically a long time after the term of pregnancy, the osseous system appeared to have a better devel- opment than in the ordinary child of nine months. The existence of several teeth has frequently been noticed, or else traces of the eruption of these little bones, which would seem to afford an indication that the foetus continued to live and grow beyond the ordinary term of gestation. The most common of the numerous alterations which it may undergo, ia the putrescent dissolution of its soft parts, from macerating in a compound of amniotic liquor, blood, and pus ; the separation of the various pieces of its skeleton, and their discharge through the divers routes just mentioned. At other times, it seems to have undergone a kind of mummification, a com- plete drying-up. Again, in other cases, all the tissues appear to be trans- formed into an osseous or cretaceous substance, or into one resembling adipocire, — and here, it is doubtless unnecessary to add, it is no longer possible to discover any trace of the foetal membranes. b. Tissues of the Mother. — Some very large vascular canals are seen to develop themselves in those parts where the ovum is attached, however devoid of blood-vessels they might have been previously ; and several great veins are found to ramify under the peritoneum towards the circumference of the placental attachment ; and where the ovary or the tube happens to be the seat of pregnancy, it presents a soft tissue, apparently fungous in char- acter, and impregnated with blood. The womb does not continue so indifferent to the advancement of the extra-uterine pregnancy as might be supposed ; for its volume increases in a remarkable degree, the tissues become softer, and the mucous membrane hypertrophied and more vascular, so as to form from the outset a true decidua. M. Velpeau, however, disputes this last assertion ; but I have endeavored to refute his opinion in the Bulletin de la SocUti Anatomique /C! ept. 1836), to which the reader is referred. Phis hypertrophy of the uterine mucous membrane is of short duration. 38 594 PATHOLOGY OP PREGNANCY. For, as the ovum does not enter the uterus, it has nu »ffice to perform. and, therefore, like every other useless organ, becomes atrophied, loses its vascularity, and in a few months has returned to its usual condition. A gelatinous substance, a kind of thick, ropy mucus, is also frequently found in the neck of the uterus; but when the pregnancy has advanced beyond term, the womb gradually regains its natural condition. Finally, in certain cases, the calibre of the Fallopian tube has been found obliterated at some part of its length. § 2. Symptoms and Diagnosis of Extra-Uterine Pregnancy. During the early months it is exceedingly difficult to recognize the exist- ence of an extra-uterine pregnancy ; for the modifications which then occur in the size, form, and consistence of the body and neck of the uterus, will certainly lead to error, and give rise to the belief of a true gestation. With regard to the menstruation and the lacteal secretion, no constant rule is observed. Sometimes the menses continue to appear ; at others, they do not. In some instances this function is not re-established, even after the period when the accouchement should have taken place ; and similar variations are met with in the secretion of milk. Again, menstruation has been known never to appear during an extra-uterine pregnancy which lasted more than thirty years, while the lacteal flow continued throughout the whole of that time. There are, likewise, some abdominal pains, at a period not very distant from the date of conception, more or less analogous to the uterine pains, and at times a constant, fixed, circumscribed one in the pelvis, groin, or umbilical region. (The woman whose preparation I presented to the Anatomical Society, had on this account been treated for a partial peritonitis.) Not un- frequently there is an inability to lie upon one side. When the tumor, whilst still small, falls into the lesser pelvis, it pushes the uterus forward, the neck being directed in front and quite high behind the pubis. This displacement of the neck of the womb, together with the presence of a large tumor occupying the excavation posteriorly, and the dysuria occasioned by the pressure made upon the neck of the bladder, has been mistaken for retroversion. Several examples of this error are mentioned by Burns. At a later period the tumor rises above the superior strait. The motions of the child are felt at the usual time, but they appear to be more super- ficial, and are generally felt on one side only. The labor-pains come on at the natural term, or at the seventh month, or even sooner, generally lasting for three or four days, but occasionally much longer; and, should the pregnancy be unusually prolonged, they are apt to return at varied intervals, and again pass off. Schmidt reports a case where the gestation lasted three years, within which period the labor-pains were renewed eight times, and on each occasion continued for several weeks. In another gestation, of ten years' duration, the pains returned annually at the period corresponding to the term of pregnancy. These pains are not produced by contraction of the walls of the cyst, as many have stated ; because, excepting the cases of tubal and interstitial OF EXTRA-UTERINE PREGNANCY. 595 pregnancy, they never contain any muscular fibres, and hence we must search for the cause in the uterus itself; for the great development exhibited by this organ, and the mucous and albuminous matters inclosed in its cavity, the expulsion of which requires some contractions, sufficiently account for the pains experienced by the patients. But it is exceedingly difficult to explain in a satisfactory manner their frequent coincidence with the usual term of gestation. The physical signs which require our notice are, the changes in the uter- ine body and neck, just indicated, the more or less irregular development of the belly, and the possibility, in some cases, of distinguishing two tumors, one being the uterus, while the other is formed by the abnormal cyst. In the sub-peritoneo-pelvic variety, the product of conception, by occupy- ing the pelvic excavation, displaces and compresses the organs there situated, the vagina and rectum, for instance, and pushes them to one side. The vagina and rectum are found to be obstructed by a tumor situated between them, and frequently the different parts of the foetus may be detected by the vaginal touch. The foetus seems to be much nearer the surface in the abdominal preg- nancy than in either of the other varieties, hence its motions are more easily perceived, and are more distressing to the mother, and the forms of the different parts more clearly distinguishable. Besides, the rounded and regularly circumscribed tumor formed by the uterus in a normal gestation is not present. In the tubal and ovarian varieties, says Baudelocque, the foetal movements should be less vague, and its limbs more retracted. The body of the uterus is associated with the tumor formed by the foetal cyst, and can neither be separated nor readily distinguished from it. I have thus brought forward the various signs by which authors endeavor to detect the different species of extra-uterine gestation, although they have, in my estimation, but little practical importance ; nor do I see that auscul- tation itself could render us much service in determining the diagnosis. I ought to observe that the possibility of a fresh fecundation is a feature common to all the varieties of extra-uterine pregnancy. Perhaps it may be serviceable to note that the vacuity of the uterus might be detected by the touch. Very frequently its habitual position will be changed by the pressure of the tumor, more especially when the latter occu- pies the excavation, and urges it against some part of the pelvic walls. Finally, when by the usual signs we have become assured of the existence of pregnancy, and we suspect that it is extra-uterine, the diagnosis will be reduced to a certainty if we can determine the capital point, which is, that the uterus is empty. Now we have just seen that this knowledge can be arrived at by means of palpation and the touch. Professor Stoltz was the first to use the uterine sound for the same purpose ; but it will be readily understood why great prudence should be exercised in deciding to employ it. In case of a normal pregnancy, the sound would, in fact, be almost sure to produce abortion, and then the mistake would be irreparable. The use of the uterine sound is more rational and truly useful when the question to be decided is, whether there be an extra-uterine pregnancy or a fibroin tumor of the uterus. 596 pathology of pregnancy. § 3. Progress axd Termination. It is but rarely that an extra-uterine pregnancy is prolonged beyond the fourth or fifth month ; for generally the walls of the cyst give way, in con- sequence of their distention, before it has had time to become very large. Sometimes, however, the fetal envelopes resist the pressure to which they are subjected, and if the fetus itself do not perish through want of nourish- ment, or by some accidental disease, its development may progress until term, and it may even live for some time after the expiration of the ninth month. Such is reported by Dr. Grossi to have been the case with a lady, who, in all probability, carried an extra-uterine fetus, whose motions were perceived clearly by himself and several consulting physicians, through a space of fourteen months. Usually, the child perishes either before or shortly after the term of pregnancy ; and we shall now proceed to point out the possible consequences of its retention. A. Rupture of the Cyst. — When left to itself, an extra-uterine pregnancy will generally terminate in a rupture of the cyst ; but the time and conse- quences thereof are very variable. Were we to class these pregnancies according to the frequency of the rupture, and the early period of its occur- rence, they would stand as follows : the tubo-interstitial, tubal, and ab- dominal. It is very rare for the period of the rupture to extend beyond the middle term of pregnancy, except in the last variety. Dr. Lesouef very properly dwells on the tendency of tubal pregnancies to rupture at a very early stage of gestation. According to the same author, and to M. Bernutz, his master, if the rupture of the tube occurs at one of the points where it is covered by the peritoneum, the consequent effusion takes place into the peritoneal cavity ; this, however, is not necessarily so, because the tube might give way at its adherent edge, and allow the ovule to slip between the two layers of the broad ligaments. In this case, the result would be a true consecutive sub-peritoneo-pelvic pregnancy. The rupture, which is usually spontaneous, always gives rise to exceed- ingly grave phenomena, which may be described as the primitive and secondary consequences. Thus, the patient at once suffers from violent pains for several hours ; then, after a pain which is much stronger than all the others, a perfect calm comes on. The abdomen sinks, or becomes flat- tened, and the former tumor disappears ; a gentle and equal heat spreads over the abdominal cavity, and if the pregnancy is well advanced, the patient feels as though a voluminous body had been suddenly displaced ; the skin loses its natural hue, faintings come on, the pulse is small and con- tracted, a cold sweat covers the whole body, and death frequently follows, because the rupture of the cyst is often the immediate cause of a hemorrhage that speedily proves fatal. Should any circumstance whatever arrest the hemorrhage, the first symptoms that follow the displacement of the product of conception, and the transference of the waters, blood, or even the fetus itself, to parts not accustomed to such contact, are those of a vei y violent peritonitis. The patient generally dies, though sometimes she is able to resist the violence of the first inflammatory symptoms, in which case the course of the ditease differs from that time, according to whether the dcbria OF EXTRA-UTERINE PREGNANCY. 597 of the pregnancy are to be inclosed in a cyst of new formation for the re- mainder of the patient's life, or whether they are to be eliminated in various ways. In the first case, the foetus may undergo all the transformations described under the head of the pathological anatomy ; and in the second, the symptoms vary with the manner in which the elimination is effected. B. Prolonged Retention of the Cyst. — As we have already stated, the peculiarities of extra-uterine pregnancy, when the integrity of the cyst allows the development of the foetus to proceed until term, and even some- what beyond it, we shall not reconsider it. We would, however, add, that in some cases the disorders of the general health, produced by the develop- ment of these abnormal pregnancies, have been so great as to prove fatal, without there being any discoverable lesion to account therefor. Thus, says M. Jacquemier, the autopsy reveals neither rupture of the cyst, nor a trace of hemorrhage, peritonitis, nor process of elimination going on in the cyst : the unfortunate sufferers appearing to have succumbed under a kind of exhaustion of vital power. The development of the cyst ceases with the life of the foetus, the circula- tion in its walls becomes feebler, the vessels which maintain the connections necessary to the support of the ibetal life, gradually become atrophied, and even in great part obliterated; so that the foetus and its envelopes are thenceforth a foreign body within the organism of the mother. Occasion- ally, the latter becomes accustomed to their presence; for some women carry a foetal cyst for many years without their health appearing to be much injured thereby : we have mentioned what transformations the foetus and its envelopes are liable to undergo in such cases. Sometimes, however, the weight of the tumor, and the pressure which it exerts upon the neighboring parts, disturb the general functions so seriously as to make the female de- mand earnestly to be relieved of the cause of her suffering by an operation. Whether the tumor be the cause of acute pain to the woman or not, it is likely, after the lapse of an indeterminate period, to become the seat of an inflammation, which extends rapidly to the neighboring parts. In conse- quence of this inflammation, which may progress with greater or less rapidity, adhesions are contracted between the walls of the cyst and the parts adja- cent ; ulceration begins at the points of adhesion, perforation follows with the formation of communications between the cavity of the cyst and that of one of the neighboring organs, or with the exterior, in case the abdominal walls be invaded by the ulceration. The foetal debris find their way to the exterior, at times by the bladder, rectum, vagina, and even the stomach, at others by means of an abscess opening into the perineum, or through the anterior abdominal parietes. Furthermore, since these latter communications are common to all kinds of extra-uterine pregnancies, we can understand that the situation of the foetus in the sub-peri toneo-pelvic variety, which, as before stated, is the most deeply engaged in the excavation, will render its expulsion by the vagina or rectum more frequent than in the others. Most generally some one of the above-mentioned organs serves as an ex- cretory c%nal, but in certain cases several of them are simultaneously attacked b} the adhesive inflammation; of course, ulceration and perforation soon 098 PATHOLOGY OF PREGNANCY. follow ; and the wreck of the foetus escapes at once by the anus, the vagina, and through a fistulous opening in the abdominal walls. This expulsion greatly endangers the mother's life — for very often the inflammation and suppuration of the cyst, by spreading to neighboring parts, exhausts the patient, and sooner or later she succumbs. In the more fortunate cases, the sac is gradually emptied, cleansed, and contracted, the suppuration ceases, and the wound cicatrizes, or at least becomes a simple fistulous ulcer. The long-continued suppuration, and consequent exhaustion of the patient's st rength, will always render a complete expulsion of the foreign bodies highly desirable, for nothing else will put an end to the suppuration and allow the fistulas to close. Unfortunately, the hair, teeth, and pieces of bony substance adhere very strongly to the walls of the cyst, in which they seem to be im- bedded, and are detached with difficulty ; yet it is very necessary to be care- ful not to use too much force for their extraction, lest the walls of the cyst should be torn, and an opening made between it and the cavity of the peri- toneum, rendering liable the occurrence of a quickly fatal peritonitis. The interference of the surgeon should be restricted to the dilatation of all the openings and fistulous passages by means of compressed sponge, to cleansing injections within the cyst, and to the withdrawal, by means of forceps, of the completely detached portions of bony matter which present themselves at the openings. In no case, I repeat, should any effort be made to detach the strongly adherent portions. § 4. Causes. Nothing can oe more obscure than the causes of extra-uterine pregnancy, although numerous facts would seem to prove that the action of terror, coin- ciding with the time of fecundation, may produce such an effect as to prevent the impregnated ovule from being ulteriorly transported into the uterus ; but notwithstanding the high authority of those who have adopted this doc- trine, it does not appear to be admissible, since the ovule does not abandon the ovary at the moment of conception, but several days after or even several days before this event. M. Dezeimeris brings forward one case that seems to prove that a blow on the hypogastrium a short time after a fruitful coition may be the cause of this anomaly, though I should rather refer it to a particular disposition of the mother's organs. When, indeed, we consider the narrowness of the tubal canal, we can readily conceive that any deviations, even slight ones, of the Fallopian tube, any paralysis or spasm, an excess or defect of length, an engorgement, the swelling and ulceration of the mucous membrane, or hard- ening of its pavilion, or any retraction at the internal orifice; in one word, all the anomalies and alterations described by authors may take place there, and give rise to it. 1 myself have had an opportunity of observing two cases i reported in the Bulletin de la SociHe Anatomique) in which the tube was obliterated between the point where the ovule was developed and the internal orifice of this canal. 1 1 Tin' obliteration of the tube in the case referred to is so remarkable an occurrence, thai I endeavored to learn, by referring to various authors, whether similar cases had OF EXTRA-UTERINE PREGNANCY. 599 Finally, if we take into consideration the singular anomaly tlescri ted bv M. G. Richard (see page 86), we may suppose that the fecundated ovule been reported. Most of them have not observed the state of permeability or imper- meability of the tube; others, on the contrary, have given their attention to this point Thus, Smellie (vol. ii. p. 77) quotes an observation of Dr. Fern, in which an oblitera- tion, or rather an excessive retraction of the tube was described. In the memoir of M. Breschet, on interstitial pregnancy, I found several instances where the oblitera tion of the uterine orifice was also noted. M. Mayer communicated a case to M Breschet, where the foetus was developed in that part of the tube which traversed the substance of the uterine walls; M. Mayer further remarks, that the right tube was dilated at its fringed extremity, contracted in the uterine portion, and was completely obliterated at about three lines from the uterus; the left one, in which the ovule was developed, was permeable as far as the morbid mass, but from this point to the uterus the canal ceased. He adds: It is very probable that an induration of the uterine substance formerly existed at the insertion of the left tube, which caused the occlusion of its orifice, and fumislted an obstacle to the passage of the ovule. M. Schmidt reports that in an example of interstitial pregnancy, of six weeks, the internal orifice of the right tube was completely closed. (The ovule was developed on the right side of the womb.) M. Meniere {Archives, June, 1826) furnishes a case of interstitial pregnancy located in the left cornua, and he says the left tube was impermeable at its internal part. M. Gaide, in a similar instance (Journal Hebdomadaire, t. i.), ascertained that the right tube had no uterine orifice. Another case is reported in the Archives of a mortal hemorrhage produced by tubal pregnancy. The author adds: " The left tube (the ruptured one) formed a consistent membranous sac, and its free extremity embraced the whole ovary; below the dilata- tion and in the uterine portion, the canal was completely obliterated in such a manner that it was wholly impossible to reach the uterus through it." From all which it follows, as a natural consequence, that, contrary to the opinion generally received, it is not necessary for the sperm to pass successively through the uterus and the Fallopian tube, so as to approach and fecundate the ovule; and, further, this conclusion permits the adoption of certain facts which have been rejected as im- probable; for we can explain by it how, in some females, there may happen to be a complete occlusion of the os tincae at the period of labor; how, in others, the fecun- dation has taken place without a proper introduction of the membrum virile, the phys- ical proofs of virginity even remaining at the time of labor. Perhaps comparative anatomy might throw some light on the question before us: thus, in certain mammalia, such as the hog, cow, &c, the Fallopian tube is not the only canal that affords a passage to the sperm; for M. Gartner, of Copenhagen, has announced the existence of a particular duct in these animals, which extends from the external parts through the substance of the broad ligaments. In 1820 he came to Paris, and, conjointly with M. de Blainville, made some new researches on this point, the results of which the French naturalist has communicated to the public in the JJul- letin de la Societe Philomatique, t. 9, p. 100, 182G. The latter Bays, that it' the vagina of a young sow be carefully examined, a particular canal will be discovered, having its external orifices on each side of the meatus urinarius, and running through the iiius cular fibres of the vagina; it becomes contracted near the neck of the uterus, but does not the less continue in the uterine tissue. This canal at fust follows the body of the womb, then abandons it, and runs in the substance of the broad ligament parallel to the corresponding cornua and close to the origin of the Fallopian tube, where it in lost by seeming to spread out, or to subdivide into two or three filaments, which can scarcely be distinguished from the vessels, and more especially from the proper tissue of the broad ligament. M. de Blainville says he has searched in vain for similar canals in women, but he fias not met with anything of the kind. Analogy, however, renders their existence probable in the human species; and this probability becomes still stronger from the 600 PATHOLOGY OF PREGNANCY. might, in its progress along the tube towards the uterus, escape through one tit' those accidental openings, and so fall into the abdominal cavity. account of a case communicated by M. Baudelocque to the Acad&nie de MeMecine (Arch. de Mid. L826), as a unique anomaly in the science, although it is a very sin- gular fact that Dulaurens, according to the report of Mauriceau i Traiti des Maladies des Femmes Grosses, p. 12, t. 1). had several times observed that the lube, after arriving at the angle of the uterus, separated into two distinct canals, the larger and shorter of which was inserted into the fundus uteri, while the other, being narrower and lunger, terminated at the neck, near its internal orifice. De Graaf (Opera Omnia, p. 212) thought he had found canals in women similar to those described by M. Gartner as existing in certain mammalia. Lastly, Mad. Boivin declares she has met with cases analogous to the bifurcated canal of M. Baudelocque. Hence, in these examples at least, there is good ground for supposing that a conception may occur, even when the internal orifice of the tube is wholly obliterated. Now if, as Mauriceau and Dulaurens say (whose researches the modern authors seem to have entirely overlooked), such anomalies were found at a period when dissec- tions wen- much more rare than at the present time, we may conclude that, if the writers of our own day have not realized that disposition, it is because their efforts are not directed to the same end. Among the causes of extra uterine pregnancy mentioned by Parry, are pelvic in- flammations, peri- and para-metritis, which produce constriction and displacement of the uterine appendages, peritonitis following previous confinement, pelvic abscess open- ing into the vagina. Numerous cases of extra-uterine pregnancy are cited in which previous inaptitude for conception, either primarily or after they have borne one or more children, existed. Hernia of some portion of the internal genital organs, uterine displacements, an unhealed section of the uterus made in the operation of gastro-hysterotomy, a fistula through the cicatrix of the neck of a uterus, in which all of the body and part of the neck were removed on account of a fibroid tumor, are also mentioned. Fig. 92a. The illustration given above of bifurcation of the Fallopian tube, serves to explain a number of cases referred to as tubo-uterine ; a notable instance occurring in the practice of Dr. Hodge is mentioned by Parry on page 2, a case of tubal pregnancy of three months treated successfully by cutting into the sac through the vaginal wall by means of the platinum knifeof the galvano- caustic battery. There was no blood lost until efforts to remote the placenta by gentle traction and detachment brought on a severe hemorrhage. A little over half of the placenta was removed when he was obliged to inject a solution of persulphate of iron. Symptoms of septicaemia set in on the fourth day, which, however, yielded to constantly-repeated injections into the sac of carbolized water. The remaining portion of the placenta came away spontaneously on the fifteenth day. The operation devised by Dr. Thomas promises very greal success in the treatment of extra-uterine pregnancy in the early stages. It has the advan- tage of less risk to the peritoneum, less danger from hemorrhage, it insures drainage of the sac, more thorough disinfection, ami therefore less danger from septicaemia. More recently he advises leaving the placenta in situ and Idling tin sac with antiseptic cotton, which should be removed once in thirty-six hours. If no obstacle can be opposed to the constant development of the foetus, every operation must be proscribed at this period for extracting the foetus from its mother's body, because an operation would be as dangerous as the anticipated accident. Even when the spontaneous rupture of the cyst, (i02 PATHOLOGY OF PKEGNANCY. during tlic early stages, occasions a just fear of mortal hemorrhage, we can only employ those general means which arc the best calculated to prevent profuse discharges, such as rest, refrigerants, etc. Again, suppos- ing thai a well-marked case of extra-uterine pregnancy lias advanced almost to term, or that the labor lias actually commenced, we may still justly dread the laceration of the cyst as a consequence of the expulsive efforts; and the question then arises whether gastrotomy, which has been successfully practised in similar cases, ought to he resorted to. If the child's safety he alone considered, this question is easily resolved. But is not the life of the mother almost necessarily compromised by such an operation ? How shall we persuade the patient, when the proper period for operating has arrived, if she herself does not suspect the danger she encounters by refusing ? Or how, indeed, can we ourselves decide, when the possible con- sequences are foreseen, the whole difficulties of a delivery appreciated, and the necessity staring us in the face of leaving open in the abdomen a vast cyst, the inflammation and suppuration of which are so difficult to dry up, and are of themselves sufficient to endanger the sufferer's life? In such cases, who can doubt, says M. Dezeimeris, that if there was any measure at all that could suspend the commencing labor, the ties of human- ity alone would render its employment a duty ? And I fully embrace the same opinion. Now among the means calculated to restrain the ordinary uterine con- tractions, I know of nothing more serviceable than opium, when exhibited in large doses per anum, and I certainly should not hesitate to employ it under these circumstances ; but if the labor continues, notwithstanding its use, gastrotomy may then be authorized. The cyst is generally opened through the abdominal parietes, the place of selection being the same as in the common Cesarean operation, though, in case the head be felt through the vagina during the expulsive efforts, less danger would certainly accompany an incision through the walls of the latter. The child may be extracted by turning, or by the forceps, if neces- sary. Parry collected 15 cases in which vaginotomy was performed. In these, nine of the mothers died and six lived — a mortality of (in per cent. In primary gastrotomy the mortality is 70 per cent. The death rate of extra- uterine pregnancy, not actively interfered with, is shown to be 52.65 per cent. If a prolonged labor has produced a rupture of the cyst, it is very doubtful whether gastrotomy could he successful. The first efforts should he directed towards moderating the hemorrhage, and opposing consecutive inflammation should he energetically employed. But the primitive phenomena once calmed, whether there be a rupture or not, our art may evidently interpose to prevent the consecutive accidents (hat have been enumerated, and which compromise to so great an extent the health and even the life of the patient. When the inflammatory symp- toms have ceased, it is proper to wait ; and especially after the cyst is ruptured, hasty action becomes unnecessary. In fact, a considerable period is requisite in such cases for the develop- ment of a new cyst around the displaced parts, and a certain length of time Or EXTRA-UTERINE PREGNANCY. 603 is necessary for the adhesions to form between them and the adjacent parts, and it would be exceedingly rash to interfere with this salutary action by any inopportune operation on our part. In old abnormal pregnancies, the resources of art vary with the particular case. Sometimes, indeed, an elimi- natory effort has already commenced by an inflammation of the integumenns placed just in front of the tumor, whereby an abscess is formed; and the only question then is, whether to open it, or by suitable incisions to enlarge the spontaneous solutions of continuity ; in either case we encounter a vast abscess, which must be emptied and cleansed by the usual methods. When some portions of the foetus get into the bladder, and we are assured of that fact by the use of the catheter, the operation for stone may be prac- tised either through the vagina or by the hypogastrium. Again, a woman may present herself with an extra-uterine fetus of one or several years' standing. Can the resources of art afford her any relief? We reply, that if the gestation is a source of severe suffering, and it renders her incapable of discharging her duties ; and if, besides, the tumor may be reached through the vagina without difficulty, the vaginal incision should doubtless be per- formed. But if she is otherwise in good health, would it be prudent to interfere for the mere purpose of anticipating the accidents to which she will probably be afterwards exposed? Or is there any ground for hoping to extract the foetus en masse, by a prudent and methodical operation? This last question is far more difficult to solve. In a case of this kind, where the head of the foetus, from being wedged at the superior strait, could readily be felt through the posterior superior part of the vaginal parietes, I knew Professor P. Dubois (notwithstanding sharp opposition from several of his brethren in consultation) to resolve upon incising freely the vaginal wall, as well as the cystic envelopes, intending to apply the forceps on the head, and thus extract the foetus bodily ; but the walls of the cyst and vagina having been cut through, an intimate adhesion was discovered l/etween the former and the foetal head, which caused the operation to be abandoned. It was not without benefit, however, for in the course of a few days it was followed by the discharge of a putrid mass, comprising all the soft parts of the foetus ; the detached bones of the skeleton were gradually extracted by the aid of long pincers, and frequently repeated injections ; the cystic walls contracted slowly; and when, at length, nothing remained, and the parietes were cleansed, the opening gradually closed up, and by the end of two months the patient was completely cured. At the time of operating she had been pregnant twenty-two months. This plan oughl to be followed up in similar cases, especially if the female's health is visibly affected. In- cision by the rectum lias hen practised in some few instances where the vulva was obliterated. Finally, gastrotomy alone would be practicable when the foetus, from its high situation in the abdomen, is inaccessible by the vagina or rectum. This operation must be regarded as the lasl resource when the patient's life is seriously endangered. In L875, Prof. T. G. Thomas reported a case successfully operated upon through the vagina by means of the platinum knife of the galvano-caustic battery. In all operations, antiseptic precautions Bhould be \\>rd. University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. ft 0BT18«* & D 000 225 427 4 WQIOO C386t2 1886 v. 1 Cazeaux, Pierre. Theory and practice of WQ100 C386t2 1886 )a.zeauy. , Pierre. v . 1 Theory and practice of obstetrics MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 HHn MMWffl HBHHHI IWBmmib Ml m