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Title: A System of Midwifery
Author: Rigby, Edward
Language: English
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A SYSTEM OF MIDWIFERY.

by

EDWARD RIGBY, M. D.,

Physician To the General Lying-In Hospital, Lecturer on
Midwifery, at St. Bartholomew's Hospital, etc. etc.


      *      *      *      *      *      *

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      *      *      *      *      *      *


A SYSTEM OF MIDWIFERY.

With Numerous Wood Cuts.

by

EDWARD RIGBY, M. D.,

Physician to the General Lying-In Hospital, Lecturer on
Midwifery, at St. Bartholomew's Hospital, etc. etc.

With Notes and Additional Illustrations.



Philadelphia:
Lea & Blanchard.
1841.

Entered, according to the Act of Congress, in the year 1841, by Lea &
Blanchard, in the District Court for the Eastern District of Pennsylvania.

Griggs & Co., Printers.



THE EDITOR'S PREFACE.


This System of Midwifery, complete in itself, was published in London, as
a part of Dr. Tweedie's "_Library of Medicine_." The first series of the
Library, that on "_Practical Medicine_," recently completed, has been
received with extraordinary favour on both sides of the Atlantic, and the
character of the publication is fully sustained in the present
contribution by Dr. Rigby, and will secure for it additional patronage.

The late Professor Dewees, into whose hands this volume was placed, a few
weeks before his death, in returning it, expressed the most favourable
opinion of its merits; and the judgment of such high authority renders it
supererogatory to add a word farther of commendation.

It is only necessary for the editor to say that the production of the
author is so complete as to have rendered his labour a light one. He has
restricted himself mainly to such additions and references as he conceived
would render the work more useful to American practitioners. The object of
the publication being to present the most condensed view of each subject,
he believed it to be inexpedient to depart from the plan by making
extensive additions, and entering into the discussion of controversial
points, most of which are of minor practical importance.



CONTENTS.


  INTRODUCTION,                                                    Page 13


  PART I. THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION.

  CHAPTER I. THE PELVIS.

  Ossa innominata.--Sacrum.--Coccyx.--Distinction between the
  male and female pelvis.--Diameters of the pelvis.--Pelvis
  before puberty.--Axes.--Inclination,                                  15

  CHAPTER II. FEMALE ORGANS OF GENERATION.

  Internal and external.--Ovaria.--Ovum.--Corpus luteum.--
  Fallopian tubes.--Uterus.--Vagina.--Hymen.--Clitoris.--
  Nymphæ.--Labia,                                                       22

  CHAPTER III. DEVELOPMENT OF THE OVUM.

  Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical
  cord.--Embryo.--Foetal circulation,                                   48


  PART II. NATURAL PREGNANCY AND ITS DEVIATIONS.

  CHAPTER I. SIGNS OF PREGNANCY.

  Difficulty and importance of the subject.--Diagnosis in the
  early months.--Auscultation.--Changes in the vascular and
  nervous systems.--Morning sickness.--Changes in the appearance
  of the skin.--Cessation of the menses.--Areola.--Sensation of
  the child's movements.--"Quickening."--Auscultation.--Uterine
  souffle.--Sound of the foetal heart.--Funic souffle.--Sound
  produced by the movements of the foetus.--Ballottement.--State
  of the urine.--Violet appearance of the mucous membrane of the
  vagina.--Cases of doubtful pregnancy.--Diagnosis of twin
  pregnancy,                                                            80

  CHAPTER II. TREATMENT OF PREGNANCY.

  Sympathetic affections of the stomach during pregnancy.--
  Morning sickness.--Constipation.--Flatulence.--Colicky
  pains.--Headach.--Spasmodic cough.--Palpitation.--Toothach.--
  Diarrhoea.--Pruritus pupendi.--Salivation,                           101

  CHAPTER III. SIGNS OF THE DEATH OF THE FOETUS.

  Difficulty of the subject.--Signs before labour.--Motion of
  the foetus.--Sound of the foetal heart.--Uterine souffle.--
  Signs during labour where the head presents--where the face,
  the nates, the arm, or the cord, present.--Fetid liquor
  amnii.--Discharge of meconium,                                       107

  CHAPTER IV. MOLE PREGNANCY.

  Nature and origin.--Varieties.--Diagnostic symptoms.--
  Treatment,                                                           112

  CHAPTER V. EXTRA-UTERINE PREGNANCY.

  Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the
  substance of the uterus,                                             117

  CHAPTER VI. RETROVERSION OF THE UTERUS.

  History.--Causes.--Symptoms.--Diagnosis.--Treatment.--
  Spontaneous terminations,                                            126

  CHAPTER VII. DURATION OF PREGNANCY,                                  136

  CHAPTER VIII. PREMATURE EXPULSION OF THE FOETUS.

  Abortion.--Miscarriage.--Premature labour.--Causes.--
  Symptoms.--Prophylactic measures.--Effects of repeated
  abortion.--Treatment,                                                141


  PART III. EUTOCIA, OR NATURAL PARTURITION.

  CHAPTER I. STAGES OF LABOUR.

  Preparatory stage.--Precursory symptoms.--First
  contractions.--Action of the pains.--Auscultation during the
  pains.--Effect of the pains upon the pulse.--Symptoms to be
  observed during and between the pains.--Character of a true
  pain.--Formation of the bag of liquor amnii.--Rigour at the
  end of the first stage.--Show.--Duration of the first stage.--
  Description of the second stage.--Straining pains.--Dilatation
  of the perineum.--Expulsion of the child.--Third stage.--
  Expulsion of the placenta.--Twins,                                   156

  CHAPTER II. TREATMENT OF NATURAL LABOUR.

  State of the bowels.--Form and size of the uterus.--True and
  spurious pains.--Treatment of spurious pains.--Management of
  the first stage.--Examination.--Position of the patient during
  labour.--Prognosis as to the duration of labour.--Diet during
  labour.--Supporting the perineum.--Treatment of perineal
  laceration.--Cord round the child's neck.--Birth of the child,
  and ligature of the cord.--Importance of ascertaining that the
  uterus is contracted after labour.--Management of the
  placenta.--Twins.--Treatment after labour.--Lactation.--Milk
  fever and abscess.--Excoriated nipples.--Diet during
  lactation.--Management of lochia.--After-pains,                      169

  CHAPTER III. MECHANISM OF PARTURITION.

  Cranial presentations--first and second position.--Face
  presentations--first and second positions.--Nates
  presentations,                                                       199


  PART IV. MIDWIFERY OPERATIONS.

  CHAPTER I. THE FORCEPS.

  Description of the straight and curved forceps.--Mode of
  action.--Indications.--Rules for applying the forceps.--
  History of the forceps,                                              216

  CHAPTER II. TURNING.

  Turning.--Indications.--Circumstances most favourable for this
  operation.--Rules for finding the feet.--Extraction with the
  feet foremost.--Turning with the nates foremost.--Turning with
  the head foremost.--History of turning,                              230

  CHAPTER III. CÆSAREAN OPERATION.

  Indications,--Different modes of performing the operation.--
  History of the Cæsarean operation,                                   243

  CHAPTER IV. ARTIFICIAL PREMATURE LABOUR.

  History of the operation.--Period of pregnancy most favourable
  for performing it.--Description of the operation,                    250

  CHAPTER V. PERFORATION.

  Variety of perforators.--Indications.--Mode of operating.--
  Extraction.--Crotchet.--Embryulcia,                                  256


  PART V. DYSTOCIA, OR ABNORMAL PARTURITION.

  CHAPTER I. FIRST SPECIES OF DYSTOCIA.

  Malposition of the child.--Arm or shoulder the only faulty
  position of a full-grown living foetus.--Causes of
  malposition.--Diagnosis before and during labour.--Results
  where no assistance is rendered.--Spontaneous expulsion.--
  Malposition complicated with deformed pelvis or spasmodically
  contracted uterus.--Embryulcia.--The prolapsed arm not to be
  put back or amputated.--Presentation of the arm and head.--
  Presentation of the hand and feet.--Presentation of the head
  and feet.--Rupture of the uterus.--Usual seat of laceration.--
  Causes.--Premonitory symptoms.--Symptoms.--Treatment.--
  Gastrotomy.--Rupture in the early months of pregnancy,               264

  CHAPTER II. SECOND SPECIES OF DYSTOCIA.

  Size and form of the child.--Hydrocephalus.--Cerebral
  tumours.--Accumulation of fluid and tumours in the chest or
  abdomen.--Monsters.--Anchylosis of the joints of the foetus,         281

  CHAPTER III. THIRD SPECIES OF DYSTOCIA.

  Difficult labour from faulty condition of the parts which
  belong to the child.--The membranes.--Premature rupture of the
  membranes.--Liquor amnii.--Umbilical cord.--Knots upon the
  cord.--Placenta,                                                     286

  CHAPTER IV. FOURTH SPECIES OF DYSTOCIA.

  Abnormal state of the pelvis.--Equally contracted pelvis.--
  Unequally contracted pelvis.--Rickets.--Malacosteon, or
  mollities ossium.--Symptoms of deformed pelvis.--Funnel-shaped
  pelvis.--Obliquely distorted pelvis.--Exostosis.--Diagnosis of
  contracted pelvis.--Effects of difficult labour from deformed
  pelvis.--Fracture of the parietal bone.--Treatment.--Prognosis,      292

  CHAPTER V. FIFTH SPECIES OF DYSTOCIA.

  _Obstructed Labour from a Faulty Condition of the Soft Passages._

  Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--
  Edges of the os uteri adherent.--Cicatrices and callosities.--
  Agglutination of the os uteri.--Contracted vagina.--Rigidity
  from age.--Cicatrices in the vagina.--Hymen.--Fibrous bands.--
  Perineum.--Varicose and oedematous swellings of the labia and
  nymphæ.--Tumours.--Distended or prolapsed bladder.--Stone in
  the bladder,                                                         308

  CHAPTER VI. SIXTH SPECIES OF DYSTOCIA.

  _Faulty Labour from a Faulty Condition of the expelling Powers._

  I. Where the uterine activity is at fault--functionally or
  mechanically--from debility--derangement of the digestive
  organs--mental affections--the age and temperament of the
  patient--plethora--rheumatism of the uterus--inflammation of
  the uterus--stricture of the uterus.--Treatment. II. Where the
  action of the abdominal and other muscles is at fault.--Faulty
  state of the expelling powers after the birth of the child.--
  Hæmorrhage.--Treatment,                                              324

  CHAPTER VII. INVERSION OF THE UTERUS.

  Partial and complete.--Causes.--Diagnosis and symptoms.--
  Treatment.--Chronic inversion.--Extirpation of the uterus,           345

  CHAPTER VIII. ENCYSTED PLACENTA.

  Situation in the uterus.--Adherent placenta.--Prognosis and
  treatment.--Placenta left in the uterus.--Absorption of
  retained placenta,                                                   354

  CHAPTER IX. PRECIPITATE LABOUR.

  Violent uterine action.--Causes.--Deficient resistance.--
  Effects of precipitate labour.--Rupture of the cord.--
  Treatment.--Connexion of precipitate labour with mania,              361

  CHAPTER X. PROLAPSUS OF THE UMBILICAL CORD.

  Diagnosis.--Causes.--Treatment.--Reposition of the cord,             368

  CHAPTER XI. PUERPERAL CONVULSIONS.

  Epileptic convulsions with cerebral congestion.--Causes.--
  Symptoms.--Tetanic species.--Diagnosis of labour during
  convulsions.--Prophylactic treatment.--Treatment--Bleeding.--
  Purgatives.--Apoplectic species.--Anæmic convulsions.--
  Symptoms.--Treatment.--Hysterical convulsions.--Symptoms,            376

  CHAPTER XII. PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.

  History.--Dr. Rigby's division of hæmorrhages before labour
  into accidental and unavoidable.--Causes.--Symptoms.--
  Treatment.--Plug.--Turning.--Partial presentation of the
  placenta.--Treatment,                                                393

  CHAPTER XIII. PUERPERAL FEVERS.

  Nature and varieties of puerperal fever.--Vitiation of the
  blood.--Different species of puerperal fever.--Puerperal
  peritonitis.--Symptoms.--Appearances after death.--
  Treatment.--Uterine phlebitis.--Symptoms.--Appearances after
  death.--Treatment.--Indications.--False peritonitis.--
  Treatment.--Gastro-bilious puerperal fevers.--Symptoms.--
  Appearances after death.--Treatment.--Contagious or adynamic
  puerperal fevers.--Symptoms.--Appearances after death.--
  Treatment,                                                           415

  CHAPTER XIV. PHLEGMATIA DOLENS.

  Nature of the disease.--Definition of phlegmatia dolens.--
  Symptoms.--Duration of the disease.--Connexion with crural
  phlebitis.--Causes.--Connexion between the phlegmatia dolens
  of lying-in women and puerperal fever.--Anatomical
  characters.--Treatment.--Phlegmatia dolens in the
  unimpregnated state,                                                 463

  CHAPTER XV. PUERPERAL MANIA.

  Inflammatory or phrenitic form.--Treatment.--Gastro-enteric
  form.--Treatment.--Adynamic form.--Causes and symptoms.--
  Treatment,                                                           473


  INDEX,                                                               483



A SYSTEM OF MIDWIFERY.



INTRODUCTION.


By the term Midwifery is understood the knowledge and art of treating a
woman and her child during her pregnancy, labour, and the puerperal state.
We employ it in this extended sense, because most systematic writers of
later times have adopted this arrangement. The terms, _Art des
Accouchemens_ of the French, the _Ostetricia_, and _Arte della Parteria_,
of the Italians and Spaniards, and the _Geburtshülfe_ of the Germans, are
restricted to the process of parturition, although they have been and
continue to be, used in the same extended sense as that in which we
propose to use the term Midwifery.

Although pregnancy and parturition, strictly speaking, are perfectly
natural functions, yet they involve such a complication and variety of
other processes, and also changes of such extent, that the whole system is
rendered more or less subservient to them during the periods of their
existence: hence, therefore, their number and variety must ever render
them more or less liable to deviations and irregularities of action, which
will necessarily be aggravated by the effects of civilized life, and in
many instances are productive of derangement in the general economy of the
system. Under such circumstances the irritability of the system increases
at the expense of its strength and vigour, and not only increases its
liability to these derangements, but diminishes its power of resisting
their effects.

In order that we may render the nature and treatment of the changes
and phenomena, which take place in the human system during the
periods above alluded to, more intelligible, we shall take a short
anatomico-physiological view of the structure, form, arrangement, and
function of the parts and organs which are more or less directly
concerned in these important processes. This will embrace the subject of
embryology, a department of physiological knowledge, which, though it has
lately been much enriched by valuable discoveries, still affords a rich
field of investigation and research.

The diagnosis and course of healthy pregnancy, and its various diseases,
terminating with the subject of healthy parturition and its treatment will
form the subject of the succeeding part.

Parturition properly speaking, will come under two separate heads
_eutocia_ and _dystocia_; the one signifying natural or favourable labour,
the other, unnatural, faulty, or unfavourable labour.

The concluding part will contain a short account of some of the more
important diseases which occur to the female during the first month after
parturition.



PART I.

THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION.



CHAPTER I.

THE PELVIS.

    _Ossa innominata.--Sacrum.--Coccyx.--Distinction between the male and
    female pelvis.--Diameters of the pelvis.--Pelvis before puberty.--
    Axes.--Inclination._


The Pelvis, as the frame-work which, in great measure, contains, supports,
and protects, the complicated apparatus of the generative organs, first
claims our attention; since an accurate knowledge of the form, size, and
uses, of its different parts is indispensably necessary, not only to
understand the situation of the viscera it contains, but also to form a
correct view of the mechanism upon which the process of parturition
depends.

This osseous canal or circular archway, consists essentially of three
bones, the right and left os innominatum, which form the sides of the
arch, with the sacrum between them, acting as a keystone, and supporting
the whole weight of the trunk above.

_Ossa innominata._ The ossa innominata in early life consists of three
distinct bones, the _iliac_ or _hip bones_ at the sides, the _ischia_ or
lower portion upon which we sit, and the _ossa pubis_ which meet each
other anteriorly to form the front part of the pelvis. In the adult these
are consolidated into one bone, merely leaving irregular lines and ridges
here and there to mark their previous existence.

These bones present several striking points of resemblance with those
which belong to the upper extremities, viz. the scapula and clavicle; and
in the early stages of development, this similarity is much more
distinctly seen: it is remarkable, that although the ischia and ossa pubis
are formed later than the ilia, yet they unite with each other much sooner
than with the ilia, so that the two consolidated bones bear the same
relation to the ilium which is separated from them, that the clavicle does
to the scapula: many other points of resemblance between the bones of the
shoulder and pelvis might be noticed if necessary. (Meckel, _Anat._ vol.
ii. p. 239.) The ossa innominata meet each other in front, forming the
_symphysis pubis_, having layers of fibro-cartilage interposed between
their extremities, and bound together by ligamentous fibres constituting
the _ligamentum arcuatum_, or _annulare ossium pubis_, and by which a more
rounded appearance is given to the pubic arch. They are united to the
sacrum posteriorly, one on each side of it, forming the _right and left
sacro-iliac symphysis_ or _synchondrosis_; this differs in many respects
from the symphysis pubis, the cartilaginous coverings of the opposing
bones being much thinner, especially those of the ossa innominata; the
surfaces are extremely uneven from the deep indentations which each bone
presents at this part, locking, as it were, into each other, and thus
contributing greatly to increase the firmness of the joint, which is also
still farther strengthened by the support of powerful ligaments.

Between the ligamento-and cartilaginous layers which cover the surfaces of
the bones at the pubic and sacro-iliac symphyses, a minute collection of
synovial fluid may be detected, like that found in the fibro-cartilages
between the vertebræ; it serves to lubricate their surfaces, and separates
them more or less, thereby increasing the thickness of the intervening
cartilaginous structure; and separating also the edges of the bones, to a
certain extent, more especially at the symphysis pubis. (Portal, _Anat.
Méd._) These laminæ of intervening fibro-cartilage are thicker in the
female than in the male, although of smaller extent; and this is still
more remarkable during pregnancy, this ligamento-cartilaginous structure
becoming now more cushiony and elastic, while in the latter months we can
easily distinguish blood-vessels ramifying through it, which are branches
of the pudic arteries and veins.

_Sacrum._ The sacrum, which forms the upper and posterior portion of the
pelvis, contributes greatly to the general solidity of the whole bony
circle. From its wedge-like shape, it is admirably adapted to support the
entire weight of the trunk, and acts, as we have before observed, as a
kind of keystone to the arch which is formed by the ossa innominata. It is
of a triangular shape, being concave before and convex behind. In the
foetus it consists of five distinct pieces of bone separated by
intervening layers of cartilage, like the vertebræ of the spinal column,
and from their resemblance to those bones they have been called false
vertebræ. These cartilages, after a time, gradually disappear; bony matter
is deposited in their place; so that by the period of puberty the five
sacral vertebræ become united into one solid bone, although they may be
distinguished, until an advanced period of life, by the ridges which their
edges form.

The upper surface of the sacrum, having to sustain the whole weight of the
spinal column, is broad and flat, and corresponds to the lower surface of
the last lumbar vertebra. Its anterior surface forms with that of the
other mentioned bone a considerable angle, which projects forwards and
more or less downwards towards the symphysis pubis, and is called the
_promontory of the sacrum_. Beneath this point, the sacrum takes a
considerable sweep backwards as it descends, gradually advancing again
forwards, as we approach its inferior extremity, forming an extensive
concavity upon its anterior surface: this is termed _the hollow of the
sacrum_.

_Coccyx._ The lower end is prolonged by a small bone, called _Coccyx_ or
_os Coccygis_, from its supposed resemblance to a cuckoo's beak. It
usually consists of four, and sometimes (especially in women) of five
portions; they are much smaller than the bones of the sacrum, and are very
imperfect rudiments of vertebral formation; like these, they are at an
early period little else than cartilage, and even when the bones are fully
formed, they are united by intermediate cartilage, and thus retain so much
mobility upon each other, as well as upon the lower end of the sacrum, as
to admit of being forced backwards to the extent of a full inch, thus
contributing greatly to increase the capacity of the outlet.

The sacrum not only serves to form the posterior parietes of the pelvis,
but by the curve which its lower portion takes forwards, together with the
coccyx, it gives a powerful support to the pelvic viscera.

When we take a general view of the bones which collectively form the
pelvis, we find that it is evidently divided into two portions--an upper
and a lower one. On the Continent these have been called the large and the
small pelvis; in Britain we merely speak of the pelvis above or below the
_brim_, the line of demarcation being the linea ilio-pectinea at the
sides, the crista of the os pubis in front, and the promontory of the
sacrum behind. The alæ of the ilia form a prominent feature in the upper
pelvis, and not only afford an attachment for numerous muscles, but
furnish a powerful and ample means of protection and support to the pelvic
and lower abdominal viscera. In the female pelvis this is remarkably the
case, the cavitas iliaca being well expanded and of greater extent than in
the male, the crista of the ilium thrown more outwards; hence the distance
between the antero-superior processes is much more considerable.

_Distinction between the male and female pelvis._ At the brim, the female
pelvis presents several well-marked points of distinction from that of the
male. The male pelvis has a contracted brim of a rounded or rather
triangular form, with the promontory of the sacrum considerably
projecting; whereas, that of the female is spacious, of an oval shape, and
with a slightly prominent sacrum, thus affording more room for the passage
of the child through the brim. The cavity of the male pelvis is deep,
while in the female pelvis it is shallow, a circumstance which is very
strikingly seen in comparing the length of the symphysis pubis in each,
that of the male pelvis being nearly double the length of the female. This
is an important point of difference as regards parturition, because in a
shallow pelvis, the extent of surface exposed to the pressure of the head
will be much less than where it is deep, and hence the resistance to the
passage of the child will be proportionably diminished: in confirmation of
this, we find that tall women, in whom the pelvis is usually deep, do not,
on the whole, bear children so easily as women of middling stature in whom
the pelvis is more shallow. The capacious hollow of the sacrum in the
female pelvis adds also greatly to the extent of its cavity, and
peculiarly adapts it for parturition, the injurious pressure of the head
upon the soft linings of the pelvis being thus prevented, and every
facility afforded for its quick and easy transit through the cavity. This
applies especially to the neck of the bladder, which would almost
inevitably suffer in every labour, were it not for the ample hollow of the
sacrum relieving the pressure of the head against the anterior portions of
the pelvis. The bones of the female pelvis being more slender and
delicately formed, the foramina ovalia and sacro-ischiatic notches are
wider, and thus add still farther to the capacity of the cavity.

In no part of the pelvis is the difference between the sexes more strongly
marked than at the outlet. The spacious and well-rounded arch of the pubes
in the female of the slender rami, is a striking contrast to the
contracted angular arch of the male pelvis; and the tuberosities of the
ischium being much wider apart, the head is enabled to pass under the arch
with greater facility, and thus still farther to relieve the anterior of
the pelvis from its pressure. The length of the sacro-sciatic ligaments,
and the mobility of the coccyx upon the sacrum, by which it can be forced
backwards to the extent of an inch by the pressure of the head during
labour, not merely serve to distinguish it from the male pelvis, but
afford a beautiful instance of design and adaptation.

The greater width of the pubic arch in the female pelvis is seen by
comparing its angle with that of the arch in the male pelvis. In the
female it has been estimated to form an angle varying between 90° and
100°, whereas in the male it is not more than between 70° and 80°.
(Osiander, _Handbuch der Embindungs-kunst_, cap. iv. p. 58.)

From the greater width of the female pelvis, the acetubula are farther
apart, and the great trochanters of the thigh-bones more projecting; hence
the greater motion of the hips in the female when she walks, which is
still more visible when she runs, for the motion is communicated to the
whole trunk, so that each shoulder is turned more or less forwards as the
corresponding foot is advanced. The thigh-bones, which are so far apart at
their upper extremities, approach each other at the knees, contributing to
produce that unsteady gait which is peculiar to the sex. "The woman," says
Mr. John Bell, "even of the most beautiful form, walks with a delicacy and
feebleness which we come to acknowledge as a beauty in the weaker sex."
(_Bell's Anat._ vol. i.)

These characteristic marks of the female figure, upon which its beauty in
great measure depends, are well seen in all great works of art, whether of
sculpture or painting. "The ancients," as Mr. Abernethy has observed, "who
had a clear and strong perception of whatever is beautiful or useful in
the human figure, and who, perhaps, delicately exaggerated beauty to
render it more striking, have represented Venus as measuring one-third
more across the hips than the shoulders, whilst, in Apollo, they have
reversed these measurements." (_Physiological Lectures._)

_Diameters of the pelvis._ It is of the utmost importance to the
obstetrician, that he should be thoroughly acquainted with the various
dimensions of the female pelvis, for, without this, he can form no correct
idea of the manner in which the presenting part of the child passes
through its brim, cavity and outlet during labour; indeed, unless he be
thoroughly versed in this necessary point of obstetric knowledge, he will
remain in almost total ignorance of the whole mechanism of parturition,
which must, in great measure, be looked upon as the basis of practical
midwifery. The dimensions of the brim cavity and outlet of the pelvis may
be given with sufficient correctness for all practical purposes, by
measuring three of their diameters,--1. the _straight_,
_antero-posterior_, or _conjugate_; 2. the _transverse_; and 3. the
_oblique_. At the brim they are as follow:--the straight diameter, drawn
from the middle of the promontorium sacri to the upper edge of the
symphisis pubis, 4·3 inches; the transverse diameter, from the middle of
the linea-ilio-pectinea of one ilium to that of the other, 5·4 inches; and
the oblique diameter, from one sacro-iliac synchondrosis to the opposite
acetabulum, 4·8 inches. The oblique diameters are called right and left,
according to the sacro-iliac symphysis from which they are drawn.

[Illustration: _Fig. 1. Fig. 2._

In the annexed representations of the superior and inferior aspects of the
female pelvis are shown the three diameters of its brim and outlet; those
of the former in _fig. 1._, and those of the latter in _fig. 2._ The same
letters of reference are used in each figure to indicate the several
diameters; thus _a p_ refers to the antero-posterior, _t t_ to the
transverse, _o o_ to the right oblique, and _o' o'_ to the left oblique
diameters.

In _fig. 2._ the coccyx is represented in situ.]

In the cavity these dimensions vary more or less. The straight diameter,
measured from the centre of the hollow of the sacrum to that of the
symphysis pubis, is 4·8 inches; the transverse, from the point
corresponding to the lower margin of the acetabulum on one side to that of
the other, 4·3; and the oblique, drawn from the centre of the free space
formed by the sacro-ischiatic notch and ligaments on one side of the
foramen ovale of the other, 5·2.

At the inferior aperture or outlet the alteration is still more
remarkable. The straight diameter, from the point of the coccyx to the
lower edge of the symphysis pubis, measures only 3·8 inches; but from the
mobility of the coccyx enabling it to be pushed back during labour to the
extent of a whole inch, it is capable of being extended to 4·8 inches. The
transverse diameter from one tuberosity of the ischium to the other,
measures 4·3 inches: and the oblique, from the middle of the lower edge of
the sacro-sciatic ligament of one side, to the point of union between the
ischium and descending ramus of the pubes on the other 4·8 inches.

Although these are the proportions of the brim cavity and outlet of the
female pelvis in the skeleton state, their real dimensions during life,
when the pelvis is thickly lined with muscular and other structures, are
very different. The large masses of the psoas magnus and iliacus internus,
besides other muscles of inferior size, contribute to alter materially the
relations of the pelvic diameters to each other; hence we find that, so
far from being the longest, the transverse diameter is one of the
shortest, being little more than the antero-posterior. This holds good,
especially during labour, because these muscles being thrown into powerful
contraction, their bellies swell, and thus tend still farther to diminish
its length. The oblique diameters are, in fact, the longest during life,
because not only are the parietes of the pelvis at the brim covered by a
very thin layer of soft tissues in these directions; but as the
extremities of these diameters, in the cavity and outlet, correspond to
free spaces which are merely filled up with soft yielding structure, it
follows that their length can be somewhat increased when pressure is
applied in these directions; the antero-posterior diameter of the outlet
can alone be compared with the oblique diameters in this respect, and then
only when the coccyx is forced backwards to its full extent by the
pressure of the head.

_Pelvis before puberty._ The proportions of the adult female pelvis are no
longer what they were during childhood; before the age of puberty they
resemble those of the male pelvis, the brim being contracted and more or
less triangular, and the antero-posterior diameter equalling or even
exceeding the transverse. Indeed, at a still earlier period, it presents
many points of resemblance even to the pelvis of animals; as, however,
growth and development advance, and the various changes which constitute
puberty take place, the transverse diameters of the brim, cavity, and
outlet increase at the expense of the antero-posterior, until at length,
it has assumed the proper proportions of the adult female pelvis.

_Axes._ Of not less importance is it that the obstetrician should be
thoroughly acquainted with the direction which the central line or axis of
the entrance and outlet of the pelvis takes. The axis of the superior
aperture has been considered to form with the horizon an angle varying
between 50° and 60°; this was noticed long ago by Dr. Smellie: "when the
body of a woman," says this valuable author, "is reclined backwards, or
half sitting half lying, the brim of the pelvis is horizontal; and an
imaginary straight line, descending from the navel, would pass through the
middle of the cavity; but in the last month of pregnancy such a line must
take its rise from the middle space between the navel and scrobiculus
cordis in order to pass through the same point of the pelvis." (_Treatise
of Midwifery_, book i. chap. i. sect. 2.)

_Inclination of the pelvis._ The angle which the axis of the superior
aperture of the pelvis forms with the horizon, when a woman is in the
upright posture, necessarily marks what has been called _the inclination
of her pelvis_, and varies, of course, in proportion to the angle which
the above mentioned axis forms. In a tall woman of slender figure, where
the different curves of the spinal columns are slight, the inclination of
the pelvis is much less than in a short thick set woman, where the spine
is much more strongly curved. Where the inclination is slight, the hollow
of the sacrum is generally small, and the vulva directed more forwards;
where, on the other hand, the pelvis is much inclined, the hollow of the
sacrum is generally observed to be deep, and the vulva directed more or
less backwards. The axis of the lower aperture or outlet appears to
depend, in great measure, on the curve which the lower part of the sacrum
takes downwards and forwards; but, as a general rule, we think it will be
found to form, more or less, a right angle with the axis of the brim. The
greater the angle which the axis of the brim forms with the horizon, the
less will be that which the axis of the outlet forms, and _vice versâ_;
or, in other words, the angle with the horizon which the axis of the one
forms is inversely to that of the other.

The consideration of the various deviations, as to size and form, from the
natural proportions which the female pelvis occasionally presents,
belongs, more strictly speaking, to that species of faulty labour which
arises from these conditions. We, therefore, refer to the fourth species
of dystocia, viz. _Dystocia Pelvica_, where the different pelvic
anormalities are described.



CHAPTER II.

FEMALE ORGANS OF GENERATION.

    _Internal and external.--Ovaria.--Ovum.--Corpus luteum.--Fallopian
    tubes.--Uterus.--Vagina.--Hymen.--Clitoris.--Nymphæ.--Labia._


The female organs of generation have been usually classed by the English
authors under the two heads of _internal_ and _external_; a similar
arrangement has also been followed by the Continental writers, but with
the advantage of using distinctive terms which are more expressive of
their peculiar functions, viz. the _formative_ and _copulative_ organs.
Under the first are included the ovaria, Fallopian tubes, and uterus:
under the second, the vagina and external parts. We propose to give a
short description of these in the unimpregnated state, and then to
describe the changes which they present during pregnancy, labour, and the
puerperal condition. In point of situation and arrangement they bear a
considerable resemblance to the generative organs in the male, being
situated at the lower portion of the trunk, and arranged in symmetrical
order, so that they either occur in pairs, one on each side the median
line of the body, or singly, being equally divided by it throughout their
whole length. Although there is in many points considerable difference
between the male and female organs, still there is sufficient resemblance
to entitle them to be considered as being formed upon the same fundamental
type, a resemblance which is seen still more strikingly in the early
periods of foetal life. They differ essentially from all the other organs
of the system, being in activity during a portion of a woman's life only,
and then only at intervals.

_Ovaria._ The ovaries are situated in the upper part of the cavity of the
pelvis, one on each side, near to the uterus, to which they are merely
attached by a ligament (the _ligamentum ovarii_) which is a portion of
that duplicature of the peritoneum which connects the uterus to the
pelvis, and is known by the name of ligamentum latum, or broad ligament.

They are of an oval figure; their anterior and posterior surface is
convex, the superior margin is also convex, while their lower edge is
straight or somewhat concave: towards their inner and outer extremities
they become thinner.

Their external surface in the virgin state is usually smooth, but in
advanced age they become uneven and shrivelled; when fully developed they
are about an inch and a half in length: their greatest breadth, which is
at that portion of the ovary which is farthest from the uterus, is half an
inch; their thickness is somewhat less.

[Illustration: Convoluted arteries of the ovary, crossing it in nearly
parallel lines.]

The ovaries are supplied with blood by the spermatic arteries, which are
of course considerably shorter in the female; they pass between the two
layers of the broad ligament to the ovarium, assuming there a beautifully
convoluted arrangement, very similar to the convoluted arteries of the
testis. These vessels traverse the ovary nearly in parallel lines, forming
numerous minute twigs, which have an irregular knotty appearance from
their tortuous condition, and appear to be chiefly distributed to the
Graafian vesicles. The external covering of the ovaries is formed by
peritoneum, which here receives the name of _Inducium_; it envelopes the
parenchymatous tissue of the gland called _stroma_, which is a dense
laminar cellular tissue of a reddish colour; its external portion which is
in contact with and firmly adherent to the indusium, is condensed into a
species of covering of a firm structure and whitish colour, and is called
the _tunica albuginea of the ovary_. In the substance of the stroma are
embedded a number of vesicles of various sizes, which, although previously
described by Vesalius and Fallopius, have been called Graafian vesicles,
after De Graaf. These do not commonly become visible until the seventh
year, from which period they gradually enlarge until puberty, when the
ovaries increase in size, become softer and more vascular, and one or two
of these vesicles may be observed to be larger, more developed, and
projecting considerably from the surface of the gland.

The proper capsule of the Graafian vesicle is composed of two layers. The
outer is formed of dense cellular tissue, in which are ramified many blood
vessels; the inner layer is thicker, softer, and more opaque than the
preceding, to which it is closely united, and from which it receives
vascular twigs.

_Ovum._ The contained part or nucleus of the vesicle of De Graaf consists
of, first, a granulary membrane, enclosing, secondly, a coagulable
granular fluid; thirdly, connected with the granulary membrane on one side
is a circular mass or disc of granulary matter, in the centre of which is
embedded, fourthly, the ovum.

This disc, called by Baer the _proligerous disc_, presents in its centre
on the side towards the interior of the vesicle, a small rounded
prominence, called the _cumulus_, and on the opposite side a small
cup-like cavity hollowed out in the cumulus. The cavity is for the
reception of the ovum.[1]

[Illustration: _Diagram of a section of the Graafian Vesicle and its
contents, showing the situation of the Ovum._

_a_ The granulary membrane. _b_ The proligerous disc. _c_ Ovum. _d_ The
inner and outer walls of the Graafian vesicle. _e_ Indusium of the ovary.
_From T. W. Jones._]

From the very minute size of the human ovum, and the difficulty of
detecting it, the existence of this little corpuscule was not
satisfactorily ascertained until modern times. Although De Graaf had
observed ova in the Fallopian tube so early as 1668, which fact had been
confirmed by the researches of Dr. Haighton and Mr. Cruickshank, still, as
no traces of such ova had been discovered in the Graafian vesicle, and as
it was evident that the Graafian vesicle, from its size, &c. could not
pass along the Fallopian tube, it was concluded that the inner surface of
the vesicle was a species of glandular structure which secreted the fluid
with which it was filled, and which was analogous to the semen of the male
testicle; hence, in former times, the ovaries were known by the name of
_testes muliebres_. The celebrated anatomist Steno[2] first pointed out
the analogy between these organs and the ovaries of the fish tribe: this
view was afterwards supported by De Graaf,[3] and they have since
continued to retain the name of ovaries.

To Professor von Baer, now of St. Petersburg, is due the merit of having
first pointed out the distance of the ovum in the Graafian vesicle, and of
thus putting beyond all doubt the accuracy of De Graaf's observations, as
well as those of Dr. Haighton and Mr. Cruickshank.

_Corpus luteum._ Upon impregnation taking place, one or more of the most
prominent Graafian vesicles begins to show marks of considerable
vascularity, both in its external capsule and in the surrounding stroma of
the ovary. The vesicle swells, and at length bursts, discharging its
contents into the funnel-shaped extremity of the Fallopian tube, which
firmly grasps the ovary at this point by means of its fimbriæ.

These changes begin to take place immediately after impregnation; the
inner lining of the vesicle, which Professor von Baer considers to be a
mucous membrane, appears to undergo a rapid development, much more so than
the external capsule which contains it. It is, therefore, thrown into a
number of corrugations by which the cavity of the vesicle is greatly
diminished; it becomes much thicker, and assumes a yellow colour. As its
growth proceeds, the cavity of the vesicle becomes still farther
contracted, until being unable longer to retain its contents, it bursts
and discharges them as above described.

[Illustration: Corrugation of the lining membrane of the Graafian capsule
after impregnation. _From Baer._]

The remains of the ruptured vesicle form a round glandular yellow coloured
body, called _corpus luteum_: it projects considerably from the surface of
the ovary, attaining the size of a small mulberry. In the middle of this
projection there is a little irregular and generally triangular depression
or indentation, which is the opening through which the ovum was discharged
from the Graafian vesicle: this after a short time closes, forming a
little cicatrix on the surface of the ovary.

[Illustration: Corpus luteum in the third month. _From Dr. Montgomery._]

"Upon slitting the ovarium at this part, the corpus luteum appears a round
body, of a very distinct nature from the rest of the ovarium. Sometimes it
is oblong or oval, but more generally round. Its centre is white, with
some degree of transparency; the rest of its substance has a yellowish
cast, is very vascular, tender and friable, like glandular flesh. Its
larger vessels cling round its circumference, and these send their smaller
branches inwards through its substance: a few of these larger vessels are
situated at the cicatrix or indentation on the outer surface of the
ovarium, and are there so little covered as to give that part the
appearance of being bloody when seen at a little distance."[4] Upon making
a section of a corpus luteum, we observe that its cavity has an angular
form, from which, as from a centre, white lines radiate to the
circumference of the vesicle; an appearance which is evidently produced by
the corrugation of the inner membrane of the vesicle, as above alluded to.
To a similar cause we may also attribute the lobular appearance, which the
structure of the corpus luteum presents when a section is made of it. The
number of these corpora lutea corresponds exactly with the number of newly
formed ova. Meckel, after having examined no less than two hundred
pregnant animals of the class mammalia, found that the number of corpora
lutea corresponded exactly with that of the young produced. "When there is
only one child," says Dr. W. Hunter, "there is only one corpus luteum, and
two in the case of twins. I have had opportunities of examining the ovaria
with care in several cases of twins, and always found two corpora lutea.
In some of these cases there were two distinct corpora lutea in one
ovarium, in others there was a distinct corpus luteum in each ovarium."

A Graafian vesicle cannot be converted into a corpus luteum except by
actual and effective sexual intercourse; and the strange and discrepant
accounts which have every now and then been published, even by authors of
considerable repute, of corpora lutea having been found in the ovaries of
virgin and even newly-born animals merely prove that the true
characteristics of the corpus luteum were not sufficiently known. The
irregular cysts, cavities, or deposites of whitish or yellowish structure
which are frequently found in the ovary, independent of impregnation, and
which have been improperly enough called virgin corpora lutea, present
points of difference so marked that they can scarcely be mistaken by an
experienced eye. The angular cavity opening externally, the stellated,
radiated, cicatrix-like appearance, which a section of the corpus luteum
presents, its soft and delicate structure as described by Dr. Hunter, and
above all its vascularity, and the facility with which its vessels can be
injected from the general tissue of the ovary, are characters only found
in a true corpus luteum. Virgin corpora lutea frequently occur under
circumstances of disease, especially those of a tubercular character. They
frequently appear as distinct cysts, the walls of which are
semi-cartilagenous; at other times they seem to be nothing more than a
coagulum of blood: they seldom project much from the ovary, and in no
instance have they the peculiar structure of the corpus luteum, nor the
external cicatrix, nor are they capable of being injected.

After awhile the cavity of the corpus luteum contracts, and the opening
into it closes. The surrounding stroma loses its vascularity, the
prominence at this part of the ovary gradually subsides, and the ovary
returns to its former size. The periods at which these changes take place
vary, but with the exception of those first mentioned they proceed slowly
whilst pregnancy lasts, after which time, now that the increased activity
of the pelvic circulation peculiar to that period has ceased, they advance
more rapidly.

[Illustration: Corpus luteum at the end of the ninth month. _From Dr.
Montgomery._]

"If an examination be made within the first three or four months after
conception, we shall, I believe, always find the cavity still existing,
and of such a size as to be capable of containing a grain of wheat at
least, and very often of much greater dimensions: this cavity is
surrounded by a strong white cyst (the inner coat of the Graafian
vesicle,) and as gestation proceeds the opposite parts of this
approximate, and at length close together, by which the cavity is
completely obliterated, and in its place there remains an irregular white
line, whose form is best expressed by calling it radiated or
stelliform."[5] Dr. Montgomery adds, "I am unable to state exactly at what
period the central cavity disappears, or closes up to form the stellated
line. I think I have invariably found it existing up to the end of the
fourth month. I have one specimen in which it was closed in the fifth
month, and another in which it was open in the sixth: later than this I
never found it."

When pregnancy is over, the corpus luteum gradually diminishes and
disappears. Dr. Montgomery states that "the exact period of its total
disappearance I am unable to state, but I have found it distinctly visible
so late as at the end of five months after delivery at the full time, but
not beyond this period." Hence it will be seen that in a few months after
the termination of pregnancy, all traces of the corpus luteum are lost,
and that, therefore, it will be impossible to decide as to how frequently
impregnation has taken place, merely by examining the ovaries, as has been
supposed. There is also another point to which Dr. Montgomery has alluded,
which is well worthy of notice: in mentioning the fact that a vesicle may
contain two ova, and thus a woman be delivered of twins, and yet there be
but one corpus luteum, he observes that "the presence of a corpus luteum
does not prove that a woman has _borne a child_, although it would be a
decided proof that she has been impregnated, and had conceived, because it
is quite obvious that the ovum, after its vivification, may be, from a
great variety of causes, blighted and destroyed, long before the foetus
has acquired any distinct form. It may have been converted into a mole or
hydatids: thus, however paradoxical it may at first sight appear, it is
nevertheless obviously true, that a woman may conceive and yet not become
truly with child, a fact already alluded to, as noticed by Harvey; but the
converse will not hold good. I believe no one ever found a foetus in utero
without a corpus luteum in the ovary; and that the truth of Haller's
carollary, 'nullus unquam conceptus est absque corpore luteo' remains
undisputed."

During childhood, the ovaries present a perfectly smooth surface, and
their structure appears to be homogeneous, consisting of a dense cellular
tissue. About the seventh year, the first traces of the Graafian vesicles
make their appearance; as the period of puberty approaches, the whole
gland enlarges, becomes softer and more vascular; the Graafian vesicles
are more numerous, and generally one or two will be found larger and more
prominent than the rest. After repeated impregnations, and especially
towards that time of life when the catamenia are about to disappear, the
ovary becomes more or less flabby and corrugated, and at a still more
advanced age presents a shrivelled appearance.

The ovaries are liable to inflammation and its consequences, more
especially abscess, general enlargement, and induration: the malignant
changes of structure, viz. cephaloma, hæmatoma, and cancer, rarely have
their origin in the ovaries, but extend to these organs from the adjacent
parts. Lipomatous or fatty tumours are occasionally met with, containing
hair, rudiments of teeth, &c. Cysts not unfrequently occur in the ovaries,
and attain a very considerable size; they are simple or compound,
sometimes consisting of several cysts one within the other, and distended
with fluids, which vary considerably in their character. These tumours
come under the general head of OVARIAN DROPSY. The ovaries are also liable
to many remarkable morbid changes in the puerperal state, such as
softening and complete disorganization, the natural structure of the organ
being entirely broken down and converted into a bloody pulpy mass; in some
cases the whole gland is apparently dissolved away, so as scarcely to
leave a trace of its previous existence.

_Fallopian tubes._ The Fallopian tubes, which act as excretory ducts to
the ovaries, take their course through the upper portion of the broad
ligaments, running from without inwards, towards the superior margin of
the uterus, the ovaries being situated behind and somewhat above them.
They are somewhat contorted, and are considerably more dilated at their
abdominal extremity where they are unattached, than where they are
connected to the uterus, being as much as from three to four lines at the
former point; whereas, at the latter, they are not more than half a line.

Their abdominal extremity, which is like the mouth of a funnel, has its
edge strongly fimbriated, and has hence been called the _morsus diaboli_.
Their other extremity opens into the cavity of the uterus at the angle
which the fundus forms with its sides, and the whole of the tube is about
five inches.

The Fallopian tubes receive their external covering from the peritoneum,
which becomes connected at their open extremity with the membrane which
lines them. Between the external and internal membrane is the proper
tissue of the tubes, and which, except in very muscular subjects, seldom
display the fibrous structure; still, nevertheless, two layers of fibres
have been observed--an outer or longitudinal, and an inner or circular
layer. The Fallopian tubes are lined with mucous membrane, forming
numerous longitudinal rugæ. The canal is not pervious during the early
months of foetal life, the abdominal extremity being closed and rounded;
this appears to open about the fourth month. The canal is relatively
larger, the younger the embryo is, and may, therefore, be easily
demonstrated at this time.

At the period of impregnation, the Fallopian tubes implant themselves by
means of their fimbriated extremity upon that part of the ovary where the
Graafian vesicle is about to burst; they become remarkably engorged with
blood, assuming a deep purple colour, and are now much thicker; the canal
enlarges, so that a tolerably-sized probe can be introduced, whereas, at
other periods it will scarcely admit a large bristle. The uterine
extremity of the tube is closed by a continuation of that pulpy coagulable
lymph-like secretion which now lines the cavity of the uterus, forming the
membrana decidua of Hunter, and which, especially on the side where the
corpus luteum is found, extends into the tube to nearly the distance of an
inch. The tubes are now observed to be in a state of distinct peristaltic
motion, "like writhing worms," as Mr. Cruickshank has well expressed it;
"the fimbriæ were also black and embraced the ovaria (like fingers laying
hold of an object) so closely and so firmly, as to require some force and
even slight laceration to disengage them."[6] From the great degree of
vascularity which is observed in the Fallopian tubes at this period, some
anatomists have been induced to consider that their proper tissue was
vascular, analogous to the corpora cavernosa penis. Besides the
peristaltic motion already mentioned, other movements called ciliary have
been observed in the Fallopian tubes at this period, consisting of minute
portions of mucous membrane moving briskly and whirling round their axis,
apparently for the purpose of propelling the ovum.[7]

As pregnancy advances, the Fallopian tubes undergo other changes as
respects their situation, which are worthy of notice. The broad
ligaments, in the upper parts of which the Fallopian tubes take their
course, are well known to be merely expansions of peritoneum from each
side of the uterus, and therefore become gradually unfolded and shorter as
the uterus increases in size. "In proportion as the fundus uteri rises
upwards and increases in size, the upper part of the broad ligament is so
stretched that it clings close to the side of the uterus, so that in
reality the broad ligament disappears, no more of it remaining than its
very root, viz. its upper and outer corner, where the group of spermatic
vessels pass over the iliacs immediately to the side of the uterus. In
this state, though the small end of the tube opens in the same part of the
uterus as before impregnation, yet the tube has a very different
direction. Instead of running outwards in the horizontal direction, it
runs downwards, clinging to the side of the uterus. And behind the fimbriæ
lies the ovarium, for the same reason clinging close to the side of the
uterus."[8]

_Uterus._ The uterus is a hollow fibrous viscus situated in the
hypogastric region between the bladder and the rectum, below the
intestinum ileum and above the vagina, and is by far the largest of the
generative organs. It is of a pyriform figure: its upper portion which is
the largest is triangular, becoming gradually smaller inferiorly; that
portion of it which is above the spot where the Fallopian tubes enter is
called the _fundus uteri_; the lower and cylindrical portion receives the
name of _cervix_; that between the cervix and fundus is called the _body
of the uterus_.

The parietes of the adult uterus are nearly half an inch in their greatest
thickness, which is about the middle of the body, the body being slightly
thicker than the cervix, which is of a somewhat harder structure. Near the
point at which the Fallopian tubes enter the uterus the parietes become
thinner, gradually diminishing from four or five to only one line in
thickness.

The cavity of the uterus is triangular, its base being directed upwards,
the superior angles corresponding to the points where the Fallopian tubes
enter it. The cavity of the uterus is so small, owing to the thickness of
its parietes, that they are nearly in contact: it is only four lines in
breadth; the fundus, which forms the base of the triangle, is convex both
internally as well as externally; whereas, the sides which form the body
are convex internally, but somewhat concave externally.

The cavity of the uterus is most contracted at the point where the cervix
is united to the body, which here forms the _os uteri internum_; from this
point the cervix gradually dilates as far as its middle portion, when it
again contracts; its lower extremity terminates in the upper part of the
vagina by an anterior and posterior cushion-like projection, of which the
posterior is usually the longest, although from the direction of the
uterine axis the anterior is commonly felt lowest in the pelvis. Between
these there is a transverse fissure known by the name of _os tincæ_ or _os
uteri externum_, the lips or labia of which are formed by the two
above-mentioned prominences. The internal surface of the body of the
uterus is smooth, whereas that of the cervix is uneven, forming upon its
anterior and posterior wall a number of delicate rugæ diverging obliquely
in an arborescent form, and hence called the _arbor vitæ_. The lips of the
os uteri are smooth, except when slight lacerations have taken place
during labour.

In the virgin state the uterus is about two inches long, of which the
cervix occupies the smaller half: the greatest breadth of the body is
sixteen lines; that of the cervix from nine to ten. The uterus which has
been impregnated, especially when this has been frequently the case,
scarcely ever regains its original dimensions, and the fissure which the
os tincæ forms becomes broader from before backwards. The weight of an
adult virgin uterus is from seven to eight drachms, but the uterus which
has been once impregnated is seldom less than an ounce and a half. It lies
between the bladder and rectum, its upper half being covered by
peritoneum, which closely adheres to it. In the adult state it is situated
entirely in the cavity of the pelvis; the fundus, which is below the upper
edge of the symphysis pubis, is turned forwards and upwards, while its
mouth is directed downwards and backwards, so that its long axis is nearly
parallel to the axis of the superior aperture of the pelvis.

The uterus is connected to the neighbouring parts by several duplicatures
of peritoneum, which are continuous with that portion of it which covers
the fundus. The most considerable are the _broad_ or _lateral ligaments_:
these arise from the sides of the uterus, which is enclosed between their
anterior and posterior layers or laminæ; they proceed transversely
outwards towards the sides of the pelvic cavity, which is thus divided
into two portions, and are then continued into that portion of the
peritoneum which lines the cavity.

The _round ligaments_ arise from the sides of the uterus close beneath and
a little anterior to the uterine extremity of the Fallopian tubes. They
pass between the two layers of the broad ligaments, behind the umbilical
arteries, and before the iliac vessels, in a direction upwards and
outwards to the external opening of the inguinal canal; they then make a
turn round the epigastric artery downwards, inwards, and forwards, and
pass through the abdominal ring, and dividing into numerous fasciculi and
fibres are gradually lost in the cellular substance of the mons Veneris
and upper portion of the labia. Besides consisting of cellular substance
and blood-vessels, the round ligaments contain some very distinct bundles
of muscular fibres, of which the upper arise from the external layer of
uterine fibres, and the lower from the inferior edge of the internal
oblique muscle, and pass upwards.

Upon a superficial examination, the structure of the uterus would almost
seem to be homogeneous, nevertheless a number of reddish yellow strata
interspersed with whitish streaks running from behind forwards may be
perceived even in the unimpregnated state; between these strata the
vessels of the uterus take their course, forming numerous anastomoses.

There is much difference of opinion among anatomists as to the fibrous
structure of the uterus. The majority however agree as to the presence of
muscular fibres,[9] some considering that they always exist, while others,
and by far the greater number, consider them as appearances peculiar to
pregnancy: they are, it is true, extremely indistinct in the unimpregnated
state, but they are far from being peculiar to pregnancy, as they are
frequently developed by any circumstances by which the formative powers of
the uterus are excited. Thus in cases where the uterus has been much
distended by some anormal growth, its fibres become much developed and
distinctly fasciculated. Lobstein observed them very distinctly in a
uterus which had been distended to the size of a seven months' pregnancy
by a fatty tumour.

The uterine fibres have been usually considered as fleshy, but they differ
from the red fibres of voluntary muscles, in being of a paler colour,
flatter, and remarkably interwoven with each other: nevertheless they
appear to be really muscular fibres from the powerful contraction with
which they expel the foetus and placenta, and nearly obliterate the cavity
of the uterus. In the unimpregnated state they resemble the fibrous coat
of an artery, whereas, those of the gravid uterus are more like the fibres
of muscle. Most anatomists agree in describing two sets of fibres, viz.
longitudinal and transverse. The external layer of fibres appears to form
the round ligaments, which seem to have the same relation with them as
tendon and muscle. "The fibres arise from the round ligaments, and
regularly diverging spread over the fundus until they unite and form the
outmost stratum of the muscular substance of the uterus. The round
ligaments of the womb have been considered as useful in directing the
ascent of the uterus during gestation, so as to throw it before the
floating viscera of the abdomen: but in truth it could not ascend
differently; and on looking to the connexion of this cord with the fibres
of the uterus, we may be led to consider it as performing rather the
office of a tendon than that of a ligament."[10] "On the outer surface and
lateral part of the womb, the muscular fibres run with an appearance of
irregularity among the larger blood-vessels, but they are well calculated
to constringe the vessels, whenever they are excited to contraction. The
substance of the gravid uterus is powerfully and distinctly muscular, but
the course of the fibres is less easily described than might be imagined:
this is owing to the intricate interweaving of the fibres with each
other--an intermixture however which greatly increases the extent of their
power in diminishing the cavity of the uterus. After making sections of
the substance of the womb in different directions, we have no hesitation
in stating that towards the fundus the circular fibres prevail, that
towards the orifice the longitudinal fibres are most apparent, and that on
the whole, the most general course of the fibres is from the fundus
towards the orifice.

"This prevalence of longitudinal fibres is undoubtedly a provision for
diminishing the length of the organ, or for drawing the fundus towards the
orifice. At the same time these longitudinal fibres must dilate the
orifice and draw the lower part of the uterus over the head of the child.

"In making sections of the uterus while it retained its natural muscular
contraction, I have been much struck in observing how entirely the
blood-vessels were closed and invisible, and how open and distinct the
mouths of the cut blood-vessels became when the same portions of the
uterus were distended or relaxed. This fact of the natural contraction of
the substance of the uterus closing the smallest pore of the vessels, so
that no vessels are to be seen, where we nevertheless know that they are
large and numerous, demonstrates that a very principal effect of the
muscular action of the womb is the constringing of the numerous vessels
which supply the placenta, and which must be ruptured when the placenta is
separated from the womb."

"Upon inverting the uterus, and brushing off the decidua, the muscular
structure is very distinctly seen: the inner surface of the fundus
consists of two sets of fibres, running in concentric circles round the
orifices of the Fallopian tubes; these circles at their circumference
unite and mingle, making an intricate tissue. Ruysch, I am inclined to
believe, saw the circular fibres of one side only; and not adverting to
the circumstance of the Fallopian tube opening in the centre of these
fibres, which would have proved their lateral position, he described the
muscle as seated in the centre of the fundus uteri. This structure of the
inner surface of the fundus of the uterus is still adapted to the
explanation of Ruysch, which was that they produced contraction and
corrugation of the surface of the uterus, which, the placenta, not
partaking of, the cohesion of the surface was necessarily broken. Farther,
I have observed a set of fibres on the inner surface of the uterus, which
are not described: they commence at the centre of the last described
muscle, and having a course in some degree vortiginous, they descend in a
broad irregular band towards the orifice of the uterus: these fibres
co-operating with the external muscle of the uterus, and with the general
mass of fibres in the substance of it, must tend to draw down the fundus
in the expulsion of the foetus, and to draw the orifice and lower segment
of the uterus over the child's head." (C. Bell, _op. cit._)

There are other circumstances which prove the muscularity of the uterus,
beyond the mere evidence of its fibres, as seen during pregnancy. "In the
quadruped," as Dr. Hunter observes, "the cat particularly and the rabbit,
the muscular action or peristaltic motion of the uterus is as evidently
seen as that of the intestines, when the animal is opened immediately
after death." It is also proved by the powerful contraction which it
exerts during labour, and "by the thickness of the fibres corresponding
with their degree of contraction." (_Ibid._)

The inner surface of the uterus is lined by a smooth or somewhat
flocculent membrane of a reddish colour, which is continued superiorly
into the Fallopian tubes; inferiorly it becomes the lining membrane of the
vagina.

Mucous follicles are only found in the cervix, especially at its lower
part: when by chance these become inflamed, the orifice closes, and the
follicle becomes more or less distended by a collection of thin fluid. The
mucous casts of these follicles have been known by the name of _ovula
Nabothi_, having been mistaken by an old anatomist for Graafian vesicles,
which had been detached from the ovary, and conveyed into the cavity of
the uterus.

The mucous membrane which lines the cervix uteri is corrugated into a
number of rugæ, between which the mucous follicles are chiefly found.

[Illustration: Uterus duplex.]

Before quitting this subject, it will be necessary to point out the
changes which the uterus presents at different periods of foetal life, and
the great resemblance it has at these periods to the uterus, as it appears
in the lower classes of the mammalia. We may, however, observe in the
first place, that the uterus is not found to exist as a separate organ
until we come to the class mammalia; and even in the lower genera of this
class it bears a strong resemblance to the tubular character of the
generative organs in the inferior classes of animal life. The nearest to
the tubular uterus, and where the transition from the oviduct in birds,
&c. to the uterus in mammalia is least distinctly marked, is in the
_uterus duplex_. Although the uterus is double, there is but one vagina
into which the two ora uteri open; its low grade of development is marked
by the resemblance which each uterus bears to an intestinal tube: there
are as yet no traces of a cervix, each os uteri merely forming a simple
opening at the lower end of what is little more than a cylindrical canal.
We do not find that thickening at the lower extremity of the uterus which
distinguishes the cervix in the higher mammalia. This species of uterus is
found among a large portion of the rodentia, and is also occasionally met
with as an abnormal formation in the human subject. The next grade of
uterine development appears under the form of the _uterus bicollis_. The
double os uteri here ceases to exist, and the division begins a little
higher up, so that the two cavities of the uterus communicate for a short
space: the ova, however, do not reach the common cavity, but remain each
in its separate cornu. In this form of uterus, the os uteri is not only
single, but the lower portion is thickened, although it has not yet formed
a distinct neck or cervix; it is met with among some of the rodentia, and
also certain carnivora.

[Illustration: Uterus bicollis.]

[Illustration: Uterus bicorporeus.]

In the _uterus bicorporeus_, the union of the cornua is higher up, so that
the lower portion is single, while the upper part alone is double,
consisting of two strongly curved cornua. This conformation is peculiar to
ruminating animals. If two ova be present they are separate from each
other, each being contained in its own distinct body or cornu, but a
portion of the membranes extends along the common cervix, from one body to
the other.

[Illustration: Uterus bifundalis.]

A still higher grade is the _uterus bifundalis_, where the fundus alone is
double, the cornu being formed only by this portion. This formation is
observed in the horse, ass, &c.: the common cavity is here the receptacle
of the ovum, so that in the unimpregnated state, the cornua appear only as
appendices, into which a portion of the membranes extend.

In the _uterus biangularis_, the double formation has nearly disappeared,
except at the fundus, where the uterus imperceptibly passes into the
tubes: this is the case among the edentata, and some of the monkey tribes.

The highest grade is the _uterus simplex_: every trace here of the double
form is lost; the fundus no longer forms an acute angle, where it
bifurcates into two cornua; but is convex. We now for the first time see
the divisions of the uterus into body and cervix distinctly marked.

[Illustration: Uterus biangularis.]

The human uterus presents a similar variety of forms, as it gradually
rises in the scale of development during the different periods of
utero-gestation. It is at first divided into two cornua, and usually
continues so to the end of the third month, or even later; the younger the
embryo the longer are the cornua, and the more acute the angle which they
form; but even after this angle has disappeared, the cornua continue for
some time longer.

[Illustration: Uterus simplex.]

The uterus is at first of an equal width throughout; it is perfectly
smooth and not distinguished from the vagina either internally or
externally by any prominence whatever. This change is first observed when
the cornua disappear and leave the uterus with a simple cavity. The upper
portion is proportionably smaller, the younger the embryo is. The body of
the uterus gradually increases, until at the period of puberty it is no
longer cylindrical, but pyriform: even in the full-grown foetus the length
of the body is not more than a fourth part of the whole uterus; from the
seventh even to the thirteenth year it has only a third, nor does it reach
a half until puberty has been fully attained. The os tincæ or os uteri
externum first appears as a scarcely perceptible prominence projecting
into the vagina; it increases gradually, in size until the latter months
of gestation, when the portio vaginalis is relatively much larger than
afterwards.

The parietes of the uterus are thin in proportion to the age of the
embryo. They are of an equal thickness throughout at first: at the fifth
month, the cervix becomes thicker than the upper parts; between five or
six years of age, the uterine parietes are nearly of an equal thickness,
and remain so until the period of puberty, when the body becomes somewhat
thicker than the cervix.

As the function of menstruation with its various derangements will be
considered among the diseases of the unimpregnated state, we proceed to
consider these changes which the uterus undergoes during pregnancy as well
as during and after labour: these are very remarkable both as regards its
structure, form, and size.

Shortly after conception, and before we can perceive any traces of the
embryo, the uterus becomes softer and somewhat larger, its blood-vessels
increased in size, and the fibrous layers of which its parietes are
composed looser and more or less separated. The internal surface when
minutely examined has a flocculent appearance, and very quickly after
conception becomes covered with a whitish paste-like substance, which is
secreted from the vessels opening upon it; this pulpy effusion soon
becomes firmer and more dense; it bears a strong analogy to coagulable
lymph, and forms a membrane which lines the whole cavity of the uterus,
and which in the course of a few weeks (from changes to be mentioned
hereafter) crosses the os uteri and thus closes it. The uterine cavity in
a short time becomes still farther closed by the canal of the cervix being
completely sealed, as it were, by a tough plug of gelatinous matter which
is secreted by the glandules of that part.

The structure of the uterus becomes remarkably altered; its fibrous
structure is much more apparent; in fact, it is only during pregnancy, or
when the uterus has been distended by some anormal growth, that we are
able to detect the uterine fibres with any degree of certainty. This has
led some anatomists to consider that they are only formed at such periods,
a supposition which is not very probable; at any rate they now become very
distinct: hence the uterus does not owe its increasing size to mere
extension, but it evidently acquires a considerable increase of substance,
a fact which is not only proved by examining the contracted uterus after
labour at the full period, but also by comparing its weight with that of
the unimpregnated organ. The adult virgin uterus weighs about one ounce,
whereas the gravid uterus at the full term of pregnancy, when emptied of
its contents, weighs at least twenty-four ounces, showing that there has
been an actual increment of substance in the proportion of one to
twenty-four. Having ascertained this point, it next becomes a question,
whether the parietes of the gravid uterus increase in thickness during
pregnancy, or whether they become thinner. Meckel, who is one of the
greatest modern authorities on these subjects, states that from careful
admeasurement of sixteen gravid uteri at different periods of gestation,
he finds the parietes become thicker during the first, second, or third
months, but after this period they become gradually thinner up to the full
time: they are thicker in the upper parts of the uterus, whereas
inferiorly they are a third or nearly a half less.

Nothing proves the actual increase of bulk and substance in the uterus
more than its appearance when contracted immediately after labour at the
full term; it forms a fleshy mass as large as the head of a new-born
child, the parietes of which are at least an inch in thickness.

"The spongy or cellular tissue (says M. Leroux) becomes considerably
developed during pregnancy, and its porous cells increase in proportion as
the uterus dilates, more especially at the fundus and the spot where the
placenta is attached, where they become so large as to admit a goosequill.
The internal membrane is pierced with numerous orifices, of which some are
the mouths of arteries, and others communicate with the cells already
mentioned. This membrane also during pregnancy forms those irregular
tufted rugæ, which serve to give a more intimate connexion between the
uterus and the placenta. In the unimpregnated uterus and in the intervals
between the menstrual periods the little orifices which are observed in
the lining membrane of the uterus contain only a transparent lymph, which
lubricates the interior of the uterus; during the appearance of the menses
they contain blood, and during pregnancy they are connected with the
vessels of the placenta and chorion."[11]

There is no circumstance in which the gravid uterus differs more from the
unimpregnated than in the size and termination of its blood-vessels. The
arteries, both spermatic and hypogastric, are very much enlarged. The
hypogastric is commonly considerably larger than the spermatic, and we
very often find them of unequal sizes in the different sides. They form a
large trunk of communication all along the side of the uterus, and from
this the branches are sent across the body of the uterus both before and
behind. The cervix uteri has branches only from the hypogastrics, and the
fundus only from the spermatics; or, in other words, the hypogastric
artery gives a number of branches to the cervix, besides sending up the
great anastomosing branch, and the spermatic artery supplies the tube and
fundus uteri before it gives down the anastomosing branch on the lateral
parts of the uterus. All through the substance of the uterus there are
infinite numbers of arteries large and small, so that the whole arterial
system makes a general network, and the arteries are convoluted or
serpentine in their course.[12] Hardly any of the larger arteries are seen
for any length of way upon the outside of the uterus. As they branch from
the sides where they first approach the uterus, they disappear by plunging
deeper and deeper into its substance.

The arterial branches which are most enlarged are those which run towards
the placenta, so that wherever the placenta adheres, that part appears
evidently to receive by much the greatest quantity of blood, and the
greatest number both of the large and small arteries at that part pass
through to the placenta, and are necessarily always torn through upon its
separation. The veins of the uterus would appear to be still more enlarged
in proportion than the arteries. The spermatic and hypogastric veins in
general follow the course of the arteries, and like them anastomose on the
side of the uterus. From thence they ramify through the substance of the
uterus, running deeper and deeper as they go on, and without following
precisely the course of the arterial branches. They form a plexus of the
largest and most frequent communications which we know of in the vessels
of the human body, and this they have in common with the arteries that
their larger branches go to, or rather come from, that part of the uterus
to which the placenta adheres: so that when the venous system of the
uterus is well injected, it is evident that that part is the chief source
of returning blood. Here, too, both the large and small veins are
continued from the placenta to the uterus, and are always necessarily
broken, upon the separation of these two parts. As I know no reason for
calling the veins of the uterus sinuses, and as that expression has
probably occasioned much confusion among the writers upon this subject, I
have industriously avoided it.[13]

The form of the uterus changes considerably during pregnancy: the upper
part appears to increase in greater proportion than the lower, a fact
which appears to be proved from the alteration which takes place in the
relative position of the Fallopian tubes, which are situated much lower
down the sides of the uterus at full term than in the unimpregnated state,
nor do they entirely regain their former position after labour, until the
female has attained an advanced age; hence as the cervix diminishes in
length during the latter half of pregnancy, it follows that the difference
in point of size between the fundus and the body of the uterus, and this
part will be continually increasing.

As the uterus increases, the fundus of course rises and can be felt
through the distended abdominal parietes: its anterior surface, especially
in the latter month of pregnancy, lies immediately behind the anterior
wall of the abdominal cavity, and pushes the small intestines upwards,
backwards, and to the sides.

The form of the gravid uterus differs also from that in the unimpregnated
state in other respects, and this difference appears to depend in great
measure upon its increase of size, and upon the form of the cavities which
it occupies. Thus in the unimpregnated state when it occupies the cavity
of the pelvis, its anterior surface which corresponds to the bladder is
flattened; whereas its posterior surface, which is turned towards the
hollow of the sacrum, is convex; it is however the reverse during the
latter half of pregnancy. The anterior surface is now strongly convex,
being merely covered by the yielding anterior wall of the abdomen; whereas
posteriorly the uterus is nearly concave, corresponding to the solid
convexity of the lumbar vertebræ, a fact which may be easily ascertained
by examining the abdomen of a patient in the last month of pregnancy while
lying down. The situation and position of the uterus are also changed in
the unimpregnated state; the fundus is inclined somewhat backwards, the
os uteri being nearly in the centre of the pelvic cavity, but the gravid
uterus during the latter half of pregnancy has its fundus strongly
inclined forwards and the os uteri directed backwards towards the upper
part of the hollow of the sacrum.[14]

A minute and intimate knowledge of the changes and appearances which the
uterus presents at every period of pregnancy, is essential to the
diagnosis and treatment of the various derangements to which this process
is subject. The numerous and important questions in medical jurisprudence
connected with pregnancy can alone be determined by its means; and it is
only by more close and attentive observation of every step in the gradual
development of the uterus up to the full term of gestation, that we can
expect to increase our means of forming a correct and certain diagnosis in
those cases of doubtful pregnancy, where not merely professional
reputation is more or less at stake, but the character, happiness, and
even life of the individual upon whose case we are required to decide.

During the first month of pregnancy the changes are not very appreciable
upon examination during life. The uterus has become larger, softer, and
more vascular, much as it does during a menstrual period. The portio
vaginalis of the cervix, which in the unimpregnated state is hard and
almost cartilaginous to the feel, becomes softer and larger:[15] the
transverse fissure which the os uteri forms is more oval.

In the second month, the abdomen becomes somewhat flat: the portio
vaginalis can be now reached by the finger with greater ease than at any
time of pregnancy, which is not from the uterus itself being lower in the
pelvis, but from not yet having altered its position; any increase of its
size therefore will cause its inferior extremity to be felt lower down and
nearer to the os externum. The os uteri has undergone a considerable
change, inasmuch as its edges have lost their lip-like figure; they now
form a ring or rather dimple-like concavity at the lower end of the
cervix, its canal being closed by the gelatinous plug already mentioned.

In primiparæ, or women pregnant for the first time, the margin of the os
uteri thus closed is not only circular but perfectly smooth; whereas in
multiparæ, not only is the cervix usually larger in every direction, but
the os uteri itself is larger, thicker, and of an irregular shape; it is
also knotty here and there from little callous cicatrices, where its edge
has been torn in former labours.

In the third month of pregnancy the uterus rises above the brim of the
pelvis. A slight protrusion of the abdomen may be sometimes observed above
the pubes; the os uteri is not reached so easily as in the preceding
month. The alteration which takes place in the situation of the uterus
during the third month appears to result from gradual shortening of the
broad ligament as it increases in size. As the uterus rises it pushes up
that portion of the small intestines which rests upon it; these however
being confined by the mesentery to the spine, and therefore prevented
ascending before the uterus, at length slip down behind it, and the fundus
being freed from the superincumbent pressure rises in a direction upwards
and forwards into the cavity of the abdomen. The direction of the uterus
becomes much altered; the os uteri is no longer in the middle of the
pelvic cavity, but inclines towards the upper part of the hollow of the
sacrum, whereas the fundus approaches more and more to the anterior
parietes of the abdomen.

In the fourth month, the fundus uteri has risen about two or three
fingers' breadth above the symphysis pubis; this is not very easily
ascertained even in a thin person, still less where the patient is stout
and the parietes of the abdomen therefore thick. The directions which the
celebrated Roederer has given for making an examination of the abdomen
during the early months of pregnancy, are well worthy of notice. Having
evacuated the bladder and rectum, the patient should be placed in a
half-sitting posture with the knees drawn up, so as to relax the abdominal
parietes as much as possible: she must then breathe slowly and deeply; and
if the hand be suddenly pressed against the abdomen a little above the
symphysis pubis, at the moment of her making a full expiration, we shall
in all probability feel the hard globe of the uterus.

In the fifth month, the fundus will be felt half way, or a little more,
between the symphysis pubis and umbilicus. The increased size of the
abdomen cannot be concealed by the dress; the portio vaginalis has become
distinctly shorter, and the os uteri is situated higher in the pelvis and
more posteriorly.

In the sixth month, the fundus has risen as high as the umbilicus; the
irregular folds of the skin which form the fovia umbilici or navel
depression begin to disappear; the first perceptible movements of the
child may occasionally be felt; the portio vaginalis has lost half its
length, being scarcely half an inch in length.

[Illustration: Cervix uteri about the sixth or seventh month.]

In the seventh month, the fundus rises an inch or so above the umbilicus,
the folds of which have nearly disappeared. In some cases it begins to
protrude, forming a species of umbilical hernia: this varies a good deal
in different individuals, being more marked in primiparæ; whereas in
women, whose abdomen has been distended in previous pregnancies, little or
no convexity of the navel is produced until a later period, and not always
even then, the umbilical depression being merely diminished in point of
depth, and its folds not so strongly marked. The movements of the child
are now perfectly distinct; the portio vaginalis is still shorter, and
approaches more and more to the upper part of the hollow of the sacrum.
The anterior portion of the inferior segment of the uterus, or that part
which extends from the os uteri towards the symphysis pubis, is now
considerably developed and convex, and on pressing the point of the finger
against it, the presenting part of the child will be felt. When this is
the head as is usually the case, it will feel like a light ball which
rises when pushed by the finger, but which, if the finger be held still,
in a few moments descends and may again be felt.

[Illustration: Cervix uteri in the eighth month.]

In the eighth month, the fundus has risen half way between the umbilicus
and the scrobiculus cordis. The abdomen has increased considerably in
size, and has become more convex; the umbilical depression in primiparæ
has entirely disappeared. The portio vaginalis is still shorter, being
barely a quarter of an inch in length. The os uteri is so high up as not
to be reached without difficulty; the presenting part of the child can be
distinctly felt.

[Illustration: Cervix uteri in the ninth month.]

In the ninth month, the fundus has reached nearly to the scrobiculus
cordis, and by the end of the month is quite in it; this is more
especially the case with primiparæ: the anterior parietes of the abdomen
not allowing the fundis to incline so strongly forwards, the oppression of
breathing is therefore more marked in them than in multiparæ, for the
fundus uteri rising so high prevents in great measure the action of the
diaphragm, so that the chest is expanded by other muscles; hence the
shortness of breath and inability of moving, so frequently complained of
at this period of utero-gestation. The portio vaginalis is still shorter,
and in the primipara forms little more than a soft cushiony ring which
marks the os uteri. The inferior part of the uterus is becoming more
spherical, and is usually occupied by the presenting part of the child:
this latter is no longer so moveable as before, its size as also its
weight being evidently increased. That portion of the uterus which extends
between the symphysis pubis and os uteri is now not only more convex but
lower in the pelvis than the os uteri itself.

During the last four weeks of pregnancy a considerable change is observed.
The fundus is now lower than it was in the preceding month, being about
half way between the scrobiculus cordis and umbilicus; the abdomen has, as
it is called, _fallen_; and from the diaphragm being now able to resume
its functions the breathing becomes more easy, and the female feels more
comfortable and capable of moving about. On examination per vaginam the
anterior portion of the inferior segment of the uterus will be felt still
deeper in the pelvis: if the head presents it distends this part of the
uterus, so that, in many cases, we have to pass the finger round it before
we can reach the os uteri, which is now in the upper part of the hollow of
the sacrum. All traces of the cervix have now disappeared, it having been
required to complete the full development of the uterus; the situation of
the os uteri itself is marked merely by a small depression or dimple;
there is no longer any distinction between the os uteri internum and
externum; the edges of the opening are so thin as to be nearly membranous,
but remain closed in primiparæ until the commencement of labour.[16]

In women who have had several children, a considerable difference is
observed as regards the state of the cervix and os uteri: the cervix does
not undergo that shortening during the latter half of pregnancy, which is
the case in a primipara, a portion of it at least remaining up to the full
term of utero-gestation: in many cases, especially where the female has
had a large family, it is nearly an inch long at this period; nor is the
lower portion of the uterus so spherical as in the primipara; to this
circumstance may probably be attributed the fact of the head not
descending so deep into the pelvis just before labour. In multiparæ the os
uteri is also very different: instead of being perfectly round with its
edges smooth, it is irregular and uneven, and seldom loses altogether the
lip-like shape of the unimpregnated state in consequence of the greater
thickness and elongation of its lips from former labours; its edges here
and there is uneven and knotty, from little callous cicatrices, where it
has been torn; moreover it does not remain closed till the commencement of
labour, but the os uteri externum (commonly called os tincæ,) and
sometimes even the os uteri internum will be more or less open during the
last three or four weeks of pregnancy. These peculiarities are of great
importance in coming to a conclusion as to whether a patient be in her
first pregnancy or not: although not invariable in the utmost sense of the
word, still their occurrence, even after a single labour, is sufficiently
frequent to make them worthy of careful observation. Indeed, on more than
one occasion, we have known them occur even after a miscarriage, a
circumstance on the strength of which the patient had ventured to deny
that she was pregnant. On the other hand, we sometimes meet with the os
uteri in a second pregnancy so little altered by the effects of the
previous labour, that it would be extremely difficult to come to a
decision.

When labour is over, the uterus contracts very considerably, and, in a few
days after, its parietes will be found at least an inch in thickness. It
now gradually diminishes in size, and continues to do so for some weeks;
the blood-vessels contract, and losing the peculiarly loose spongy
structure of pregnancy it becomes harder, firmer, and more compact. It
nevertheless remains softer and larger than in the virgin state, and does
not attain its original size and hardness until an advanced period of
life.

The os uteri, which in the latter months of pregnancy had formed a
circular opening, resumes its former shape, except that its lips,
especially the posterior one, which are more or less irregular and uneven,
are thicker and longer than in the virgin state. For the first weeks after
labour, the os uteri is high in the pelvis, soft, and easily admits the
tip of the finger; at the end of the second week it is much lower in the
pelvis, and no longer permits the finger to pass. Immediately after
labour, the contracted uterus forms a hard solid ball, the size of a
new-born child's head; this state of contraction is not, however, of long
continuance: in the course of half an hour, or even less, it begins to
increase in size, becoming softer and larger, and continuing to increase
slowly for some hours, when it again gradually diminishes, until, as
before observed, it approaches its original size in the unimpregnated
state. The state of powerful contraction in which the uterus is felt
immediately after labour, after a time gradually relaxes; its spongy
texture, from which the blood had been forcibly expelled by the violent
action of its fibres, becomes again filled with blood; the organ swells
and becomes softer and more bulky, and the orifices of the vessels which
open into the cavity of the uterus are again partly pervious, and emit a
sanious fluid called the _lochia_. This state lasts for two or more days
after delivery, when the vessels begin to recover their former caliber,
and lose that degree of dilatation peculiar to the gravid state. The
lochia become less and less coloured, and now, and not before the uterus
undergoes that gradual diminution of size and bulk which we have just
alluded to.

The copulative or external organs of generation are the _vagina_, _hymen_,
_clitoris_, _nymphæ_, and _labia_, the three last being known by the term
_vulva_.

_Vagina._ The vagina is a canal of about four inches in length and one in
breadth, broader above than below; its parietes are thin and are
immediately connected with the uterus. It envelopes the portio vaginalis
of the uterus at its upper or blind extremity (fundus vaginæ,) and is
continuous with its substance; inferiorly, where it is narrowest, it
passes into the vulva. It is situated between the bladder and rectum, and
attached to each by loose cellular tissue. Its direction differs from that
of the uterus, for its axis corresponds very nearly with that of the
pelvic outlet, running downwards and forwards. Posteriorly it is somewhat
convex, anteriorly concave.

The vagina consists of two layers; the external, which is very thin, firm,
of a reddish-white colour, and continuous with the fibrous tissue of the
uterus; and a lining mucous membrane which is closely united to it. This
latter is much corrugated, especially in the virgin state, the rugæ
running transversely in an oblique direction, and gathered together on its
anterior and posterior surface, forming the _columna rugarum anterior and
posterior_, which appear to be a continuation of the corrugations which
form the arbor vitæ of the cervix.

In the upper part of the vagina there are considerable mucous follicles,
which moisten the canal with their secretion, and which during sexual
intercourse, and particularly during the first stage of labour, pour forth
an abundant supply of colourless mucus for the purpose of lubricating the
vagina, and rendering it more dilatable. Near its orifice, especially at
the upper part, the veins of the vagina form the _plexus retiformis_, a
congeries of vessels which has almost a cellular appearance, and from this
reason has been called the _corpus cavernosum_ of the vagina; it appears
to be capable of considerable swelling from distension with blood, like
the corpus cavernosum penis, and by this means serves to contract still
farther the os externum during the presence of venereal excitement. A
similar disposition to form plexuses of vessels is seen in the venous
circulation of the nymphæ, bladder, and rectum.

_Hymen._ The lining membrane of the vagina is of a reddish-gray colour,
interspersed here and there, especially at its upper part, with livid
spots like extravasation. At the os externum it forms a fold or
duplicature called _hymen_, running across the sides of the posterior part
of the opening, and usually of a crescentic figure, the cavity looking
upwards. The duplicatures of membrane are united by cellular tissue. In
some instances, the hymen arises from the whole circumference of the os
externum, having a small orifice in the centre for the escape of the
menses and vaginal secretions: in some rare cases it is cribriform; and in
others it completely closes the vaginal entrance. When torn in the act of
sexual intercourse, it generally forms three or four little triangular
appendages, called _carunculæ myrtiformes_, arising from the posterior and
lateral portions of the os externum.

From the identity of its fibrous coat with that of the uterus, the vagina
possesses considerable powers of contraction, when excited by the presence
of any body which distends it; hence it is a valuable assistance to the
uterus during labour: it also stands in the same relation to the abdominal
muscles that the rectum does, so that as soon as it is distended by the
head, &c. it calls them into the strong involuntary action, which
characterizes the bearing down pains of the second stage of labour. The
orifice of the vagina (os externum) is surrounded by a thin layer of
muscular fibres, which arise from the anterior edge of the sphincter ani;
they enclose the outer margin of the vagina, cover its corpus cavernosum,
and are inserted into the crura clitoridis at their union. It has been
called the sphincter or constrictor vaginæ, and assists the corpus
cavernosum still farther in contracting the os externum.

_Clitoris._ The clitoris is an oblong cylindrical body, situated beneath
the symphysis pubis, arising from the upper and inner surface of the
ascending rami of the ischium, by means of two crura of about an inch
long, and uniting with each other at an obtuse angle. It terminates
anteriorly in a slight enlargement, called the _glans clitoridis_, which
is covered with a thin membrane or a loose fold of skin, viz. the
_preputium clitoridis_. It is a highly nervous and vascular organ, and
like the penis of the male, is composed of two crura and corpora
cavernosa, which are capable of being distended with blood; they are
contained in a ligamentous sheath, and have a septum between them. The
clitoris is also provided with a suspensory ligament, by which it is
connected to the ossa pubis. Like that of the penis, the glans clitoridis
is extremely sensible, but has no perforation. Upon minute examination, it
will be found that the gland is not a continuation of the posterior
portion of the clitoris, but merely connected with it by cellular tissue,
vessels, and nerves; the posterior portion terminates on its anterior
surface in a concavity which receives the glans. In the glans itself there
is no trace of the septum, which separates the corpora cavernosa. On the
dorsum of the clitoris several large vessels and nerves take their course,
and are distributed upon the glans, and upon its prepuce are situated a
number of mucus and sebaceous follicles.

The crura clitoridis at their lower portion are surrounded by two
considerable muscles, called the erectores clitoridis, arising by short
tendons close beneath them from the inner surface of the ascending ramus
of the ischium, and extending nearly to their extremity.

_Nymphæ._ The _nymphæ_ or _labia pudendi interna_, are two long corrugated
folds, resembling somewhat the comb of a cock, arising from the prepuce
and glans clitoridis, and remaining obliquely downwards and outwards along
the inner edge of the labia, increasing in breadth, but suddenly
diminishing in size. At their lower extremity they consist of a spongy
tissue, which is more delicate than that of the clitoris, but resembles
considerably that of the glans, of which it appears to be a direct
continuation. It has been called the _corpus cavernosum nympharum_, and is
capable of considerable increase in size when distended with blood. The
two crura of the prepuce terminate in their upper and anterior
extremities; they are of a florid colour, and in their natural state they
are contiguous to, and cover the orifice of the urethra. The skin which
covers them is very thin and delicate, bearing a considerable resemblance
to mucous membrane, especially on their inner surface, where it is
continuous with the vagina; externally it passes into the labia.

The space between the nymphæ and edge of the hymen is smooth, without
corrugation, and is called _vestibulum_.

Close behind the clitoris, and a little below it, is the orifice of the
urethra, lying between the two nymphæ: it is surrounded by several lacunæ
or follicles of considerable depth, secreting a viscid mucus; its lower or
posterior edge is, like the lower portion of the urethra, covered by a
thick layer of cellular tissue, and a plexus of veins, which occasionally
become dilated and produce much inconvenience; it is this which gives the
urethra the feel of a soft cylindrical roll at the upper part of the
vagina; and in employing the catheter, by tracing the finger along it, the
orifice will be easily found.

_Labia._ The labia extend from the pubes to within an inch of the anus,
the space between the vulva and anus receiving the name of _perineum_.

The opening between the labia is called the _fossa magna_: it increases a
little in size and depth, as it descends, forming a scaphoid or boat-like
cavity, viz. the _fossa navicularis_.

The labia are thicker above, becoming thinner below, and terminate in a
transverse fold of skin, called the _frænulum perinei_, or _fourchette_,
the edge of which is almost always slightly lacerated in first labours.
They are composed of skin cushioned out by cellular and fatty substance,
and lined by a very vascular membrane, which is thin, tender, and red,
like the inside of the lips; they are also provided with numerous
sebaceous follicles, by which the parts are kept smooth and moist.



CHAPTER III.

DEVELOPMENT OF THE OVUM.

    _Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical
    cord.--Embryo.--Foetal circulation._


_Membrana decidua._ The earliest trace of impregnation which is to be
observed in the cavity of the uterus, and even before the ovum has reached
it, is the presence of a soft humid paste-like secretion, with which the
cavity of the uterus is covered, and which is furnished by the secreting
vessels of its lining membrane. This is the _membrana decidua_ of Hunter:
properly speaking, it should be called the _maternal membrane_, in
contra-distinction to the chorion and amnion, which, as belonging
peculiarly to the foetus, are called the _foetal_ membranes.[17]

Although at first in a semi-liquid state, it soon becomes firmer and more
compact, assuming the character of a membrane: it appears to be nothing
else than an effusion of coagulable lymph on the internal surface of the
uterus, having "scarcely a more firm consistence than curd of milk or
coagulum of blood." (Hunter, _op. cit._ p. 54.) Hence, although much
thicker than the other membranes, it is weaker; it is also much less
transparent.

It is not of an equal thickness, being considerably thicker in the
neighbourhood of the placenta than elsewhere; inferiorily, and especially
near the os uteri, it becomes thinner: during the first weeks of pregnancy
it is much thicker than afterwards, becoming gradually thinner as
pregnancy advances, until it is not half a line in thickness. In the
earlier months its external surface is rough and flocculent, but
afterwards it becomes smoother as its inner surface was at an earlier
period.

It is much more loosely connected with the uterus during the first months
of pregnancy than afterwards, and this is one reason why premature
expulsion of the ovum is more liable to take place at this period than
during the middle and latter part of utero-gestation. It is more firmly
attached to the uterus in the vicinity of the placenta than any where
else, which is owing to the greater number of blood-vessels it receives
from the uterus at this point; whereas commonly "it has no perceptible
blood-vessels at that part which is situated near the cervix uteri,"
(_Ibid._,) this portion being much more loosely connected with the uterus.
The course which the decidual vessels take on coming from the inner
surface of the uterus is admirably adapted to render the attachment of
this membrane to it as firm as possible.

[Illustration: Vascularity of the decidua. _From Baer._]

Upon examining the lining membrane of the uterus at a very early period,
when the decidua was still in a pulpy state, Professor v. Baer
observed[18] that its villi, which in an unimpregnated state are very
short, were remarkably elongated: between these villi, and passing over
them, was a substance, not organized but merely effused, and evidently the
membrana decidua at an extremely early age. The uterine vessels were
continued into this substance, and formed a number of little loops round
the villi, thus anastomosing with each other. On account of this reticular
distribution it was impossible to distinguish arteries from veins; there
is evidently the same relation between the uterus and the decidua as
between an inflamed surface and the coagulable lymph effused upon it.

[Illustration: Decidual cotyledons. _From Dr. Montgomery._]

Professor v. Baer considers that at a later period the connexion between
the decidua and mucous membrane becomes so intimate, that it is impossible
to separate the former without also separating the latter from the fibrous
tissue of the uterus. This, we apprehend, is the stratum which, as Dr.
Hunter observes, "is always left upon the uterus after delivery, most of
which dissolves and comes away with the lochia." He does not appear to
have been fully aware of the close connexion between the decidua and
lining membrane of the uterus, although he evidently observed the fact
from the following sentence: "in separating the membranes from the uterus
we observe that the adhesion of the decidua to the chorion, and likewise
its adhesion to the _muscular fibres of the uterus_, is rather stronger
than the adhesion between its external and internal stratum, which, we may
presume, is the reason that in labour it so commonly leaves a stratum
upon the inside of the uterus." According to the observations of Dr.
Montgomery, a great number of small cup-like elevations may be seen upon
the external surface of the decidua vera, "having the appearance of little
bags, the bottoms of which are attached to, or embedded in, its substance;
they then expand or belly out a little, and again grow smaller towards
their outer or uterine end, which, in by far the greater number of them,
is an open mouth when separated from the uterus: how it may be while they
are adherent, I cannot at present say. Some of them which I have found
more deeply embedded in the decidua were completely closed sacs. They are
best seen about the second or third month, and are not to be found at the
advanced periods of gestation."[19]

[Illustration: _a_ Uterus. _d_ Decidua reflexa. _b_ Fallopian tube. _e_
Ovum. _c_ Decidua.]

The membrana decidua does not envelope the ovum with a single covering,
but forms a double membrane upon it, somewhat like a serous membrane; in
fact, the descent of the ovum through the Fallopian tube is very similar
to that of the testicle through the inguinal canal into the scrotum. The
ovum pushes before it that portion of the decidua which covers the uterine
extremity of the Fallopian tube, and enters the cavity of the uterus,
which is already lined with decidua, covered by the protruded portion
which forms the _decidua reflexa_. It must not be supposed that this
reflexion of the decidua is completed as soon as the ovum enters the
uterine cavity; the ovum usually remains at the mouth of the Fallopian
tube, from which it has emerged, covered by the plastic mass of soft
decidua, and the reflexion of this membrane will take place in proportion
as the ovum gradually increases in size. The external layer of decidua is
called _decidua vera_; the internal or reflected portion is called the
_decidua reflexa_, having received this appellation from its discoverer,
Dr. Hunter. These membranes would, as Dr. Baillie has correctly observed,
be more correctly named the _decidua uteri_ and _decidua chorii_: the
decidua chorii or reflexa is reflected inwardly from above downwards; it
is connected on its inner surface with the chorion: externally it is
unattached, whereas, the decidua uteri or vera is unconnected on its inner
surface, but attached to the uterus externally.

The membrana decidua differs in its arrangement from that of a serous
membrane, inasmuch, as it is not only reflected so as to cover the
chorion, but at the point of reflexion it is continued over the chorion
externally, where it forms the placenta, so that the chorion is enclosed
in all directions by the decidua: this latter portion, however, is not
formed till about the middle of pregnancy. The decidua uteri or vera does
not extend farther than the os uteri internum, which is filled up by the
plug of tough gelatinous substance above described; the decidua chorii or
reflexa, from its forming the outer covering of the chorion, of course
passes over the os uteri.

[Illustration: _Membrana decidua._

The lower orifice corresponds to the os uteri, the two upper ones to the
Fallopian tubes. _From Dr. Hunter._]

According to Mr. John Hunter, the decidua vera is continued some little
way into the Fallopian tubes, more especially, on that side where the
corpus luteum has been formed; it is perforated at the points where the
Fallopian tubes enter, as well as at the os uteri, a fact which is
beautifully shown in Dr. Hunter's last plate: but this does not continue
long, for, as Mr. John Hunter observes, the inferiour opening becomes
closed in the first month, and, according to Lobstein's observations, the
openings of the Fallopian tubes are closed after the second month. "Where
the decidua reflexa is beginning to pass over the chorion, there is, at an
early period of pregnancy, an angle formed between it and the decidua,
which lines the uterus; and here the decidua is often extremely thin and
perforated with small openings so as to look like a piece of lace.

"In proportion as pregnancy advances, the decidua reflexa becomes
gradually thinner and thinner, so that at the fourth month it forms an
extremely fine layer covering the chorion; it comes at the same time more
and more closely in contact with the decidua, which lines that part of the
uterus to which the placenta is not fixed, till at length they adhere
together."[20] That portion of the decidua which passes between the
placenta and uterus during the latter half of gestation, is called the
_placental decidua_, the description of which will be given with that of
the placenta.

To Dr. W. Hunter are we indebted for the first correct description of the
decidua; indeed, so excellent is it, that the membrane has been called
after him, the _decidua of Hunter_. Although he was the undoubted
discoverer of the reflexa, the existence of the decidua was distinctly
noticed by Burton, in 1751. In stating the _post mortem_ examination of a
woman, who died undelivered at the full time of pregnancy, he says, "Upon
wiping the inside of the uterus very gently with a sponge, there seemed to
be pieces of a very tender thin transparent membrane adhering to it in
such parts of the uterus where the placenta did not stick to it; but as
the womb was somewhat corrupted, and the membrane so very tender, we could
not raise any bulk of it so as to be certain what it was." (Burton's
_Midwifery_.)

The decidua seems chiefly intended to form the maternal part of the
placenta: (see _Placenta_:) hence in all those quadrupeds when the
maternal part of the placenta is permanently appended to the internal
surface of the uterus, no decidua is found.

Having described the maternal membranes of the ovum, we come now to the
membranes which form the parietes of the ovum. These are called the
_foetal membranes_, for they are essentially connected with the origin of
the foetus itself. They are the _chorion_ and the _amnion_; besides which,
there are two others that require notice, viz. the _vesicula umbilicalis_
and _allantois_.

_Chorion._ The chorion is the proper covering of the ovum, and corresponds
to the membrane lining the shell of an egg, in oviparous animals. It is a
thin and transparent membrane, and presents on its external surface a
ragged tufted appearance, being covered externally with groups of
arborescent villous processes, which after a time unite into trunks to
form the umbilical vessels, which, according to Lobstein's observations,
are merely veins during the early period of gestation. These loose tufts
of venous radicles appear to absorb nourishment for the ovum, much in the
same manner as the roots of a plant. Although the chorion is so thin and
transparent, it consists nevertheless of two laminæ or layers, between
which the villi, which produce this shaggy appearance, take their course.
Although the chorion on its external surface is nothing but a net-work of
villi, which in process of time become vascular, anatomists have been
unable to detect blood-vessels in the structure of the membrane itself.
Its vascularity, however, has been asserted chiefly on the ground of the
known vascularity of the decidua, it being supposed that the vessels of
the decidua penetrate into the chorion. The chorion, however, belongs so
essentially and exclusively to the foetus, that it appears extremely
improbable that any maternal vessels should ramify in its structure for
the purposes of its nourishment and growth, and the more so when we
reflect that the nutrition of the foetus itself at this early period is
obtained in so different a manner. It is, moreover, extremely difficult to
distinguish between the venous absorbing radicles of the chorion, which
form the early rudiments of the umbilical vessels, and any vessels which
may take their course in the structure of the membrane itself; and the
more we consider the relation between the chorion and the decidua, the
less are we inclined to accept Meckel's explanation of the vascularity of
the chorion, viz. that the vessels of the decidua have the same relation
to those of the chorion as the blood-vessels of the maternal part of the
placenta have to those of the foetal part.

Neither nerves nor lymphatics have been discovered in the structure of the
chorion, unless, indeed, those white filaments, which are observed here
and there about the edge of the placenta, perform the office of
lymphatics. This has been hinted at by Dr. Hunter, where he says, "these
are the remains of those shaggy vessels which shoot out from the chorion
in a young conception, and give the appearance of the ovum being
altogether surrounded by the placenta at that time. With a magnifying
glass, they appear to be transparent ramifying vessels, which run in
corresponding furrows upon the internal surface of the decidua, and a good
deal resemble lymphatics." (W. Hunter, _op. cit._ p. 53.)

The chorion undergoes various changes during the different periods of
pregnancy, and forms a very important part of the physiology of
utero-gestation. Its thickness, which in the earlier months of pregnancy
is more considerable than afterwards, at this period is uniform in every
part of the ovum: its external surface covered with those villous
prolongations which have already been alluded to. In the second month of
pregnancy these become larger, and much more arborescent; after the third
month a considerable portion of them gradually disappears, generally from
below upwards, so that the greater part of its external surface becomes
nearly smooth, except at that point where the umbilical cord has its
origin, at which spot the villous prolongations become more developed, and
unite to form the umbilical vessels. This part of the chorion, together
with the corresponding portion of the membrana decidua, forms a flat
circular mass, which at the end of pregnancy covers nearly one-third of
the surface of the ovum, and constitutes the placenta or after-birth. At
this point the chorion, which forms its inner surface, is considerably
thicker than elsewhere.

At the commencement of pregnancy the chorion is but loosely connected with
the decidua, but by degrees it becomes so closely connected by fibres,
which are the remains of the little vascular prolongations, especially
where these two membranes combine to form the placenta, that in the latter
months of pregnancy, they can scarcely, if at all, be separated.

For the more minute consideration of the formation, development, and
functions of the chorion, we must refer to the description of the placenta
and foetus.

_Amnion._ The amnion is the inner membrane of the ovum. It is transparent,
and of great tenuity, "yet its texture is firm, so as to resist laceration
much more than the other membranes." (W. Hunter, _op. cit._ p. 50.) It is
loosely connected with the chorion on its external surface, except when
this membrane unites with the decidua to form the placenta at which spot
it adheres to the chorion much more firmly. Its inner surface, which is in
immediate contact with the liquor amnii, is very smooth; whereas
externally, from being connected with the chorion by an exceedingly fine
layer of cellular tissue, its surface is not so smooth. Dr. W. Hunter
considers that this intervening tissue, is a gelatinous substance: it
seems, however, to possess too much elasticity for such a structure; and,
from the reticular appearance which it generally presents upon the
membranes to which it adheres, we are inclined to adopt the opinion of
Meckel in considering it cellular. "In the very early state of an ovum the
amnium forms a bag, which is a good deal smaller than the chorion, and,
therefore, is not in contact with it." (_Ibid._ p. 75:) hence, therefore,
a space is formed between the two membranes which is filled with a fluid
called the _liquor amnii spurius_, or more correctly the _liquor
allantoidis_. "In the course of some weeks, however, it comes nearly into
contact with the chorion, and through the greater part of pregnancy the
two membranes are pretty closely applied to each other." (_Ibid._)
Lobstein, in his admirable _Essai sur la Nutrition du Foetus_, observes,
that the membranes continues separate from each other so late as the third
and fourth month. Cases every now and then occur where a considerable
quantity of fluid is found between the chorion and amnion in labour at the
full period of pregnancy.

We shall defer the minute description of the amnion and its relations,
during the very early periods of utero-gestation, until we describe the
embryo. The amnion is reflected upon the umbilical cord at its insertion
into the placenta, envelopes the umbilical vessels, the external covering
of which it forms, and is continued to the anterior surface of the child's
abdomen, passing into that projecting portion of the skin which forms the
future navel.

Blood-vessels and nerves have not as yet been discovered in the structure
of the amnion, but Meckel considers it extremely probable that the fine
layer of cellular tissue by which it is connected with the chorion
contains vessels for its nutrition.

_Liquor amnii._ The amnion contains a fluid known by the name of liquor
amnii. In the earlier months of pregnancy it is nearly, if not quite
transparent; as pregnancy advances it becomes turbid, containing more or
less of what appears to resemble mucus: it has a distinctly saline taste;
its specific gravity is rather more than that of water. Its relative and
absolute quantity vary considerably at different periods of pregnancy:
thus the relative weight of liquor amnii to that of the foetus is very
considerable at the beginning of pregnancy, at the middle they are nearly
equal, but towards the end, the weight of fluid to that of the child,
diminishes considerably, so that during the last weeks of pregnancy it
scarcely equals a pound, and seldom more than eight ounces, whereas the
medium weight of the child is usually between six and seven pounds: the
quantity, however, varies considerably, sometimes amounting to several
quarts. In the early months the absolute quantity increases, so that
between the third and fourth months it sometimes equals as much as
thirty-six ounces. Chemically it consists chiefly of water, a small
quantity of albumen and gelatine, a peculiar acid called amniotic, with a
little muriate of soda and ammonia, and a trace of phosphate of lime.

The source of the liquor amnii is still unknown. Dr. Burns asserts that
"it is secreted from the inner surface of the membrane by pellucid
vessels," but as he confesses that "these have never been injected or
traced to their source (_Principles of Midwifery_, by J. Burns, M. D. p.
222.,) little weight can be attached to such a view." Meckel considers
(_Handbuch der Menschlichen Anatomie_, vol. iv. p. 707,) that the greater
part of it, especially in the early months, is a secretion from the
maternal vessels, but that afterwards, as pregnancy advances, it becomes
mingled with the excretions of the foetus. It appears to be a means of
nourishment to the foetus during the first part of pregnancy, from the
fact that it contains more nutritious matter in the early than in the
latter months, since at that time a considerable coagulation is produced
by alcohol, &c. The disappearance of this coagulable matter of the liquor
amnii, towards the end of pregnancy, may be attributed to its having been
absorbed at an earlier period, and to the process of nutrition being now
carried on by other means. Besides being a source of nourishment to the
foetus, it serves many useful purposes; it secures the foetus against
external pressure or violence, and supports the regular distension of the
uterus; on the other hand it diminishes and equalises the pressure of the
foetus upon the uterus; during labour by distending the membranes into an
elastic cone, it materially assists to dilate the os uteri; it also serves
to lubricate and moisten the external passages.

_Placenta._ The placenta is formed essentially by the chorion and
decidua; it is a flat, circular, or more or less oval mass, soft, but
becoming firmer towards its edge. It is the most vascular part of the
ovum, and by which it is connected most intimately with the uterus. Its
longest diameter is generally about eight, its shortest about six inches;
its greatest thickness is at that spot where the umbilical cord is
inserted, which is usually about the middle of the placenta, although it
occasionally varies considerably in this respect, the cord coming off
sometimes at the edge. The placenta, as ordinarily seen after labour, is
barely an inch in its thickest part, but when filled with blood or
injection it swells very considerably, and is then little short of two
inches. It is generally attached to the upper part of the uterus in the
neighbourhood of one of the Fallopian tubes, and more frequently on the
left side than on the right; its inner or foetal surface is smooth, being
covered by the chorion, which at this part is much thicker.

The placenta cannot be distinguished from the other parts of the ovum
until the end of the second month, at which period it covers nearly half
the surface of the ovum, gradually diminishing in relative size, but
increasing in thickness and absolute bulk up to the full period of
utero-gestation. It forms a spongy vascular mass, its uterine surface
being divided unequally into irregular lobes called _cotyledons_.

The uterine surface of a full-grown placenta is covered by a pulpy
membrane, resembling in structure the decidua which covers the chorion,
and of which it seems to be a continuation. This is always found present
at the end of pregnancy: it covers the lobes of the uterine surface of the
placenta, descending into the sulci which runs between them: in some parts
it is thicker than in others, especially where it is connected with, or in
fact becomes, the decidua of the chorion or decidua reflexa. This
membrane, which has been called the _placenta decidua_, is pretty firmly
attached to the vessels of the placenta, so as not to be separated without
rupture; but by maceration, its texture is more or less destroyed, so that
we may easily distinguish the extremities of these vessels. "This decidua,
or uterine portion of the placenta," says Dr. Hunter, "is not a simple
thin membrane expanded over the surface of the part: it produces a
thousand irregular processes, which pervade the substance of the placenta
as deep as the chorion or inner surface; and are every where so blended
and entangled with the ramifications of the umbilical system, that no
anatomist will perhaps be able to discover the nature of their union.
While these two parts are combined, the placenta makes a pretty firm mass,
no part of it is loose or floating; but when they are carefully separated,
the umbilical system is evidently nothing but loose floating ramifications
of the umbilical vessels, like that vascular portion of the chorion, which
makes part of the placentula in a calf; and the uterine part is seen
shooting out into innumerable floating processes and rugæ, with the most
irregular and minutely subdivided cavities between them that can be
conceived. This part answers to the uterine fungus in the quadrupeds: it
receives no vessels demonstrable by the finest injection from those of the
navel string; yet it is full of both large and small arteries and veins:
these are all branches of the uterine vessels, and are readily filled by
injecting the arteries and veins of the uterus, and they all break through
in separating the placenta from the uterus, leaving corresponding orifices
on the two parted surfaces." (Hunter, _op. cit._ p. 42.)

According to Lobstein's observations, although this membrane appears to be
a continuation of the decidua which covers the chorion, it nevertheless
does not exist during the earlier months. During the first months of
pregnancy the placenta does not present a solid mass, with its uterine
surface covered with projecting lobuli, as it does at the full term of
pregnancy; but the vessels of which it is composed (foetal) are loose and
floating, as if it had been subjected to maceration. It has been supposed,
that this irregular lobulated appearance of the uterine surface of the
placenta was produced at the moment of its separation from the uterus
during labour; this, however, is not the case, for Lobstein having opened
the uterus of a woman who died in the fifth month of pregnancy, and
separated the placenta with great care, found these lobular prominences,
although not yet covered by the membrane of which we have just spoken.
Wrisberg, professor of anatomy at Göttingen, considered that this membrane
was distinct from the decidua reflexa, since with care the two membranes
can be easily separated.

[Illustration: _Uterine surface of the Placenta._]

In examining the uterine surface of a full grown placenta it is necessary
to place it upon something convex, in order that it may resemble, as
nearly as possible, the form which it had when attached to the concave
surface of the uterus; the cotyledons are thus rendered prominent and
separated from each other; the sulci, which run between them, are wide and
gaping: whereas, when the placenta is laid upon a flat surface, its
cotyledons are closely pressed together, and the sulci more or less
completely concealed. On minute examination of these sulci a number of
openings may be observed, varying in size and shape, but usually more or
less oval, their edges distinct, smooth, and thin; on directing a strong
light into some of the larger ones a number of smaller apertures may be
observed opening into them, in much the same way as is observed when
looking down a large vein. Some of these canals do not immediately lead to
smaller orifices as above described, but open at once into an
irregular-shaped cell or cavity, in the parietes of which numerous small
apertures may be observed, through which blood oozes when the adjacent
parts of the placenta are slightly pressed upon. Besides these openings at
the bottom of the interlobular sulci, others may be seen here and there
upon the cotyledons; these are generally smaller, their edges thicker, and
in most instances they are round; but they are not so invariably met with
as the openings between the cotyledons, these lobular projections being
sometimes very thickly covered with placental decidua. The openings
observed on the uterine surface of the placenta correspond to the mouths
of the uterine veins and arteries, which, in the unimpregnated state, open
into the cavity of the uterus, but which now, by means of the decidua,
convey maternal blood to and from the placenta. "Any anatomist," says Dr.
W. Hunter, "who has once seen and understood them, can readily discover
them upon the surface of any fresh placenta; the veins, indeed, he will
find have an indistinct appearance from their tenderness and frequent
anastomoses, so as to look a good deal like irregular interstitial void
spaces: the arteries which generally make a snake-like convolution or two,
on the surface of the placenta, and give off no anastomosing branches, are
more distinct." (Hunter, _op. cit._ p. 46.) From the observations of
Messrs. Mayo and Stanley, and from their examination of the original
preparations in the Hunterian museum at the College of Surgeons, London,
illustrating this subject, it appears that, in all probability, most of
the large thin-edged apertures at the bottom of the interlobular sulci are
connected with the uterine veins; whereas, the smaller orifices, the
margins of which are thicker, and which are chiefly observed upon the
cotyledons, are continuations of the uterine arteries.

These openings were also pointed out by the late Dr. Hugh Ley, in
describing the _post mortem_ examination of a woman who had died at the
full term undelivered (_Med. Gaz._ June 1, 1833:) "The uterine surface (of
the placenta) thus detached from the uterus, exhibited its lobules with
their intersecting sulci, even more distinctly than they are seen in the
uninjected placenta; and in several parts there could be perceived, with
the naked eye, small apertures of an oval form, with edges perfectly
smooth, regularly defined, and thicker, as well as more opaque, than the
contiguous parts which they penetrated." The communication between the
openings of the placental cells, and the mouths of the uterine veins and
arteries, which convey their blood to the placenta, as before observed,
is effected by means of the placental decidua. The connecting portion of
canal is of a flattened shape, runs obliquely between the uterus and
placenta, and appears to be formed entirely of decidua. The manner in
which the arteries pass to the placenta is very different to that of the
veins: "the arteries," as Dr. W. Hunter observes, "are all much convoluted
and serpentine; the larger, when injected, are almost of the size of
crow-quills: the veins have frequent anastomoses." Mr. J. Hunter has
described this point more minutely, and gives still more precise notions
of the manner in which the arteries pass to the placenta. "The arteries of
the uterus which are not immediately employed in conveying nourishment to
it, go on towards the placenta, and, proceeding obliquely between it and
the uterus, pass through the decidua without ramifying: just before they
enter the placenta, making two or three close spiral turns upon
themselves, they open at once into its spongy substance, without any
diminution of size, and without passing beyond the surface as above
described.

The intention of these spiral turns would appear to be that of diminishing
the force of the circulation as it approaches the spongy substance of the
placenta, and is a structure which must lessen the quick motion of the
blood in a part where a quick motion of this fluid was not wanted. The
size of these curling arteries at this termination is about that of a
crow's quill. The veins of the uterus appropriated to bring back the blood
from the placenta, commence from this spongy substance by such wide
beginnings as are more than equal to the size of the veins themselves.
These veins pass obliquely through the decidua to the uterus, enter its
substance obliquely, and immediately communicate with the proper veins of
the uterus; the area of those veins bear no proportion to their
circumference, the veins being very much flattened."[21]

On examining these vessels in an injected uterus to which the placenta is
attached, we shall therefore find that all traces of a regular canal or
tube are suddenly lost upon their entering the placenta; each vessel
(whether artery or vein) abruptly terminating in a spongy cellular tissue.
If a blow-pipe be introduced into a piece of sponge, we shall have a very
simple but correct illustration of the manner in which the uterine blood
circulates through the placenta. The cell into which each vessel
immediately opens is usually much larger than the rest, so that when the
cellular structure of the placenta is filled with wax, a number of
irregular nodules[22] are found continuous with these vessels and passing
into an infinity of minute granules, which are merely so many casts of
smaller cells. That this cellular tissue pervades the whole mass of the
placenta, and communicates freely with the uterine vessels by which it is
filled with blood, is proved by repeating a very simple experiment of Dr.
Hunter, viz. "if a blow-pipe be thrust into the substance of the placenta
any where, the air which is blown into the cellular part opens, and rushes
out readily by, the open mouths both of the arteries and veins." (Hunter,
_op. cit._ p. 46.) That it also envelopes the umbilical vessels of the
cord is shown by the fact, that if a pipe be inserted beneath the outer
covering of the cord near to its insertion into the placenta, we shall be
able to "fill the whole placenta uniformly in its cellular part, and
likewise all the venous system of the uterus and decidua, as readily and
fully as if we had fixed the pipe in the spermatic or hypogastric vein; so
ready a passage is there reciprocally between the cells of the placenta
and the uterine vessels." (_Ibid._ p. 47.)

The maternal portion of the placenta therefore consists of a spongy
cellular tissue, which is filled by the uterine vessels, and also of those
trunks which pass through the decidua, and which form the communication
between these vessels and the placental cells.

[Illustration: _Foetal surface of the placenta._]

The foetal surface of the placenta is smooth and glossy, being covered by
the amnion and chorion; it is much harder than the uterine surface, and is
streaked over by the larger branches of the umbilical vein and arteries,
which radiate irregularly from the point where the cord is inserted; and
which pass beneath the amnion, and between the two layers of which the
chorion is composed, to which they are intimately connected. These vessels
supply the various lobuli of which the placenta is composed, so that each
lobulus receives at least one of these branches; for, although the
umbilical cord consists of two arteries and one vein, this arrangement
does not continue into the body of the placenta. "Every branch of an
artery," as Dr. Hunter observes, "is attended with a branch of a vein:
these cling to one another, and frequently in the substance of the
placenta entwine round one another, as in the navel string." (_Ibid._ p.
40.) Each cotyledon receives its own vessels, so that the vessels of one
cotyledon have no direct communication with those of the adjacent ones, as
proved by Wrisberg's examinations; for if we inject the vessel or vessels
of one of these lobuli, the injection will not pass into those of the
others. When the vessels have reached the cotyledons, they are divided and
subdivided _ad infinitum_; they are connected together by a fine cellular
membrane, which may be very easily removed by maceration, and then they
may be seen ramifying in the most beautiful and delicate manner possible;
the main branches having no communication or anastomosis with each other.

The umbilical arteries anastomose freely with each other upon the foetal
surface of the placenta, before dividing into the branches
above-mentioned; hence, if an injection be thrown into one umbilical
artery it will return almost immediately by the other; but if this be tied
also, the injection, after a time, will return by the umbilical vein, but
not until all the vessels of the placenta have been filled, proving that
there is a free passage of blood from the arteries into the veins.

From these remarks, founded chiefly on the admirable observations of the
Hunters, and repeated examinations of the placenta, which we have made
with the greatest care and impartiality, it may be stated with confidence,
that the placenta consists of two portions--a maternal and a foetal. The
maternal portion consists, as we have before observed, of a spongy
cellular tissue; and also of those trunks which pass through the decidua,
and which form the communication between the uterine vessels and the
placental cells. The foetal part is formed by the ramifications of the
umbilical vessels: "that each of those parts has its peculiar system of
arteries and veins, and its peculiar circulation, receiving blood by its
arteries, and returning it by its veins; that the circulation through
these parts of the placenta differs in the following manner: in the
umbilical portion the arteries terminate in the veins by a continuity of
canal; whereas, in the uterine portion there are intermediate cells into
which the arteries terminate, and from which the veins begin." (Hunter,
_op. cit._ p. 48.)

Although various observations and anatomical injections show that to a
certain degree, there is a communication between the uterus and the
placenta, inasmuch as the blood of the former is received into the sinuses
or cells of the latter, we possess no proof that the blood can pass from
these sinuses into the umbilical vessels: on the contrary, every thing
combines to prove that the circulation of the foetus is altogether
independent of that of the mother. We know from daily experience that in
labour at the full term of pregnancy, the placenta is easily expelled
from the uterus: that, upon examining the surface which had been attached
to the uterus we find no laceration, and that a discharge of more or less
blood takes place for some days afterwards. We know, also, that when the
placenta becomes detached from the uterus during the progress of
gestation, it is followed by a considerable hemorrhage, which greatly
endangers the life of the mother. These facts prove that there is a
circulation of uterine blood in the placenta, which is destroyed upon its
being separated from the uterus. That this uterine circulation in the
placenta is unconnected with the circulation of foetal vessels in the
placenta is proved by the fact first pointed out by Wrisberg, viz. that,
where the mother has died from loss of blood, and the maternal vessels
therefore drained of their contents, those of the foetus have been full of
blood. Still farther to illustrate this fact, he killed several cows big
with calf, by a large wound through the heart or great vessels, so as to
ensure the most profuse and sudden loss of blood possible, and never found
that the vessels of the calf were deprived of blood, although those of the
mother were perfectly empty; moreover, no anatomist has ever yet succeeded
in making injections pass from the foetal into the uterine vessels, or
_vice versâ_. Lobstein has mentioned a mode of illustrating this fact
(_Essai sur la Nutrition du Foetus_,) which is both simple and striking.
Upon examining the uterine surface of a placenta which has been expelled
at the full term, it presents the appearance of a spongy mass gorged with
blood, which may be removed by washing or maceration, and if a placenta
thus prepared be injected, the fluids will pass with the greatest facility
from the umbilical arteries into the umbilical vein, but not one drop into
its cellular structure; it is evident, therefore, that the blood which had
filled the intervals between the vessels, and which had been removed by
washing and maceration, could not have belonged to the foetus, but must
have come from the mother; for if any of the vessels had been ruptured the
injection would not have succeeded.

In concluding these observations upon the placenta, we may briefly state,
that there is the same relation between the umbilical vessels and the
maternal blood, which fills the placental cells, as there is between the
branches of the pulmonary artery, and the air which fills the bronchial
cell.[23]

_Umbilical cord._ The umbilical cord, funis, or navel string, is a
vascular rope extending between the foetus and placenta, by which they are
connected together. It usually arises, as we have before observed, from
about the middle of the placenta, and terminates at the umbilical ring of
the foetus; it consists of two umbilical arteries and one umbilical vein;
the former conveying the blood from the common iliac arteries of the
foetus to the cotyledons of the placenta; the latter formed by the union
of the collected umbilical veins, on the inner surface of the placenta,
and returning this blood to the foetus. In the early periods of pregnancy
it also consists of the duct and vessels of the vesicula umbilicalis, the
urachus, and more or less of the intestinal canal. The umbilical cord does
not present the same form or appearance at every period of gestation; the
younger the embryo, the shorter and thicker is the cord; in fact, there
are no traces whatever of a cord at first, the embryo adhering, by its
lower or caudal extremity, directly to the membranes. By the fifth or
sixth week it becomes visible; at this early period the vessels of which
it is composed pass from the foetus in a straight direction, but as
pregnancy advances they become more or less spiral, winding round each
other, and usually from left to right: according to Meckel, they take the
opposite direction much less frequently, viz. in the proportion of one to
nine.

The vessels of the umbilical cord are imbedded in a thick viscid
substance; upon minute examination, it will be found to consist of a very
fine cellular tissue, containing an albuminous matter which slowly exudes,
when pressed between the fingers. This cellular tissue itself may be
demonstrated by the inflation of air or injection with mercury: it seems
to accompany the umbilical vessels as far as the posterior surface of the
peritoneum; and Lobstein is of opinion that it is a continuation of the
cellular tissue, which covers this membrane. (Lobstein, _sur la Nutrition
du Foetus_. § 75.)

Externally, the umbilical cord is covered by a continuation of the amnion,
which, although it be the inner membrane of the ovum, is the outer
covering of the cord: in some places it is very thick and strong, and not
easily ruptured. From repeated observations, the weakest part of the cord
seems to be at about three or four inches distant from the umbilicus, this
being the spot where it has invariably given way in every case we have
seen, where the cord has been broken at the moment of the child's birth.

From the time of the commencement to the full time of utero-gestation, the
cord becomes gradually longer, so that it attains an average length of
from eighteen to twenty inches; this, however, varies remarkably. We have
known the cord exceed forty inches; and a case is described by
Baudelocque, where it was actually fifty-seven inches long: on the other
hand, it is sometimes not more than four or five inches in length.

It is remarkable that the cord, which at the end of pregnancy is usually
of about the same length as the foetus, is relatively much longer during
the sixth month; hence we may conclude, that in those cases where knots
have been found upon the cord, the knot must have been formed at this
period when the foetus was small enough to pass through a coil of it.

Neither blood-vessels nor lymphatics have as yet been found in the
structure of the cord itself. A filament of nerve from the solar plexus
has been occasionally seen passing through the umbilical ring, and
extending to a distance down the cord.

The vesicula umbilicalis and allantois, being essentially connected with
the earliest grades of foetal development, will be considered under that
head.

_Embryo._ There is, perhaps, no department of physiology which has been so
remarkably enriched by recent discoveries, as that which relates to the
primitive development of the ovum and its embryo. The researches of Baer,
Rathke, Purkinje, Valentin, &c. in Germany; of Dutrochet, Prevost, Dumas,
and Coste, &c. in France; and of Owen, Sharpey, Allen Thomson, Jones, and
Martin Barry in England, but more especially those of the celebrated Baer,
have greatly advanced our knowledge of these subjects, and led us deeply
into those mysterious processes of Nature which relate to our first origin
and formation.

These researches have all tended to establish one great law, connected
with the early development of the human embryo, and that of other
mammiferous animals, viz, that it at first possesses a structure and
arrangement analogous to that of animals in a much lower scale of
formation: this observation also applies of course to the ovum itself,
since a variety of changes take place in it after impregnation, before a
trace of the embryo can be detected.

At the earliest periods, the human ovum bears a perfect analogy to the
eggs of fishes, amphibia, and birds; and it is only by carefully examining
the changes produced by impregnation in the ova of these lower classes of
animals, that we have been enabled to discover them in the mammalia and
human subject.

As the bird's egg, from its size, best affords us the means of
investigating these changes, and as in all essential respects they are the
same in the human ovum, it will be necessary for us to lay before our
readers a short account of its structure and contents, and also of the
changes which they undergo, after impregnation. In doing this we shall
merely confine ourselves to the description of what is applicable to the
human ovum.

[Illustration: _Section of a hen's egg within the ovary._

_a_ The granulary membrane forming the periphery of the yelk. _b_ Vesicle
of Purkinje imbedded in the cumulus. _c_ Vitellary membrane. _d_ Inner and
outer layers of the capsule of the ovum. _e_ Indusium of the ovary.]

The egg is known to consist of two distinct parts, the vitellus or yelk
surrounded by its albumen or white; to the former of these we now more
particularly refer. The yelk is a granular albuminous fluid, contained in
a granular membranous sac (the _blastodermic membrane_) which is covered
by an investing membrane called the _vitelline membrane_ or _yelk-bag_.
The impregnated vitellus is retained in its capsule in the ovary,
precisely as the ovum of the mammifera is in the Graafian vesicle. The
whole ovary in this case has a clustered appearance, like a bunch of
grapes, each capsule being suspended by a short pedicle of indusium.

[Illustration: _a_ Vitelline membrane _b_ Blastoderma. _From T. W.
Jones._]

In those ova which are considerably developed before impregnation, the
granular blastermodic membrane is observed to be thicker, and the granules
more aggregated at that part which corresponds to the pedicle, forming a
slight elevation with a depression in its centre, like the cumulus in the
proligerous disc of a Graafian vesicle. This little disc is the
blastoderma, germinial membrane or cicatricula; in the central depression
just mentioned is an exceedingly minute vesicle first noticed by Professor
Purkinje of Breslau, and named after him: in more correct language it is
the _germinal vesicle_.

According to Wagner, the germinal vesicle is not surrounded by a disc
before impregnation; and it is only after this process that the
above-mentioned disc of granules is formed. By the time the ovum is about
to quit the ovary the vesicle itself has disappeared, so that an ovum has
never been found in the oviduct containing a germinal vesicle, nothing
remaining of it beyond the little depression in the cumulus of the
cicatricula.

The rupture of the Purkinjean or germinal vesicle has been supposed by Mr.
T. W. Jones to take place before impregnation; but the observations of
Professor Valentin seem to lead to the inference that it is a result of
that process, and must be therefore looked upon as one of the earliest
changes which take place in the ovum or yelk-bag upon quitting the
ovary.[24]

During its passing through the oviduct (what in mammalia is called the
Fallopian tube,) the ovum receives a thick covering of albumen, and as it
descends still farther along the canal the membrane of the shell is
formed.

On examining the appearance of the ovum in mammiferous animals, and
especially the human ovum, it will be found that it presents a form and
structure very analogous to the ova just described, more especially those
of birds. It is a minute spherical sac, filled with an albuminous fluid,
lined with its blastodermic or germinal membrane, in which is seated the
germinal vesicle or vesicle of Purkinje. When the ovum has quitted the
ovary the germinal vesicle disappears, and on its entering the Fallopian
tube it becomes covered with a gelatinous, or rather albuminous covering.
This was inferred by Valentin, who considered that "the enormous swelling
of the ova, and their passage through the Fallopian tubes," tended to
prove the circumstance. (_Edin. Med. and Surg. Journ._ April, 1836.) It
has since been demonstrated by Mr. T. W. Jones in a rabbit seven days
after impregnation. The vitellary membrane seems, at this time, to give
way, leaving the vitellus of the ovum merely covered by its spherical
blastoderma, and encased by the layer of albuminous matter which surrounds
it.

From what we have now stated, a close analogy will appear between the ova
of the mammalia and those of the lower classes, more especially birds,
which from their size afford us the best opportunities of investigating
this difficult subject.

In birds, the covering of the vitellus is called _yelk-bag_; whereas, in
mammalia and man it receives the name of _vesicula umbilicalis_. Its
albuminous covering, which corresponds to the white and membrane of the
shell in birds, is called _chorion_: by the time that the ovum has reached
the uterus, this outer membrane has undergone a considerable change; it
becomes covered with a complete down of little absorbing fibrillæ, which
rapidly increase in size as development advances, until it presents that
tufted vascular appearance, which we have already mentioned when
describing this membrane.

The first or primitive trace of the embryo is in the cicatricula or
germinal membrane, which contained the germinal vesicle before its
disappearance. In the centre of this, upon its upper surface, may be
discovered a small dark line;[25] "this line or primitive trace is swollen
at one extremity, and is placed in the direction of the transverse axis of
the egg."

[Illustration: _a_ Transparent area. _b_ Primitive trace.]

As development advances, the cicatricula expands. "We are indebted to
Pander,"[26] says Dr. Allen Thomson in his admirable essay above quoted,
"for the important discovery, that towards the twelfth or fourteenth hour,
in the hen's egg the germinal membrane becomes divided into two layers of
granules, the serous and mucous layers of the cicatricula; and that the
rudimentary trace of the embryo, which has at this time become evident,
is placed in the substance of the upper-most or serous layer." "According
to this observer, and according to Baer, the part of this layer which
surrounds the primitive trace soon becomes thicker; and on examining this
part with care, towards the eighteenth hour, we observe that a long furrow
has been formed in it, in the bottom of which the primitive trace is
situated; about the twentieth hour this furrow is converted into a canal
open at both ends, by the junction of its margins (the _plicæ primitivæ_
of Pander, the _laminæ dorsales_ of Baer:) the canal soon becomes closed
at the cephalic or swollen extremity of the primitive trace, at which part
it is of a pyriform shape, being wider here than at any other part.
According to Baer and Serres, some time after the canal begins to close, a
semi-fluid matter is deposited in it, which on its acquiring greater
consistence, becomes the rudiment of the spinal cord; the pyriform
extremity or head is soon after this seen to be partially subdivided into
three vesicles, which being also filled with a semi-fluid matter, gives
rise to the rudimentary state of the encephalon." "As the formation of the
spinal canal proceeds, the parts of the serous layer which surrounds it,
especially towards the head, become thicker and more solid, and before the
twenty-fourth hour we observe on each side of this canal four or five
small round opaque bodies, these bodies indicate the first formation of
the dorsal vertebræ.

[Illustration: _a_ Transparent area. _b_ Laminæ dorsales. _c_ Cephalic
end. _d_ Rudiments of dorsal vertebræ. _e_ Serous layer. _f_ Lateral
portion of the primitive trace. _g_ Mucous layer. _h_ Vascular layer. _k_
Laminæ dorsales united to form the spinal canal.]

"About the same time, or from the twentieth to the twenty-fourth hour,
the inner layer of the germinal membrane undergoes a farther division, and
by a peculiar change is converted into the vascular mucous layers." (A.
Thomson, _op. cit._) It will thus be seen, that the germinal membrane is
that part of the ovum in which the first changes produced by impregnation
are observed. The rudiments of the osseous and nervous systems are formed
by the outer or serous layers; the outer covering of the foetus or
integuments, including the amnois, are also furnished by it. "The layer
next in order has been called _vascular_, because in it the development of
the principal parts of the vascular system appears to take place. The
third, called the _mucous_ layer, situated next the substance of the yelk,
is generally in intimate connexion with the vascular layer, and it is to
the changes which these combined layers undergo, that the intestinal, the
respiratory, and probably also the glandular systems owe their origin."
(A. Thomson, _op. cit._ p. 298.)

[Illustration: _a_ Serous layer. _b c_ Vascular layer. _d_ Mucous layer.
_e_ Heart.]

The embryo is therefore formed in the layers of the germinal membrane, and
becomes, as it were, spread out upon the surface of the ovum: the changes
which the ovum of mammalia undergoes appear from actual observation, to be
precisely analogous to those in the inferior animals. (_Baer_, _Prevost_
and _Dumas_.) From the primitive trace, which was at first merely a line
crossing the cicatricula, and which now begins rapidly to exhibit the
characters of the spinal column, the parietes of the head and trunk
gradually approach farther and farther towards the anterior surface of the
abdomen and head until they unite; in this way the sides of the jaws close
in the median line of the face, occasionally leaving the union incomplete,
and thus appearing to produce in some cases the congenital defects of
hare-lip and cleft palate. In some way the ribs meet at the sternum; and
it may be supposed that sometimes this bone is left deficient, and thus
may become one of the causes of those rare cases of malformation, where
the child has been born with the heart external to the parietes of the
thorax. In like manner the parietes of the abdomen and pelvis close in the
linea alba and symphysis pubis, occasionally leaving the integuments of
the navel deficient, or, in other words, producing congenital umbilical
hernia, or at the pubes a non-union of its symphysis with a species of
inversion of the bladder, the anterior wall of that viscus being nearly or
entirely wanting.

The cavity of the abdomen is therefore at first open to the vesicula
umbilicalis or yelk, but this changes as the abdominal parietes begin to
close in; in man and the mammalia merely a part of it, as above mentioned,
forms the intestinal canal, whereas, in oviparous animals the whole of the
yelk-bag enters the abdominal cavity, and serves for an early nutriment to
the young animal. Another change connected with the serous or outer layer
of the germinal membrane is the formation of the _amnion_. The foetal
rudiment which from its shape has been called _carina_, now begins to be
enveloped by a membrane of exceeding tenuity, forming a double covering
upon it; the one which immediately invests the foetus is considered to
form the future epidermis; the other, or outer fold, forms a loose sac
around it, containing the liquor amnii. Whilst these changes are taking
place in the serous layer of the germinal membrane, and whilst the
intestinal canal, &c. are forming on the anterior surface of the embryo,
which is turned towards the ovum, by means of the inner or mucous layer,
equally important changes are now observed in the middle or vascular
layer. "In forming this fold," says Dr. A. Thomson, "the mucous layer is
reflected farthest inwards; the serous layer advances least, and the space
between them, occupied by the vascular layer, is filled up by a dilated
part of this layer, the rudiment of the heart." (_Op. cit._ p. 301.)

Whilst this rudimentary trace of the vascular system is making its
appearance, minute vessels are seen ramifying over the vesicula
umbilicalis, forming, according to Baer's observations, a reticular
anastomosis, which unites into two vessels the vasa omphalo-meseraica.
(_British and Foreign Med. Rev._ No. 1.) These may be demonstrated with
great ease in the chick: the cicatricula increases in extent; it becomes
vascular, and at length forms a heart-shaped net-work of delicate vessels,
which unite into two trunks, terminating one on each side of the abdomen.

[Illustration: _b_ Is a portion of the convexity of the amnion, upon
which, at _a_ is the fundus of the diminutive human allantois.

_c_ The duct of the vesicula umbilicalis, dividing into two intestinal
portions; and besides this duct are two vessels which are distributed upon
the vesicula umbilicalis, and form a reticular anastomosis with each
other. _From Baer._]

The umbilical vesicle now begins to separate itself more and more from the
abdomen of the foetus, merely a duct of communication passing to that
portion of it which forms the intestinal canal. The first rudiment of the
cord will be found at this separation; its foetal extremity remains for a
long time funnel-shaped, containing, besides a portion of intestine, the
duct of the vesicula umbilicalis, the vasa omphalo-meseraica (the future
vena portæ,) the umbilical vein from the collected venous radicles of the
chorion, and the early trace of the umbilical arteries. These last-named
vessels ramify on a delicate membranous sac of an elongated form which
rises from the inferior or caudal extremity of the embryo, viz. the
_allantois_; whether this is formed by a portion of the mucous layer of
the germinal vesicle, in common with the other abdominal viscera, appears
to be still uncertain: in birds this may be very easily demonstrated as a
vascular vesicle, arising from the extremity of the intestinal canal; and
in mammalia, connected with the bladder by means of a canal called
_urachus_: from its sausage-like shape, it has received the name of
_allantois_.

The existence of an allantois in the human embryo has been long inferred
from the presence of a ligamentous cord extending from the fundus of the
bladder to the umbilicus, like the urachus in animals. But from the
extreme delicacy of the allantois, and from its function ceasing at a very
early period, it had defied all research, until lately when it has been
satisfactorily demonstrated in the human embryo by Baer and Rathke. It
occupies the space between the chorion and amnion, and gives rise
occasionally to a collection of fluid between these membranes, familiarly
known by the name of the liquor amnii spurius, which, strictly speaking is
the liquor allantoidis.

The function of the allantois is still in a great measure unknown. In
animals it evidently acts as a species of receptaculum urinæ during the
latter periods of gestation; but it is very doubtful if this be its use
during the earlier periods. It does not seem directly connected with the
process of nutrition, which at this time is proceeding so rapidly, first
by means of the albuminous contents of the vitellus, or vesicula
umbilicalis, and afterwards by the absorbing radicles of the chorion; but,
from analogy with the structure of the lower classes of animals, it would
appear that it is intended to produce certain changes in the rudimentary
circulation of the embryo, similar to those which, at a later period of
pregnancy, are effected by means of the placenta, and after birth by the
lungs, constituting the great functions of respiration.

In many of the lower classes of animals, respiration (or at least the
functions analogous to it) is performed by organs situated at the inferior
or caudal extremity of the animal: thus for instance, certain insect
tribes, as in hymenoptera, or insects with a sting, as wasps, bees, &c.;
in diptera, or insects with two wings, as the common fly; and also the
spider tribe, have their respiratory organs situated in the lower part of
the abdomen. In some of the crustacea, as, for instance, the shrimp, the
organs of respiration lie under the tail between the fins, and floating
loosely in the water. Again, some of the molusca, viz. the cuttle-fish,
have the respiratory organs in the abdomen. We also know that many
animals, during the first periods of their lives, respire by a different
set of organs to what they do in the adult state: the most familiar
illustration of this is the frog, which, during its tadpole state, lives
entirely in the water.

[Illustration: _a_ Bronchial processes. _b_ Vesicula umbilicalis. _c_
Vitellus. _d_ Allantois. _e_ Amnion. _From Baer._]

As the growth of the embryo advances, other organs whose function is as
temporary as that of the allantois, make their appearance: these also
correspond to the respiratory organs of a lower class of animals, although
higher than those to which we have just alluded,--we mean bronchial
processes or gills. It is to Professor Rathke (_Acta Naturæ Curios._ vol.
xiv,) that we are indebted for pointing out the interesting fact, that
several transverse slit-like apertures may be detected on each side the
neck of the embryo, at a very early stage of development. In the chick, in
which he first observed it, it takes place about the fourth day of
incubation: at this period the neck is remarkably thick, and contains a
cavity which communicates inferiorly with the oesophagus and stomach, and
opens externally on each side by means of the above-mentioned apertures,
precisely as is observed in fishes, more especially the shark tribe; these
apertures are separated from each other by lobular septa, of exceedingly
soft and delicate structure. Rathke observed the same structure in the
embryo of the pig and other mammalia; and Baer has since shown it
distinctly in the human embryo. It is curious to see how the vascular
system corresponds to the grade of development then present: the heart is
single, consisting of one auricle and one ventricle; the aorta gives off
four delicate, but perfectly simple branches, two of which go to the
right, and two to the left side; each of these little arteries passes to
one of the lobules or septa at the side of the neck, which correspond to
gills, and having again united with the three others, close to what is the
first rudiment of the vertebral column, they form a single trunk which
afterwards becomes the abdominal aorta. In a short time these slit-like
openings begin to close; the bronchial processes or septa become
obliterated, and indistinguishable from the adjacent parts; the heart
loses the form of a single heart; a crescentic fold begins to mark the
future division into two ventricles, and gradually extends until the
septum between them is completed. It is also continued along the bulb of
the aorta, dividing it into two trunks, the aorta proper and pulmonary
artery; at the upper part the division is left incomplete, so that there
is an opening from one vessel to the other, which forms the ductus
arteriosus.[27] A similar process takes place in the auricles, the
foramen ovale being apparently formed in the same manner as the ductus
arteriosus; these changes commence in the human embryo about the fourth
week, and are completed about the seventh.

At first the body of the embryo has a more elongated form than afterwards,
and the part which is first developed is the trunk, at the upper extremity
of which a small prominence less thick than the middle part, and separated
from the rest of the body by an indentation, distinguishes the head. There
are as yet no traces whatever of extremities, or of any other prominent
parts; it is straight, or nearly so, the posterior surface slightly
convex, the anterior slightly concave, and rests with its inferior
extremity directly upon the membranes, or by means of an extremely short
umbilical cord.

The head now increases considerably in proportion to the rest of the body,
so much so, that at the beginning of the second month, it equals nearly
half the size of the whole body: previous to, and after this period, it is
usually smaller. The body of the embryo becomes considerably curved, both
at its upper as well as its lower extremity, although the trunk itself
still continues straight. The head joins the body at a right angle, so
that the part of it which corresponds to the chin is fixed directly upon
the upper part of the breast; nor can any traces of neck be discerned,
until nearly the end of the second month.

The inferior extremity of the vertical column, which at first resembles
the rudiment of a tail becomes shorter towards the middle of the third
month, and takes a curviture forwards under the rectum, in the fifth week
the extremities become visible, the upper usually somewhat sooner than the
lower, in the form of small blunt prominences. The upper close under the
head, the lower near the caudal extremity of the vertebral column. Both
are turned somewhat outwards, on account of the size of the abdomen; the
upper are usually directed somewhat downwards, the lower ones somewhat
upwards.

[Illustration: _Diagram of the foetus and membranes about the fourth
week._

_a_ Vesicula umbilicalis already passing into the ventricular and rectum
intestine at _g_. _b_ Vena and arteria omphalo-meseraica. _c_ Allantois
springing from the pelvis with the umbilical arteries. _d_ Embryo. _e_
Amnion. _f_ Chorion. _From Carus._]

The vesicula umbilicalis may still be distinguished in the second month as
a small vesicle, not larger than a pea, near the insertion of the cord, at
the navel, and external to the amnion. From the trunk, which is almost
entirely occupied by the abdominal cavity, arises a short thick umbilical
cord, in which some of the convolutions of the intestines may still be
traced. Besides these it usually contains, as already observed, the two
umbilical arteries and the umbilical vein, the urachus, the vasa
omphalo-meseraica, or vein and artery of the vesicula umbilicalis, and
perhaps, even at this period, the duct of communication between the
intestinal canal and vesicula umbilicalis, the foetal extremity of which,
according to Professor Oken's views, forms the processus vermiformis.

[Illustration: _Diagram of the foetus and membranes about the sixth week._

_a_ Chorion. _b_ The larger absorbent extremities, the site of the
placenta. _c_ Allantois. _d_ Amnion. _e_ Urachus. _é_ Bladder. _f_
Vesicula umbilicalis. _g_ Communicating canal between the vesicula
umbilicalis and intestine. _h_ Vena umbilicalis. _i i_ Arteriæ
umbilicales. _l_ Vena omphalo-meseraica. _k_ Arteria omphalo-meseraica.
_n_ Heart. _o_ Rudiment of superior extremity. _p_ Rudiment of lower
extremity. _From Carus._]

The hands seem to be fixed to the shoulders without arms, and the feet to
adhere to the ossa illi; the liver seems to fill the whole abdomen; the
ossa innominata, the ribs, and scapulæ are cartilaginous.

In a short time the little stump-like prominences of the extremities
become longer, and are now divided into two parts, the superior into the
hand and the fore arm, the inferior into the foot and leg; in one or two
weeks later, the arms and thighs are visible. These parts of the
extremities which are formed later than the others, are at first smaller,
but as they are gradually developed they become larger. When the limbs
begin to separate into an upper and lower part, their extremities become
rounder and broader, and divided into the fingers and toes, which at first
are disproportionately thick, and until the end of the third month are
connected by a membranous substance analogous to the webbed feet of water
birds; this membrane gradually disappears, beginning at the extremities of
the fingers and toes, and continuing the division up to their insertion.
The external parts of generation, the nose, ears, and mouth appear after
the development of the extremities. The insertion of the umbilical cord
changes its situation to a certain degree; instead of being nearly at the
inferior extremity of the foetus as at first, it is now situated higher up
on the anterior surface of the abdomen. The comparative distance between
the umbilicus and pubis continues to increase, not only to the full period
of gestation, when it occupies the middle point of the length of the
child's body, as pointed out by Chaussier, but even to the age of puberty,
from the relative size of the liver becoming smaller.

Though the head appears large at first, and for a long time continues so,
yet its contents are tardy in their development, and until the sixth month
the parietes of the skull are in great measure membranous or
cartilaginous. Ossification commences in the base of the cranium, and the
bones under the scalp are those in which this process is last completed.

The contents of the scull are at first gelatinous, and no distinct traces
of the natural structure of the brain can be identified until the close of
the second month; even then it requires to have been sometimes previously
immersed in alcohol to harden its texture. There are many parts of it not
properly developed until the seventh month. In the medulla spinalis no
fibres can be distinguished until the fourth month. The thalami nervorum
opticorum, the corpora striata, and tubercula quadrigemina, are seen in
the second month; in the third, the lateral and longitudinal sinuses can
be traced, and contain blood. In the fifth we can distinguish the corpus
callosum; but the cerebral mass has yet acquired very little solidity, for
until the sixth month it is almost semi-fluid. (Campbell's _System of
Midwifery_.)

About the end of the third, during the fourth, and the beginning of the
fifth months, the mother begins to be sensible of the movements of the
foetus. These motions are felt sooner or later, according to the bulk of
the child, the size and shape of the pelvis, and the quantity of fluid
contained in the amnion, the waters being in larger proportionate quantity
the younger the foetus.

The secretion of bile, like that of the fat, seems to begin towards the
middle of pregnancy, and tinges the meconium, a mucous secretion of the
intestinal tube which had hitherto been colourless, of a yellow colour.
Shortly after this the hair begins to grow, and the nails are formed about
the sixth or seventh month. A very delicate membrane (membrana
pupillaris,) by which the pupil has been hitherto closed, now ruptures,
and the pupil becomes visible. The kidneys, which at first were composed
of numerous glandular lobules (seventeen or eighteen in number,) now
unite, and form a separate viscus on each side of the spine; sometimes
they unite into one large mass, an intermediate portion extending across
the spine, forming the horse-shoe kidney.

Lastly, the testes, which at first were placed on each of the lumbar
vertebræ, near the origin of the spermatic vessels, now descend along the
iliac vessels towards the inguinal rings, directed by a cellular cord,
which Hunter has called _Gubernaculum testis_: they then pass through the
openings carrying before them that portion of the peritoneum which is to
form their tunica vaginalis.

The length of a full-grown foetus is generally about eighteen or nineteen
inches; its weight between six and seven pounds. The different parts are
well developed and rounded; the body is generally covered with the vernix
caseosa;[28] the nails are horny, and project beyond the tips of the
fingers, which is not the case with the toes; the head has attained its
proper size and hardness; the ears have the firmness of cartilage; the
scrotum is rugous, not peculiarly red, and usually containing the testes.
In female children the nymphæ are generally covered entirely by the labia,
the breasts project, and in both sexes frequently contain a milky fluid.
As soon as a child is born, which has been carried the full time, it
usually cries loudly, opens its eyes, and moves its arms and legs briskly;
it soon passes urine and fæces, and greedily takes the nipple. (Naegelé's
_Hebammenbuch_.)

Thus, then, in the space of forty weeks, or ten lunar months, from an
inappreciable point, the foetus attains a medium length of about eighteen
or nineteen inches, and a medium weight of between six and seven pounds.
As these observations on the development of the ovum show that the
structural arrangement of the embryo undergoes a succession of changes, by
which it gradually rises from the lowest to the highest scale of
formation, so we shall find it furnished with a succession of means for
its nutrition, each corresponding more or less to the particular grade of
development which it may have attained. Its earliest source of nourishment
is doubtless the vitellus, or albuminous contents of the vesicula
umbilicalis. The radicle or primitive trace, in this respect, bears a
strong analogy to the seed of a plant; it brings with it its own supply of
nourishment for its first stage of growth; in the latter, the cotyledons
afford nourishment to the little plumula, until, by the formation of roots
and absorption of moisture from the surrounding soil, it is enabled to
support the early rudiment of the future plant. The early function of the
chorion is very analogous to that of roots; it is an absorbing apparatus,
collecting nourishment by means of its numerous absorbing fibrillæ: hence,
according to Lobstein, the umbilical vein exists for some time previous to
the umbilical arteries, and seems to perform an office in the foetus
similar to that of the thoracic duct at a later period; its radicles or
absorbing extremities seem to absorb a milky fluid, which after the first
two months is found in the placenta, and which must be looked upon as a
means of nourishment which does not exist in the latter months. This milky
fluid was noticed by Leroux, who even then expressed his doubts, whether
the radicles of the umbilical vein receive blood from the mother, or
whether they only serve to absorb a white fluid which resembles chyle. In
some manuscript notes of Dr. Young's lectures, which were taken by the
late Dr. Parry, of Bath, when a student at Edinburgh, we find the
following observation: "There is evidently in the placenta, besides
blood-vessels, some other substance, which serves to absorb juices from
the uterus, and to convert these into a chylous matter proper to nourish
the foetus, and this matter is absorbed by the umbilical veins. This seems
to be proved from the consideration of the placenta of animals which have
cotyledons; for, on squeezing these glandular substances, we force out a
sort of chylous liquor, and these are surrounded by the placenta, which
absorb their liquor and convey it to the foetus."

The absorbing power of the umbilical vein continues till the fifth month;
during the second or third, the foetus receives a good deal of nourishment
from the liquor amnii, which at this period contains a considerable
quantity of albuminous matter; this diminishes in the latter months of
pregnancy. Moreover the body of the foetus begins to be covered with the
vernix caseosa towards the seventh month, so that in the eighth and ninth
months the absorption of liquor amnii by the skin is considerably impeded.

How far the full formed placenta, as seen after the fifth month, serves as
a means of nutrition to the foetus, may still be a matter of doubt; its
chief use after this period is, as we have already shown, for the purpose
of producing certain changes in the blood of the foetus analogous to those
of respiration;[29] still, however, it would seem that its function of
nutrition is not entirely at an end, even at a late period of pregnancy.
The numerous little granules of phosphate of lime, which are frequently
found on the uterine surface of a full-grown placenta at a time when
ossification is rapidly advancing in the foetal skeleton, would surely
lead us to infer that the placenta in some way or other supplies the
materials for this process.

_Foetal circulation._ We have already shown, that, in the early stages of
development, the heart of the embryo is single, consisting of one auricle
and one ventricle; that a septum gradually divides these into two parts
until the double heart is formed, leaving two openings of communication
between the right and left sides, the one between the auricles called the
_foramen ovale_, the other between the pulmonary artery and aorta, viz.
the _ductus arteriosus_.

From these and other peculiarities it will be seen that the foetal
circulation differs essentially from that of a child after birth; and, in
order to comprehend the nature and mechanism of the changes which take
place in it when respiration first commences, it will be necessary that
these peculiarities should be thoroughly understood. The condition of the
foetus must also be remembered: surrounded by the liquor amnii, the foetus
does not respire; its lungs have as yet been unemployed; they are
therefore small and collapsed, and present a firm solid mass, nearly
resembling liver in appearance. In this state but little blood from the
pulmonary arteries can circulate through them; for, as the extreme
ramifications of these vessels are distributed upon the mucous membrane
lining the bronchi and air-cells, the free passage of blood through them
will in great measure depend upon a previous condition of the air-cells.
The pulmonary arteries in the foetal state are therefore small, and
transmit but a small quantity of blood into their numerous ramifications,
just sufficient to keep pervious these vessels which after birth are to be
so greatly distended: in this state the lungs when thrown into water sink.

Hence, as the pulmonary arteries do not afford a sufficiently free exit to
the contents of the right side of the foetal heart, nature has provided it
with a peculiar means for carrying off the overplus quantity of blood,
which is poured into the right auricle from the vena cava. This is
attained first by the _foramen ovale_, an oval-shaped opening in the
septum between the right and left auricles, and furnished with a semilunar
valvular flap, so constructed, as to allow a free passage for the blood
from the right to the left auricle, but none in the contrary direction. By
this means a considerable quantity of blood is transmitted at once from
the right to the left auricle, and, consequently, much less into the right
ventricle and pulmonary artery. Still, however, more blood passes into the
right ventricle than the pulmonary artery, in the collapsed state of the
foetal lungs, is capable of conveying away. The pulmonary artery is
therefore continued beyond its bifurcation into the aorta at its
curvature, by means of the _ductus arteriosus_, which, in the full-grown
foetus, forms a short thick passage between these two vessels; and in this
manner is the right ventricle enabled to get rid of its surplus quantity
of blood. Thus we see that the foetal heart although consisting of two
auricles and two ventricles, continues to perform the functions only of a
single heart, both ventricles assisting simultaneously to propel the same
column of blood, viz. that of the aorta, and thus enabling the heart to
act with considerable power.

The chief part of the blood, which flows through the iliac arteries,
instead of being sent to the inferior extremities, is carried into the
umbilical arteries, which passing up along the sides of the bladder meet
the umbilical vein at the navel, and thus form the vessels of the
umbilical cord. These arteries convey the blood of the foetus to the
placenta, where, having undergone changes to which we have already
alluded, it is returned by the umbilical vein. This vessel, which
afterwards forms the round ligament of the liver, passes through the
umbilicus along the anterior edge of the suspensory ligament; it supplies
the left lobe with blood, and having given off a communicating branch to
the vena portæ, which supplies the right lobe, it passes at once by a
short passage, called _canalis venosus_, into the vena cava.

Thus, then, the peculiarities of the foetal circulation may be considered
as four, viz. the _foramen ovale_, or passage from the right to the left
auricle; the _ductus arteriosus_, or communication from the bifurcation of
the pulmonary artery into the arch of the aorta; the _umbilical arteries_
arising from the iliac arteries, and carrying the blood along the cord
into the placenta; and, lastly, the _canalis venosus_, or passage between
the umbilical vein and vena cava.

Let us now examine the changes which take place in the foetal circulation
at the moment of the child's birth. The child, which had hitherto been
immersed in the bland and warm medium of the liquor amnii, is at once
exposed to the action of the external air. By means of the sympathy
existing between the skin and respiratory muscles, sudden and convulsive
efforts at inspiration take place; the air-cells of the lungs become
partially inflated, and, after a short time as the respiration increases
in power and activity, become distended throughout their whole extent. The
thorax rises; the flaccid diaphragm, which hitherto had been pushed up by
the large foetal liver, now contracts, pressing down the liver into its
natural situation. The lungs, from being a hard solid heavy substance,
resembling liver, at once become inflated, elastic, and crepitous, light
and permeable to air in every part.

The capillary terminations of the pulmonary artery, which ramify in the
mucous membrane, forming the parietes of the air-cells, and which
hitherto had been firmly compressed by the collapsed state of the foetal
lungs, are suddenly rendered pervious throughout their whole extent. By
this means, a vacuum, as it were, is formed in the ramifications of the
pulmonary artery; each inspiration is accompanied by a rush of blood from
the right ventricle into the newly-inflated structure. The pulmonary
artery, at its bifurcation, swells and becomes turgid: the blood is
carried off into its numerous ramifications as fast as the right ventricle
can supply it; this may be easily understood from the law, in anatomy,
viz. that the area of two arteries is greater than that of the trunk from
which they bifurcate. From this state of distension, the distance between
the pulmonary artery and the aorta is increased; the ductus arteriosus,
which has now become empty, is stretched, and thus partially closed; the
right auricle, which, but for the foramen ovale, could not have cleared
itself of the whole quantity of blood which was poured into it from the
vena cava, is now enabled to transmit its entire contents into the right
ventricle; the left auricle, which before birth was supplied only by the
foramen ovale from the right auricle, is now rapidly filled by the blood
brought into it by the four pulmonary veins;--the equilibrium between the
two auricles becomes altered;--the right, which hitherto had been somewhat
gorged with blood, is now able to clear itself with facility; whereas, the
left, which was but partially supplied, is now distended with a much
greater quantity: there is now rather a disposition for the blood to
regurgitate from the left to the right auricle; this, however, is
prevented by the semilunar fold of the foramen ovale, which now acts as a
valve, and generally becomes firmly attached to the septum. The
obliteration of the canalis venosus at the posterior margin of the liver,
and of the umbilical vein at the anterior edge, may, we think, be
explained by the changes which necessarily follow the inflation of the
lungs: the diaphragm, when it contracts, pulls down the liver into its
natural situation; the distance, therefore, between the liver and the
heart is increased, and the canalis venosus is consequently stretched, and
considerably pressed upon, and precisely the same results follow with the
umbilical vein.



PART II

NATURAL PREGNANCY AND ITS DEVIATIONS.



CHAPTER I.

SIGNS OF PREGNANCY.

    _Difficulty and importance of the subject.--Diagnosis in the early
    months.--Auscultation.--Changes in the vascular and nervous
    systems.--Morning sickness.--Changes in the appearance of the
    skin.--Cessation of the menses.--Areola.--Sensation of the child's
    movements.--"Quickening."--Ausculation.--Uterine souffle.--Sound of
    the foetal heart.--Funic souffle.--Sound produced by the movements of
    the foetus.--Ballottement.--State of the uterine.--Violet appearance
    of the mucous membrane of the vagina.--Cases of doubtful
    pregnancy.--Diagnosis of twin pregnancy._


There is, perhaps, no subject connected with midwifery, which is of such
importance, or which, from its difficulty and the serious questions it
involves, demands such attentive consideration, and requires so familiar
an acquaintance with every part of it, as the diagnosis of pregnancy. The
responsibility which a medical man incurs in deciding cases of doubtful
pregnancy, and in thus giving an opinion which may not only affect the
fortune, happiness, character, but even life itself of the individual
concerned, is rendered more painful by the perplexing obscurity of the
circumstances under which these cases sometimes occur, being not
unfrequently complicated with diseases which add still farther to the
difficulty of coming at the truth, and occasionally rendered peculiarly
obscure by wilful and determined falsehood and duplicity.

To render this subject more intelligible to our readers, we propose first
to consider the general effects which pregnancy produces upon the system,
and then to describe those changes and phenomena which are _peculiar_ to
this state, and which may therefore be taken as so many means of
diagnosis.

Under all circumstances, the diagnosis of pregnancy must ever be difficult
and obscure during the early months; the development of the uterus is
still inconsiderable, and the effects which it may have produced upon the
system, although appreciable and even distinct, are nevertheless too
capable of being also produced by other causes, to warrant our drawing any
decided conclusion from them.

The effects over the whole animal economy, which result from the presence
and advance of this great process, are very remarkable, and show
themselves in every portion of it.

The vascular system undergoes a considerable change; the actual quantity
of blood in the circulation appears to be increased; the pulse is harder,
stronger, and more full; in many instances the blood, when drawn, exhibits
the buffy coat, as in cases of inflammation; the vagina is more vascular,
it is warmer, and the secretion of mucus considerably increased; there is
a disposition to headach, and occasional flushing of the face; the animal
heat over the whole body is increased. In the nervous system we also
observe distinct evidences of a change having taken place: the
irritability is increased; there is weariness, lassitude, and a peculiar
alteration of taste and disposition; women, who otherwise are of a
cheerful disposition, are now gloomy and reserved, and _vice versâ_; in
some the temper becomes fretful and hasty, and in those who are naturally
so, a most agreeable change for the better is sometimes observed.[30] Some
are liable to spasmodic affections, palpitations, spasmodic cough,
vomiting, fainting, headach, toothach, &c.: under this head will come the
"morning sickness," which is so commonly observed during the first weeks;
the nature and treatment of which will be considered under the DISEASES OF
PREGNANCY; on the other hand, women who are constantly suffering from
spasmodic affections, for instance, asthma, &c. are now entirely free from
them, and appear to be insensible to causes which, in the unimpregnated
state, would induce an attack. To changes in the nervous system must we,
in great measure, attribute not only the sickness just mentioned, but also
those extraordinary longings or antipathies for certain articles of food
or drink, and in some cases, as in chlorosis, for substances which, under
other circumstances, would excite disgust. In many, the changes in the
function of the digestive apparatus does not amount to actual disease, the
stomach merely refusing to digest articles of food which before had agreed
with it: but in others, producing severe cardialgia, acidity, or even
vomiting. Hence, we not unfrequently observe that women who had hitherto
enjoyed a good digestion, now suffer from dyspepsia, and are obliged to be
exceedingly careful in their diet; whereas those, in whom the digestion
had been previously weak, are now able to digest almost any thing. The
secretions of the whole alimentary canal are altered both in quality and
quantity; the saliva frequently becomes tenacious, white, and frothy
(_Dewees_,) and at times is so much increased in quantity as to amount to
actual salivation; the secretions of the stomach are remarkably altered,
as shown by the copious formation of acid in some cases during pregnancy;
the mucus is ropy, and frequently vomited up in considerable quantities.
The bowels are in some cases much relaxed; in others, constipated. This
latter condition, however, may in part be attributed to the pressure of
the gravid uterus obstructing the peristaltic motion.

The changes in the appearance of the skin during pregnancy are also worthy
of notice. Women, who are naturally pale and of a delicate complexion,
have frequently a high colour, and _vice versâ_; in some the skin assumes
a sallow or cadaverous hue; copper-coloured blotches appear on the face
and forehead: in others the skin appears loose and wrinkled, giving the
patient an aged haggard expression, and destroying her good looks. Mole
spots become darker and larger, and these, with a dark ring beneath the
eyes and the changes already mentioned, combine to alter the whole
appearance of the face. In some women a considerable quantity of hair
appears in those parts of the face where the beard is seen in the other
sex; it disappears after labour, when the skin resumes its natural
functions, but returns on every succeeding pregnancy. In others a similar
appearance takes place upon the breasts. The secretions of the skin are
more or less altered; women who perspire freely have now a dry, rough
skin; whereas those who at other times have seldom or never a moist skin,
have copious perspiration, which is not unfrequently of a peculiarly
strong odour. Cutaneous affections, also, which have been very obstinate,
or had even become habitual, sometimes disappear, or at least are
suspended during the period of utero-gestation. Similarly favourable
changes are observed for a time in severe structural diseases of certain
organs: the fact of well-marked phthisis apparently disappearing whilst
pregnancy lasts, is well known.

The breasts become larger, blue veins are seen ramifying beneath the skin,
and the circular disc of rose-coloured skin which surrounds the nipples
becomes remarkably changed in colour, &c.; appearances, the description
of which we shall defer until we come to the consideration of those
phenomena produced by pregnancy, which may be looked upon as diagnostic.

The urine undergoes various changes; it is sometimes considerably
increased, at others it is very high-coloured, or shows a peculiar milky
sediment. A case has been quoted by Dr. Montgomery from Professor Osann's
_Clin. Rep._ for 1833, p. 27., where the patient in three successive
pregnancies was affected with diabetus mellitus, which each time
completely ceased on delivery, and again returned when she became
pregnant. None of the changes above enumerated excepting of those of the
breasts, whether taken separately or conjointly, will enable us to form a
correct diagnosis as to the existence of pregnancy. The appearance and
feel of the abdomen during the early months afford no sure data: in fact,
there is not a single symptom of pregnancy at this period, upon which we
can rely with any degree of certainty.

_Cessation of the menses._ One of the most remarkable changes produced by
pregnancy, and one which most constantly appears, is the cessation of the
menstrual discharge. From its occurring so uniformly and so soon after
conception, it is generally used by women as the best means of reckoning
the duration of their pregnancy: still, however, it is very far from being
a certain sign, and never can be depended upon by itself in forming our
diagnosis. It is well known how many causes produce suppression of the
catamenia, independent of pregnancy; and, on the other hand, ample
experience has shown that suppressed catamenia are by no means a necessary
consequence of pregnancy.

Although the fact has been contradicted by men of experience, still the
regular appearance of the menses for the first few months of pregnancy is
of such frequent occurrence as to place the matter beyond all doubt: in
stating this, we do not allude to occasional discharges of blood from the
vagina, but to regular periodical appearances of fluid distinctly bearing
all the characters and peculiarities of the catamenia. This fact has been
noticed so long ago, as by Mauriceau, who says, "I know a woman who had
four or five living children, and who had with every child her menses from
month to month, as at other times, only in a little less quantity, and was
so till the sixth month, yet notwithstanding she was always brought to bed
at her full time."[31]

It is rare, however, to meet with the catamenia at so late a period,
although cases do now and then occur where it lasts throughout pregnancy;
more frequently it does not continue beyond the third or fourth month. The
source of this discharge appears to be from the vessels of the upper part
of the vagina[32] and from the cervix uteri;[33] the gradually shortening
of the latter as pregnancy advances may be considered as the reason why,
in the majority of instances, the discharge diminishes after the second or
third month, and usually ceases by the fifth or sixth. Dr. Dewees supports
the same opinion with some excellent observations which are worthy of
attention. "We are" says he "acquainted with a number of women who
habitually menstruate during pregnancy until a certain period, but when
that time arrives it ceases: several of these menstruated until the second
or third months, others longer, and two until the seventh month; the last
two were mother and daughter. We are certain there was no mistake in all
the cases to which we now make reference. First, they (the menses) were
regular in their returns, not suffering the slightest derangement from the
impregnated condition of the uterus; 2. they employ from two to five days
for their completion; 3. that the evacuation differed in no respect from
the discharge in ordinary, except that they did not think it so abundant;
4. there were no coagula in any one of these discharges, consequently it
could not be common blood of hæmorrhage; 5. in the two protracted cases,
the quantity discharged regularly diminished after the fourth month, a
circumstance perhaps not difficult of explanation." (_Compendious System
of Midwifery_, § 235.)

It occasionally happens that the first appearance of the catamenia after
conception is more abundant than usual, a circumstance which had been
noticed by Dr. W. Johnson in 1769, and confirmed by Dr. Montgomery in his
admirable work on the signs of pregnancy, who also confirms the general
fact of the menses occasionally appearing during pregnancy by his own
experience, and by very ample references. (_Op. cit._ p. 46.)

The rarest and most extraordinary deviation of this kind from the usual
course of things is the appearance of the menses _only during pregnancy_.
Cases of this sort have been recorded by authors of the highest
respectability, so that there can be no doubt as to the correctness of
their statements. Thus, for instance, Baudelocque says, "I have met with
several women, who assured me that they had not had their menses
periodically except during their pregnancies; their testimony appeared to
me to deserve more credit, because they only applied for an explanation of
this extraordinary phenomenon."[34]

By far the most interesting and detailed case of this nature is one
described by Dr. Dewees. "A woman applied for advice for a long standing
suppression of the menses; indeed she never had menstruated but twice. She
had been married a number of months, and complained of a good deal of
derangement of stomach, &c. We prescribed some rhubarb and steel pills;
about six months after this she called to say that the medicine had
brought down her courses, but that she was more unwell than before. The
sickness and vomiting had increased, besides swelling very much in her
belly; we saw this pretty much distended and immediately examined it, as
we suspected dropsy; but from the feel of the abdomen, the want of
fluctuation and the solidity of the tumour, we began to think it might be
pregnancy, and told the woman our opinion. On mentioning our impression
she submitted to an examination per vaginam; this proved her to be six
months advanced in pregnancy. After this she had the regular returns of
the catamenial period, until the full time had expired; during suckling
she was free from the discharge. She was a nurse for more than twelve
months; she weaned her child, and shortly after was again surprised by an
eruption of the menses, which as on a former occasion proved to be a sign
of pregnancy." (_Op. cit._ § 237.)

There are other circumstances also connected with the catamenia, which
warn us against placing too much confidence in its disappearance as a sign
of pregnancy: a woman may become pregnant who has never menstruated, a
fact which has been noticed by several authors, and which has been
explained as well as confirmed by Levret in his _Art des Accouchemens_, §
230:--"A woman," says he, "may conceive, although she has not yet
menstruated, provided menstruation would otherwise have made its
appearance shortly."[35]

Another circumstance, of much more frequent occurrence, is the fact that a
woman may become pregnant without having had a return of the menses since
her last confinement; hence we occasionally meet with cases where, from a
rapid succession of pregnancies, the menstruation has not appeared for
several years. From what has now been said, it will be seen, beyond all
doubt, that the non-appearance of the menses cannot be looked upon by
itself as a diagnostic of pregnancy, or _vice versâ_: this is more
particularly the case when any morbid condition of the system is also
present; under such circumstances, little or no confidence can be placed
upon it as a guide in forming our diagnosis. In cases where it is an
object to conceal pregnancy, the appearance of the menstrual fluid upon
the clothes has been imitated in order to deceive. (Montgomery, _op. cit._
p. 50.) Although, therefore, the cessation of the menses, when taken in
connexion with other symptoms, will prove useful in assisting us to a
correct opinion, nevertheless, when taken by itself, it will scarcely ever
enable us to decide with certainty.

_Areola._ Among the earliest of those symptoms which must be considered as
diagnostic are the changes observed in the appearance of the breasts;
"they increase, become full; they are occasionally painful and grow hard:
the veins in them are rendered conspicuous from their blue colour; the
nipple becomes more bulky and appears inflated, its colour becomes darker,
the surrounding disc undergoes a similar change, increases in extent, and
is covered with little prominences like so many diminutive nipples."[36]
"The several circumstances (says Dr. Montgomery, p. 59,) here enumerated
at least ought in all cases to form distinct subjects of consideration,
when we propose to avail ourselves of this part as an indication of the
existence or absence of pregnancy. One other, also, equally constant and
deserving of particular notice, is a soft and moist state of the
integument, which appears raised and in a state of turgescence, giving one
the idea that if touched by the point of the finger it would be found
emphysematous. This state appears, however, to be caused by infiltration
of the subjacent cellular tissue, which together with its altered colour,
gives us the idea of a part in which a greater degree of vital action is
going forward than is in operation round it, and we not unfrequently find
that the little glandular follicles, or tubercles, as they are called by
Morgagni, are bedewed with a secretion sufficient to damp and colour the
woman's inner dress.

These changes do not take place immediately after conception, but occur in
different persons after uncertain intervals. We must therefore consider,
in the first place, the period of pregnancy at which we may expect to gain
any useful information from the condition of the areola. I cannot say
positively what may be the earliest period at which this change can be
observed, but I have recognised it fully at the end of the second month,
at which time the alteration in colour is by no means the circumstance
most observable; but the puffy turgescence, though as yet slight, not
alone of the nipple, but of the whole surrounding disc, and the
development of the little glandular follicles, are the objects to which we
should principally direct our attention, the colour at this period being
in general little more than a deeper shade of rose or flesh colour,
slightly tinged occasionally with a yellowish or light brownish hue.
During the progress of the next two months the changes in the areola are
in general perfected, or nearly so, and then it presents the following
characters: a circle around the nipple, whose colour varies in intensity
according to the particular complexion of the individual, being usually
much darker in persons with black hair, dark eyes, and sallow skin, than
in those of fair hair, light-coloured eyes, and delicate complexion.[37]
The extent of this circle varies in diameter from an inch to an inch and a
half, and increases in most persons as pregnancy advances, as does also
the depth of the colour."[38]

"In the centre of the coloured circle the nipple is observed partaking of
the altered colour of the part, and appearing turgid and prominent, while
the surface of the areola, especially that part of it which lies more
immediately around the base of the nipple, is studded over, and rendered
unequal by the prominence of the glandular follicles, which, varying in
number from twelve to twenty, project from the sixteenth to the eighth of
an inch; and lastly the integument covering the part appears turgescent,
softer, and more moist than that which surrounds it; while on both there
are to be observed at this period, especially in women of dark hair and
eyes, numerous round spots, or small mottled patches of a whitish colour,
scattered over the outer part of the areola, and for about an inch or more
all round, presenting an appearance as if the colour had been discharged
by a shower of drops falling on the part. I have not seen this appearance
earlier than the fifth month, but towards the end of pregnancy it is very
remarkable, and constitutes a strikingly distinctive character exclusively
resulting from pregnancy. The breasts themselves are at the same time
generally full and firm, at least more so than was natural to the person
previously, and venous trunks of considerable size are perceived ramifying
over their surface, and sending branches towards the disc of the areola,
which several of them traverse along with these vessels. The breasts not
unfrequently exhibit about the sixth month, and afterwards, a number of
shining, whitish, almost silvery lines like cracks; these are most
perceptible in women, who, having had before conception very little
mammary development, have the breasts much and quickly enlarged after
becoming pregnant."

In enumerating these various changes which are observed in the breasts, we
fully agree with Dr. Montgomery in saying, that the alteration in the
colour of the areola is by no means that upon which we can depend with
most certainty: in the first place, we frequently meet with so little
discolouration during the earlier months as to be altogether
inappreciable; we have also already shown that if the patient be a
brunette, and has already had children, the colour of the areola cannot be
trusted to, as it never entirely disappears after her first pregnancy. On
the other hand, we occasionally meet with a considerable change of colour
in the unimpregnated state, arising from uterine irritation, as in
dysmenorrhoea, &c. Where, however, this is accompanied by the other
changes above enumerated, there can be, we apprehend, no doubt as to the
existence of the pregnancy. Dr. Smellie, and also Dr. W. Hunter both
considered the areola as proof positive of pregnancy. The latter one
decided upon a case of pregnancy under very extraordinary circumstances;
the body of a young female was brought into the dissecting room, which at
the first glance he pronounced to be pregnant, but the accuracy of his
diagnosis was not a little doubted when it was ascertained that a perfect
hymen was present: to decide the point he had the abdomen opened when the
uterus was found to contain a small foetus.

_Movements of the foetus._ The sensation to the mother of the child moving
in the uterus, cannot be looked upon as a certain sign of pregnancy, for
even women who have had large families of children are frequently deceived
in this respect by the movement of flatus in the intestines, by occasional
spasmodic twitchings of the abdominal muscles, &c.; but when the motion of
the child can be distinctly felt by the hand of an experienced
practitioner, it will no longer admit of any doubt: this, however, is a
symptom which can seldom be made use of before the middle of the sixth or
seventh month.

_Quickening._ This leads us to the subject of quickening as a symptom of
pregnancy. The very vagueness of the term _quickening_ is of itself a
sufficient objection to its use as a source of information on these
points. Strictly speaking, it refers to that moment of pregnancy when the
woman is supposed to have become _quick with child_, or in other words,
when the foetus becomes endued with life, "an error," as Dr. Montgomery
observes, "which the continued use of the term was obviously calculated to
foster and to prolong" (p. 75.) As far as we can understand, the word
"quickening" at the present day refers to two different events during
pregnancy: the one is when the motion of the child first becomes
perceptible to the mother; the other consists of those effects which are
frequently observed when the uterus quits the pelvis, and rises into the
abdominal cavity, viz. fainting, sickness, &c.; in either case it will be
evident that no correct conclusion can be formed by this means. It may
safely be asserted that until the last twenty years we possessed only
three diagnostic marks of pregnancy, viz. the appearance of the areola, a
series of changes but little understood; the being able to feel the
movements of the child through the abdominal parietes, and the head of it
per vaginam. Hence Dr. W. Hunter in describing the uncertainty of the
signs of pregnancy says, "I find I cannot determine at four months, I am
afraid of myself at five months, but when six or seven months are over, I
urge an examination."

In the primipara, the changes which pregnancy produces upon the os and
cervix uteri are generally sufficient to lead to an accurate conclusion.
The round dimple-like depression which the os uteri forms, the soft
cushiony state of the cervix, are changes which we consider as peculiarly
the effects of pregnancy, but their distinctness and certainty ceases when
the patient has had several children; the irregular shape of the os uteri,
its thickened edges, hard here and there, and the os tincæ, itself more or
less open, the cervix scarcely, if at all, shortened, even at a late
period of gestation, tend not a little to perplex the diagnosis furnished
by this mode of examination; and where disease is complicated with
pregnancy, the difficulty is greatly increased, and not unfrequently so
much, that scarcely a single satisfactory point will be obtained.

_Auscultation._ Of late years, an immense advance has been made in the
diagnosis of pregnancy, by means of the stethoscope. M. Major of
Geneva,[39] in 1819, observed the interesting fact that he could hear the
pulsations of the foetal heart through the parietes of the mother's uterus
and abdomen: he appears, however, to have carried his researches no
farther; and little attention was excited to the circumstance until three
years afterwards, when a masterly essay on the subject was read before the
Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.[40] In
this interesting memoir, the author has described two sounds, which are
perfectly distinct from each other in point of character. One of them
consists of single pulsations, synchronous with those of the mother's
heart, accompanied with the deep whizzing rushing sound, which may be
heard over a large portion of the uterus at once; the other of sharp,
distinct, double pulsations, producing a ticking sound, and following a
rythm, which is not synchronous with that of the maternal circulation.
Kergaradec supposed that the former sound was produced by the circulation
of the blood in the spongy structure of the placenta, and hence called it
the _souffle placentaire_; later observations[41] have, however, shown
that it is not connected with the placenta, but depends upon the increased
vascularity and peculiar arrangement of the uterine vessels during the
gravid state. The other sound is produced by the pulsations of the foetal
heart.

_Uterine souffle._ The uterine sound, or _souffle_, may invariably be
heard in one or other of the inguinal regions, and usually over a
considerable portion of the uterus, extending anteriorly or along the
sides of the organ; and according to the observations of Professor Naegelé
jun.,[42] there is no part of the uterus, capable of being osculted, in
which this sound may not be heard. He considers that the souffle, which is
so uniformly heard in the lower parts of the uterus, especially in the
inguinal regions, seems to be produced by the uterine arteries before they
enter the uterus; these vessels, as soon as they arrive at the broad
ligament, assume a different character, become larger than they were on
branching off from their original trunk, and are much contorted before
entering the parietes of the uterus. Dubois first pointed out the
similarity which exists between the sound heard in the gravid uterus, and
that of aneurismal varix, where there is a direct passage of blood from an
artery into a vein: the sound in this latter condition is produced by the
current of blood rapidly issuing from the dilated artery, and mixing with
the slower flowing stream of the dilated vein. The circulation of blood in
the dilated arteries of the uterus present a considerable resemblance, in
many respects, to that of the above-mentioned disease.

That the uterine sound is not confined to that part of the uterus where
the placenta is attached, as was supposed by Professor Hohl,[43] is proved
by the fact that we can frequently hear it in two different and sometimes
opposite parts of the uterus at the same time, which, if his opinion be
correct, would indicate the presence of twins; and yet the result of
labour has proved that the uterus has contained but one child, and that
the placenta had neither been attached in the one or other of these
situations. The very circumstance which we have already mentioned, of this
sound being invariably heard in one, if not in both, of the inguinal
regions, shows that it is independent of the vicinity of the placenta;
nevertheless, it must be allowed, that as the uterine vessels undergo the
greatest degree of development at this part, the sound will usually be at
least as distinct here as in any other portion of the uterus.

The uterine souffle is the first sound which auscultation detects during
pregnancy; it may be heard as early as the fifteenth or sixteenth week,
but cases now and then occur where it has been even distinguished in the
thirteenth or fourteenth week, and Dr. Evory Kennedy, has given some very
interesting examples where he was able to hear it with certainty at the
twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy,
_op. cit._ p. 80.) During these earlier periods, the sound is weaker, but
extends over the whole uterus, from the diminutive size of which it can be
heard most readily immediately above the symphysis pubis; in fact, there
is every reason to suppose, that the uterine souffle might be detected at
a still earlier period, if the uterus were at this time within reach of
the stethoscope. As pregnancy advances, it becomes more distinct and
powerful, and is occasionally so to a remarkably degree. During the latter
periods of pregnancy, it frequently presents considerable modifications of
tone, especially where there is general or local vascular excitement, as
in cases of fever, or dispositions to hæmorrhage, where the vessels are
usually distended, or where (Naegelé, _op. cit._ p. 86,) the placenta is
situated near the os uteri, it assumes a piping, twanging sound of
considerable resonance: the same is also observed where, either from the
weight of the gravid uterus or any other cause, pressure has been exerted
on any of the main arterial trunks: hence, as we shall show more fully
when speaking of labour, a remarkable change is produced in the tone of
the uterine souffle by the first contractions of that process. The causes
of these modifications are not always very easily explained; we sometimes
observe the souffle on the same side of the uterus vary rapidly in its
degree of intensity, and occasionally even disappear for awhile without
our being able to assign any satisfactory reason for such changes.

The uterine souffle taken by itself, although a very valuable sign of
pregnancy, can scarcely be looked upon as one which is perfectly certain
and diagnostic, since a similar sound may be produced by aneurism of the
abdominal aorta and its large branches: there is much reason to think that
the uterus, enlarged from other causes than that of pregnancy, and
pressing upon the iliac arteries, will produce a similar sound. Professor
Naegelé, jun., has also shown that the sounds of the patient's heart may
sometimes be heard very low in the abdomen, even as far as the ossa ilii,
a circumstance which seems to have depended upon the sound being
transmitted through the intestines distended with flatus. Where any of
these causes of abdominal souffle have existed in connexion with
suppressed catamenia, swelling of the breasts, &c., we might be liable to
be deceived if we allowed ourselves to be entirely guided by this sound.

With regard to the foetal pulsations, we find them generally beating at
the rate of from 130 to 150 double strokes in a minute, and the age of the
foetus appears to have no effect upon their rapidity, for even at the
earliest periods at which we can detect these sounds the rate of the
pulsation is the same as at the full term of pregnancy.

Although Dr. Kennedy has in a few cases detected this sound even before
the expiration of the fourth month, it will not in the majority be
possible until a later period. "At the fourth month it frequently requires
not only close attention, but considerable perseverence to detect the
foetal heart; and at this period it has occurred to us to examine patients
whom there was strong reason to suppose pregnant, and after spending a
considerable time in endeavouring to detect this sound, we have been on
the point of giving up the search as hopeless, when it has been suddenly
discovered in the identical spot that had before perhaps been explored
without success." (Kennedy, _op. cit._ p. 101.)

The sound of the foetal heart is usually heard at about the middle point
between the scrobiculus cordis and symphysis pubis, usually to one side,
and that, generally speaking, the left. The extent of surface over which
the sound may be heard varies a good deal, and depends, in great measure,
on the distance which intervenes between the foetus and stethoscope;
hence, when the uterus is distended with a large quantity of liquor amnii,
or when the uterine and abdominal parietes are very thick, it is heard
over a much larger space, although with diminished intensity; on the other
hand, when there is but little liquor amnii in the uterus, it is audible
over a small portion only, but is remarkably distinct: this is peculiarly
the case during labour after rupture of the membranes. The rapidity and
strength of the foetal pulsations appear to be entirely independent of the
mother's circulation; violent exercise, spirituous liquors, &c., which
will raise her pulse to a considerable degree, have no influence whatever
on the foetal pulse. In cases of fever, where the mother's pulse has
ranged between 110° and 120°, and even higher, not the slightest change
was observable in the sound of the foetal heart; even in acute
inflammatory affections, in pneumonia, pleurisy, where there was severe
dyspnoea, and also in tubercular phthisis; in cases where the patient has
been bled; in cases of menstruation during pregnancy; and even in severe
flooding, and when the mother's pulse has been greatly reduced, no
perceptible change has been observed in that of the foetus. (Naegelé, _op.
cit._ p. 39.) Dr. Kennedy has observed some remarkable cases where the
foetal pulse appeared to vary in accordance with that of the mother (_op.
cit._ p. 91;) but when we bear in mind the frequent changes in point of
rapidity, &c., to which the foetal heart is subject, independent of any
thing of the kind in the mother's pulse, and that similar changes are
constantly observed in the child shortly after birth; and, moreover, that
very considerable acceleration of the maternal pulse has decidedly no
effect upon that of the foetus in many well-marked instances, we cannot
agree with him in supposing that a connexion of the sort to which he has
alluded exists. The double pulsations of the foetal heart can only be
heard at one point of the uterus at a time, provided there be but one
child; but if there be twins, then the sound is heard in two places at
once. It has been supposed by some authors (_Dubois_) that the heart of
the second child could not be distinctly heard until labour, when the
membranes of the first child had ruptured. Generally speaking, both sounds
can be heard pretty distinctly during the last weeks of pregnancy, one of
them being low down on one side, and the other high up in an opposite
direction. Although in some twin cases there is an evident difference of
rhythm between the two foetal hearts, still in many others they are so
nearly synchronous as to be scarcely if at all distinguishable in this
respect. Hence, therefore, from the known variable character of the foetal
pulse, it will be necessary that the sound of each heart should be
ausculted at the same moment, minute for minute, by two observers, and
thus the slightest appreciable difference between them determined.

_Funic souffle._ Dr. Kennedy has shown that, where a portion of the
umbilical cord passes between the child's body and the anterior wall of
the uterus, or crosses any of its limbs or other projections, pulsations
are heard synchronous with those of the foetal heart; although not
possessing the same characters. "In some cases where the uterus and
parietes of the abdomen were extremely thin, I have been able," says Dr.
K., "to distinguish the funis by the touch externally, and felt it rolling
distinctly under my finger, and then, on applying the stethoscope, its
pulsations have been discoverable remarkably strong; and, on making
pressure with the finger for a moment on that part of the funis which
passed towards the umbilicus of the child, I have been able to render the
pulsations less and less distinct, and even, on making the pressure
sufficiently strong, to stop it altogether." (_Op. cit._ p. 121.) In many
cases where the umbilical arteries, by their convolutions round a limb, or
by any other cause, are subjected to slight pressure, a distinct whizzing
sound is produced, which is called by Dr. Kennedy the _funic souffle_.

The sound of the foetal heart must be looked upon as a sign of the highest
value in the diagnosis of pregnancy, since, however complicated and
obscure the other symptoms may be, whether from co-existing disease,
wilful deception, &c. if this sound be once heard unequivocally, the real
nature of the case is satisfactorily established beyond all possibility of
doubt.

Another sound in the gravid uterus has been lately noticed by Professor
Naegelé, junior, which promises to equal that of the foetal heart, as a
certain diagnostic of pregnancy, and must be looked upon as a valuable
addition to our means of ascertaining the truth in cases of this sort. The
movements of the foetus may be distinguished by the stethoscope at a very
early period of pregnancy, long before they are perceptible to the hand of
the accoucheur, and in many cases before the patient has been aware of
them herself. According to Professor Naegelé's observations, these sounds
may usually be heard some little time before the foetal heart is audible,
and are sounds which can neither be feigned nor concealed: they can only
be heard in the gravid uterus, and under no other circumstances.

Although the sounds of the heart and movements of the foetus are
unequivocal proofs of pregnancy, which may be heard at a very early
period, still it must, in some degree, remain uncertain at this time, how
far their absence can be looked upon as a proof of its non-existence.
Under such circumstances, the examinations require to be conducted with
the greatest possible care, and to be repeated at favourable
opportunities, until no doubt as to the correctness of their results can
any longer exist.

The soft cushiony feel of the cervix uteri is a change produced by
pregnancy, which, in our opinion, has not received that attention which it
deserves; as far as we are able to judge, this condition of the cervix is
peculiar to pregnancy, and exists very shortly after conception. We
occasionally meet with a soft flaccid state of the os and cervix uteri in
certain diseases; but the feel which this communicates to the finger is
very different to that above-mentioned, which resembles more the elastic
inflated condition of the nipple during pregnancy, than any thing to which
we can compare it.

_Ballottement._ At the beginning of the seventh month we shall be able to
feel the head of the foetus upon examination per vaginam. If we direct our
finger against the uterus, midway between the os uteri and symphysis
pubis, and suddenly exert a slight degree of pressure, we shall become
sensible of having struck against something hard within the cavity of the
uterus; upon repeating the experiment immediately, we shall probably not
feel it, the foetus having risen in the liquor amnii to the upper parts of
the uterus; but if hold our finger still for a few moments, it will, by
this time, have again descended, and we shall again feel it; at other
times, when the foetus is larger and heavier, the head will rest like a
light ball, on the tip of the finger, from which circumstance it has
received the name of _ballottement_ by the French authors.

_Motion of the child._ The sensation of the child's movements to the
mother is a symptom of very little value, and is liable to mislead the
practitioner if he place much reliance upon it; for the passage of the
flatus along the bowels, or little spasmodic flickerings of the abdominal
muscles, will produce a very similar sensation, and will even completely
deceive a patient who has been the mother of several children; but when
they become perceptible to the experienced hand of the practitioner, this
may also be looked upon as a certain indication that pregnancy exists. The
foetal movements can seldom be felt distinctly until the beginning of the
seventh month, and even then it requires some caution before we can
venture upon a positive opinion. Their activity varies considerably in
different cases; in some their nature is almost immediately evident;
whereas, in others they are so few and feeble, as to make it very
difficult to decide. It has been recommended to put the head in cold water
previous to applying it upon the abdomen, as, by this means, a
considerable shock is produced which excites these movements more
distinctly. We cannot say that we have found this proceeding of any use,
since, by this means, the abdominal muscles are rendered so irritable as
frequently to obstruct the examination considerably: it is rather
desirable to have them in as perfect a state of repose as possible, in
order that no movement of the foetus, however slight, should escape our
notice. It is in cases of abdominal enlargement from disease; that this
means of diagnosis is occasionally very difficult, and where men, even of
great experience, have been led to form a very erroneous opinion. The
celebrated Peter Franck has related a case of this sort which occurred to
himself, where the patient was supposed pregnant, and where he imagined
that he had felt the motions of the child: she died shortly afterwards,
and the examination of the body showed it to have been a case of ascites
complicated with hydatids. Dr. Dewees has given a still more remarkable
case of a similar error having occurred to himself. A young lady had her
menses suppressed for several months; the abdomen swelled very much, the
breasts became enlarged, she had nausea and vomiting in the morning, and
other indications of pregnancy; "examining the abdomen carefully, I found
it," says Dr. Dewees, "considerably distended; there was a circumscribed
tumour within it, which I was very certain was an enlarged uterus. While
conducting this examination I thought I distinctly perceived the motions
of a foetus. The case proved to be one of accumulation of menstrual fluid
in the uterus." (Dewees's _Essays on several Subjects connected with
Midwifery_, p. 337-8.)

In reviewing what has now been stated respecting the diagnosis of
pregnancy, it will be observed that we have enumerated four symptoms,
which must be looked upon as perfectly diagnostic of this condition, and
in the accuracy and certainty of which we may place the fullest
confidence: two may be recognised at an early period by means of
auscultation, viz. the sounds produced by the movements of the foetus and
by the pulsations of its heart; the two others are not appreciable until
a later period, and are afforded by manual examination, viz. the being
able to feel the head of the foetus per vaginam, and its movements through
the abdominal parietes. The next in point of value after these are the
changes in the os and cervix uteri, those connected with the formation of
the areola in the breasts, and, at a somewhat later period, the sound of
the uterine circulation, changes, which, although they cannot separately
be entirely depended upon, are nevertheless symptoms of very great
importance in the diagnosis of pregnancy.

Two other signs of pregnancy have also been mentioned, viz. the appearance
of a peculiar deposite in the urine as described by M. Nauche, or rather
by Savonarola (Montgomery, _op. cit._ p. 157.,) and the purple or violet
appearance of the mucous membrane lining the vagina and os externum, as
described by Professor Kluge of the Charité at Berlin, and by M. M.
Jacquemin, Parent Duchatelet, &c. of Paris. With regard to the first,
which is an old popular symptom of pregnancy, there is too much variety in
the appearances of the urine, depending on general health, diet,
temperature, &c., to enable us to place much confidence in any change of
this sort. "I have myself tried it," says Dr. Montgomery, "in several
instances, and the result of my trials has been this:--In some instances
no opinion could be formed as to whether the peculiar deposite existed or
not, on account of the deep colour and turbid condition of the urine; but
in the cases in which the fluid was clear, and pregnancy existing, the
peculiar deposite was observed in every instance. Its appearance would be
best described by saying that it looks as if a little milk had been thrown
into the urine, and having sunk through it had partly reached the bottom,
while a part remained suspended and floating through the lower part of the
fluid in the form of a whitish semi-transparent filmy cloud." (_Op cit._
p. 157.)[44]

The purple colour of the vaginal entrance appears, from the extensive
experience of the above-mentioned authors, to be a pretty constant change
produced by the state of pregnancy; it probably occurs at a very early
period. How far a similar tinge is produced by the state of uterine
congestion immediately before a menstrual period, we are unable to say; at
any rate, the character of the examination itself must ever be sufficient
to preclude its being practised in this country.

The diagnosis of pregnancy is a subject well worthy of the student's most
serious attention; for he will of course be liable, when in practice, to
be called upon to give his evidence before a court of justice under
circumstances when the responsibility must ever be of the most serious and
not unfrequently of the most fearful nature, the more so as the old custom
of impanelling a jury of "twelve discreet matrons" to determine whether
the woman be _quick with child_ has fallen deservedly into disrepute. He
should lose no opportunity of making himself familiar with the various
symptoms of pregnancy above enumerated, and of so practising the different
senses of hearing, touch, and sight, as instantly and certainly to detect
their presence.

Numerous cases are on record, where a false diagnosis in women convicted
of capital offences, has led to most lamentable results, and where
dissection of the body after death has shown that she was pregnant. Dr.
Evory Kennedy has recorded an interesting case of this sort which occurred
at Norwich in 1833, when a pregnant woman was on the point of being
executed through the ignorance of a female jury. (E. Kennedy's
_Observations on Obstetric Auscultation_, &c., p. 197.) We may also
mention a dreadful case of this nature which occurred to the celebrated
Baudelocque at Paris, during the horrors of the French revolution.[45] A
young French countess was imprisoned during the revolution, being
suspected of carrying on a treasonable correspondence with her husband, an
emigrant. She was condemned, but declared herself pregnant; two of the
best midwives in Paris were ordered to examine her, and they declared that
she was not pregnant. She was accordingly guillotined, and her body taken
to the school of anatomy, where it was opened by Baudelocque, who found
twins in the fifth month of pregnancy.

Equally important is it (and perhaps in some respects even more so) to
determine the absence of pregnancy in cases where it has been supposed to
exist. In many instances the character and happiness of the individual
must depend upon the judgment which the practitioner pronounces; and,
painful as will be the task of communicating an opinion which implies
guilt and loss of honour, how infinitely revolting and inexcusable must
that step be considered, which turns out to have been founded upon an
incorrect diagnosis. Hence the importance of separating those symptoms of
pregnancy which may be considered certain, and therefore trustworthy, from
the crowd of others, which, although collectively they may warrant a
suspicion, yet never can justify a decision that pregnancy exists, more
especially in cases where so much is at stake. No two symptoms have led
more frequently to this cruel error, and therefore to the most unjust
suspicions, than the cessation of the menses with swelling of the abdomen,
and yet from how many different causes may they arise besides that of
pregnancy? Putting even the impulse of common feeling aside, we would ask
how a practitioner can dare recklessly to incur the responsibility of
injuring a woman's character by hazarding an opinion which involves so
much, and is based upon symptoms which, by themselves, prove so little?
Whether he exercise his profession in town or country, cases of doubtful
pregnancy will constantly come under his notice. We cannot, therefore, too
strongly urge the importance of ascertaining how many of the certain
symptoms are present, before we allow ourselves to be influenced by those
which are uncertain. In speaking of the enlargement of the abdomen as a
sign of pregnancy which is extremely equivocal, Dr. Dewees well observes,
"But little reliance can be placed upon this circumstance alone, or even
when combined with several others; for I have had the pleasure in several
instances of doing away an injurious and cruel suspicion, to which this
enlargement had given rise. Within a short time, I relieved an anxious and
tender mother from an almost heart-breaking apprehension for the condition
of an only and beautiful daughter on whom suspicion had fallen, though not
quite fifteen years of age: this case, it must be confessed, combined
several circumstances which rendered it one of great doubt, and, without
having had recourse to the most careful and minute examination, might
readily have embarrassed a young practitioner. This lady's case was
submitted to a medical gentleman, who, from its history and the feel of
the abdomen, pronounced it to be a case of pregnancy, and advised the
sorrow-stricken mother to send her daughter immediately to the country as
the best mode of concealing her shame. Not willing to yield to the opinion
of her physician (a young man,) and moved by the positive denials of her
agonized child, the mother consulted me in this case. The menses had
ceased, the abdomen had gradually swelled, the stomach was much affected,
especially in the morning, and the breasts were a little enlarged. On
examination it proved to be a case of enlarged spleen." (Dewees, _on the
Diseases of Females_, p. 178.)

We occasionally, also, meet with cases of self-deception, as to the
existence of pregnancy, to an extent which would scarcely seem credible.
Women who have been the mothers of several children, will, upon some very
slight foundation, suppose themselves with child. Knowing from previous
experience many of the symptoms of this state, they will frequently
enumerate them most accurately to the practitioner, who, if he rest
satisfied with general appearances, may easily be led into a wrong
diagnosis. A case of this kind we published in our midwifery reports,
where the patient, the mother of two children, came into the General
Lying-in Hospital, not only under the supposition that she was pregnant,
but that labour had actually commenced; the catamenia had ceased about
nine months previously, and the abdomen was considerably enlarged.
Examination proved that she was not pregnant. (_Med. Gaz._ June, 1834.)

In a work solely devoted to cases of doubtful pregnancy by the late W. J.
Schmitt, of Vienna, these cases have been very fully discussed. "We
occasionally observe certain conditions of the female system, which put on
a most striking resemblance to pregnancy, both functionally as well as
organically, without at all depending on the actual presence of pregnancy.
The abdomen begins to swell from the pubic region exactly in the same
gradual manner as in pregnancy; the breasts become painful, swell, and
secrete a lymphatic fluid, frequently resembling milk; the digestive
organs become disordered; there is irregular appetite, nausea, and
inclination to vomit; constipation, muscular debility, change in the
colour of the skin, and frequently of the whole condition of the body; the
nervous system suffers, and even the mind itself frequently sympathizes;
the patient is sensible of movements in the abdomen like those of a living
foetus, then bearing down pains running from the loins to the pubes; at
last actual labour-pains come on as with a woman in labour, and if by
chance her former labours have been attended by any peculiar symptoms,
these, as it were, to complete the illusion, appear likewise." (W. J.
Schmitt, _Zweifelhafte Schwangerschafts-fälle_.) A most extraordinary case
of the self-deception with regard to pregnancy, has been published by the
celebrated Klein of Stuttgardt: it has been quoted in the work of W. J.
Schmitt above alluded to, and a brief sketch of it has been given by Dr.
Montgomery in his _Expositions of the Signs and Symptoms of Pregnancy_, p.
172, to which we must refer the reader for much valuable information on
this and all other subjects connected with the diagnosis of pregnancy.

_Diagnosis of twin pregnancy._ Before concluding this chapter, we shall
offer a few observations on the diagnosis of twins. A variety of symptoms
have been enumerated as indicating the presence of two foetuses in utero,
such as the great size of the abdomen, its flat square shape, the
movements of a child at different parts of it, &c. The size of the abdomen
can never be admitted as a diagnostic mark of twin pregnancy; first,
because it equally indicates the presence of an unusual quantity of liquor
amnii, or of a very large child; and secondly, because women pregnant with
twins are not always remarkable for their size: the flatness, &c., of the
abdomen is, we presume, a symptom based on the supposition that there is a
foetus in each side of the uterus: this is very far from being correct, as
it is well known that the children usually lie obliquely, the one being,
perhaps, downwards and backwards, while the other is situated upwards and
forwards. The sensation of the child's movements in different or opposite
parts of the uterus is no proof whatever that there are twins, because it
is constantly observed where there is but one child--a circumstance which
is very easy of explanation.

The stethoscope affords us the only certain diagnosis of twin pregnancy;
and even here it is limited to the sounds of the foetal hearts; the
increased extent and power of the uterine souffle, as remarked by Hohl,
arising, as he supposed, from the large mass of the double placenta, is
not a proof which can be depended upon. In cases of suspected twin
pregnancy the auscultation must be conducted with the greatest possible
care, and, generally speaking, a certain diagnosis can only be obtained by
two observers ausculting the two hearts at one and the same moment; for,
otherwise, the difference between their rhythm is frequently so small as
to be inappreciable. The sounds are seldom or never heard at the same
level, one being generally heard high up on one side, the other in a
contrary direction.



CHAPTER II.

TREATMENT OF PREGNANCY.

    _Sympathetic affections of the stomach during pregnancy.--Morning
    sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.--
    Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--Pruritus
    pudendi.--Salivation._


In the preceding chapter we have enumerated those changes and phenomena
which are observed to take place in the system during pregnancy: many of
these amount to actual derangements of function, and will, therefore, as
such, demand our attention in a practical point of view, for the purpose
of alleviating or removing them. Many of these changes are produced by the
altered distribution of blood, as well as by the actual increase of
quantity which now exists in the circulation; the nervous and also the
vascular system of the uterus are now in a state of high excitement and
activity--a condition which must necessarily communicate itself to those
organs which are supplied by the same nerves; viz. the sympathetic, and by
the same portion of the circulation, viz. the branches of the abdominal
aorta.

No organ, except the stomach, possesses sympathetic connexions so widely
extended over the rest of the system as the uterus; and, we may add, that
no two organs are so intimately and reciprocally united as the uterus and
the stomach. In the unimpregnated state, we see this manifested in a
remarkable degree; if the stomach becomes deranged the uterus sympathizes;
thus the states of gastric disturbance, known under the general term of
dyspepsia, are frequently followed by leucorrhoea, or some derangement of
the menstrual function: on the other hand, uterine disease is invariably
accompanied by symptoms of gastric disturbance, and, in many cases, to
such an extent as to conceal the real seat of the evil, and mislead the
attention of the patient and her medical attendant. In like manner we find
that during pregnancy, especially in the early stages of it, the patient
is annoyed with a great variety of symptoms more or less indicative of
derangement in the functions of the primæ viæ.

_Morning sickness._ One of the most troublesome, and by no means the least
frequent, is vomiting, which, from coming on usually in the morning, is
commonly called morning sickness; in some cases the female merely rejects
what food or mucus may be present in the stomach, after which she feels
relieved; in others she continues to strain violently and ineffectually
for some time. In the former case it resembles the common vomiting from a
deranged stomach, and cannot be considered as the direct result of
sympathy with the uterus: the tone of the stomach has become impaired, and
vomiting has followed as a consequence of its being loaded with undigested
food and depraved secretions. Hence, in these cases, it is generally
preceded by nausea and the other common precursory symptoms of this act:
in the latter, however, it appears to be the immediate result of
irritation transmitted from the uterus, and assumes rather a spasmodic
character; the patient is suddenly seized with involuntary efforts to
vomit, which are not preceded by nausea or oppression, and come on
independently of the stomach being full or empty.

Morning sickness usually appears during the first few weeks after
conception, and continues until the third or fourth month; in some cases
it continues throughout pregnancy; in a few it does not begin till much
later, and in many it does not appear at all. It scarcely deserves to be
called a disease of pregnancy, for it frequently appears as a salutary
effort of nature to relieve a cause of much gastric irritation, and,
unless it proceeds to a very exhausting degree, must rather be looked upon
as a favourable symptom, as it tends to prevent the formation of too much
blood, which is so frequent a cause of abortion during the early months.
(Hamilton, _on Female Complaints_.) Hence, therefore, experience verifies
the correctness of the old proverb, that a "sick pregnancy is a safe one."

The ejected matter on these occasions, when there is but little or no food
upon the stomach, consists of a glairy ropy mucus, sometimes mixed with a
considerable quantity of intensely sour fluid, containing a large
proportion of muriatic and acetic acid: in some cases more or less bile is
vomited.

The treatment of morning sickness will depend in great measure on the
severity of the attack: where it is slight, the patient may assist its
operation with a little warm water, or chamomile tea: after which the
bowels should be briskly opened by a saline laxative, as for instance, a
seidlitz powder, sulphate and carbonate of magnesia, &c.: small doses do
more harm than good, as, from their slow and ineffective action, they
rather tend to increase the irritation and aggravate the symptoms. In
severe cases, especially where the pulse is excited, a small bleeding may
be used with much advantage, but in most instances the usual treatment of
gastric derangement, as it occurs in the unimpregnated state, produces
most relief. The bowels should be first opened in the way already
mentioned, after which a combination of Pil. Hydrarg. and Extr. Hyosc. or
Extr. Humuli, is to be given at night, and a vegetable tonic during the
day.

Acids, more especially the mineral, have been very judiciously recommended
by Dr. Dewees, and, when combined with any bitter infusion, will be found
of great service. Where the constant secretion of acid is very
distressing, the nitric acid will be found particularly useful; it allays
the irritability of the stomach, and produces a healthy state of its
secretion. Opiates are by no means desirable remedies, and rather tend to
aggravate the disease by still farther injuring the tone of the stomach
and producing constipation. We have known them given in considerable doses
and in very powerful forms, but without relief. Hydrocyanic acid,
creosote, &c., have also been tried, but with no permanent success; in
such cases Dr. Burns has found the application of leeches useful,
"especially if accompanied with pain or tension in the epigastric region."
On the same principle, we presume, have we found a sinapism of great
service. Where the vomiting, in spite of all the above modes of treatment,
still goes on unabated, there is nothing which, in our experience, is so
useful as covering the epigastrium with a hot flannel, upon which a
mixture of camphorated spirits of wine and laudanum has been sprinkled.
"We have," says Dr. Dewees, "in several instances, confined patients for
days together, upon lemon juice and water with the most decided advantage.
We have repeatedly found much benefit from the use of the spirit of
turpentine three or four times a day, in doses of twenty drops: this
medicine is very easily taken, if it be mixed in cold sweetened water.
When the system is not excited to febrile action, and where the stomach
rejects every thing almost as soon as swallowed, we have often known a
table-spoonful of clove-tea act most promptly and successfully."
(_Compendious System of Midwifery._)

_Heartburn_ is another form of gastric derangement which frequently occurs
to a very distressing degree, and must be looked upon as a modification of
morning sickness; in many cases it arises from the presence of acid in the
stomach, but in others it is merely a sympathetic result of gastric
irritation, without any proof of acidity being present. The treatment of
heartburn is much the same as that just described for morning sickness,
the main object being to restore the stomach and bowels to a healthy
condition. Besides the mineral acids, small quantities of iced water will
be found very grateful, relieving the sense of burning in the back of the
pharynx, and diminishing, in great measure, that gastric irritability of
which it is a symptom.

The frequent, and sometimes almost unlimited, use of antacid absorbents,
viz. magnesia or chalk, in this disease, is a practice much to be
deprecated: compounds are thus formed in the stomach which are positively
injurious, and, beyond the temporary relief procured by removing the acid,
they tend to aggravate these symptoms, by increasing the state of gastric
derangement. The only chemical antacid which should be given in these
cases is the carbonate of soda; by this means a compound is formed (the
common muriate of soda,) which of all others is most grateful to the
stomach, and which, from its gently laxative effects, is well adapted to
keep up a healthy action of the bowels. It is scarcely credible to what
extent the use of antacids may be carried to relieve the cardialgia of
pregnancy. Dr. Dewees mentions having attended a lady with several
children, "who was in the constant habit of eating chalk during the whole
term of pregnancy; she used it in such excessive quantities as almost
rendered the bowels useless. We have known her many times not to have an
evacuation for ten or twelve days together, and then only procured by
enemata, and the stools were literally nothing but chalk. Her calculation,
we well remember, was three half pecks for each pregnancy. She became as
white nearly as the substance itself, and it eventually destroyed her, by
deranging her stomach so much that it would retain nothing whatever upon
it." (_System of Midwifery_, § 275.)

The _constipation, flatulence, colicky pains, and headach, the spasmodic
cough, palpitation, toothach_, &c. are symptoms arising from the same
cause, a knowledge of which circumstance will influence our treatment of
them more or less. Still, however, the indications are the same, viz. to
restore and keep up a healthy action of the stomach and bowels. Thus, we
frequently find that a severe headach, obstinate cough, or attacks of
palpitation, are relieved by aperient medicines; that toothach may be
relieved, or even removed, by occasional doses of carbonate of soda, or by
blue pill and aperient tonics. Indeed, it is a question in many cases,
whether it is proper to extract a carious tooth under these circumstances,
for the shock which it produces is sometimes so great as to run the risk
of exciting abortion; and in many instances we might extract every tooth
on the painful side, and yet not relieve the suffering which arises from
nervous pain induced by gastric irritation, and, if carefully examined,
the pain will be found to be not confined to a single tooth but to spread
over the whole side of the face, darting from the edge of the ear, and
extending even to the forehead. The breath is usually sour, and the acid
state of the saliva is indicated by the instantaneous reddening of litmus
paper laid upon the tongue; in many cases there is at the same time a
considerable deposit of lithic acid observed in the urine.

Spasmodic cough, or palpitation, if allowed to continue, may ultimately
bring on abortion. The treatment just detailed is equally applicable here,
and if the circulation be at all excited blood-letting will prove useful.
In bleeding women at this early stage of pregnancy it is not desirable, or
even safe, to draw a large quantity suddenly from the system, as it may
greatly endanger the life of the foetus, and from the state of the
nervous irritability, may even run the risk of bringing on convulsions;
syncope is always more or less hazardous to a pregnant woman, and should
if possible be avoided. Some caution will be also necessary in our choice
of aperient medicines; drastic purgatives, as aloes, colocynth, scammony,
&c. are not suited to the state of pregnancy, as they irritate the lower
bowels, and thus excite a disposition to uterine contraction; mild, but
effectual laxatives, such as castor oil, confectio sennæ, a seidlitz
powder, are better adapted; the latter, especially will be found useful,
as, from its being taken during effervescence, it is better calculated to
quiet the stomach.

_Diarrhoea_ is sometimes an exceedingly troublesome symptom during
pregnancy. It not only weakens the patient and thus tends indirectly to
induce abortion by destroying the life of the foetus, but it acts also in
a more direct manner by exciting uterine contractions, particularly when
accompanied, as is frequently the case, with tenesmus. The diarrhoea which
is met with in pregnant women is not so frequently, as has been supposed,
the result of irritation from the uterus, producing simply an increased
peristaltic action of the bowels without any considerable derangement of
their functions; by far the most usual form is connected with a very
deranged state of the alimentary canal; the evacuations are offensive and
generally very acrid; the liver is torbid or secretes an unhealthy bile,
so that at length a state approaching to dysentery is produced. Even if
the patient go to the full term of utero-gestation, she is much reduced,
and is ill able to make those exertions which will be required during
labour. If the motions, though frequent, are scanty in proportion to the
ingesta, or if scybala are occasionally expelled, one or two doses of
castor oil will be required; a few drops of Liq. Opii Sedativ. may be
added with advantage to allay the irritability of the bowels, after which,
equal parts of blue pill, or Hydr. c. Cretâ, and Dover's powder, will
excite the liver to a healthier action, and still farther control their
inordinate activity. If the disposition to tenesmus be troublesome, a
small injection of starch and opium will afford relief. If the stomach
will bear it, a rice-milk diet for a day or two is desirable; it is a
gentle demulcent to the irritable intestines, and has a slightly
constipating effect.

_Pruritus pudendi_ to a very distressing degree occasionally comes on
during pregnancy, and though in most instances a very manageable form of
disease, yet if its nature be not properly understood it proves
exceedingly obstinate, and much suffering is the result. It appears to be
essentially different from the common prurigo, being an aphthous state of
the lining membrane of the vagina and skin which covers the perineum and
external organs. There is great heat and redness of the parts, which are
more or less swollen, and from the scratching which the intense itching
demands, the cuticle, where it has been raised by the pustules, becomes
abraided, so that severe excoriations, and, where there has not been
sufficient attention to cleanliness, even ulcerations may be produced. The
pustules on the external parts frequently attain a considerable size,
being more distinct than in the vagina, which is usually incrusted with
one confluent mass of aphthæ; whereas, on the perineum and margins of the
labia we have seen them as large as peas. These cases for the most part
yield to the tepid Goulard lotion, or solution of borax.

Where the patient is plethoric, and the system in a state of considerable
excitement from the irritation, blood-letting will be necessary, followed
by cooling saline laxatives; and if there be much inflammation of the
parts, leeches will prove of great service. In every case the bowels ought
to be attended to, for constipation will greatly increase the
inflammation, and the obstinacy of the disease. It is to Dr. Dewees that
we are indebted for first pointing out the real cause and nature of this
troublesome affection.[46]

Aphthæ of the vagina are not unfrequently met with in cases of uterine
disease, where the discharge is extremely acrid, but the prominent
symptom, viz. the intense pruritus, is absent. The aphthous vagina of
pregnancy is not a common affection.

_Salivation_ is another affection which is occasionally, though rarely,
met with in pregnancy. It is usually attended with morning sickness,
constant nausea, and deranged bowels, and may reduce the patient
excessively: attention to the state of the bowels, followed by gentle
alteratives and tonics, generally gives relief.



CHAPTER III.

SIGNS OF THE DEATH OF THE FOETUS.

    _Difficulty of the subject.--Signs before labour.--Motion of the
    Foetus.--Sound of the foetal heart.--Uterus souffle.--Signs during
    labour where the head presents--where the face, the nates, the arm, or
    the cord, present.--Fetid liquor amnii.--Discharge of meconium._


Well has the celebrated Mauriceau observed, "S'il y a occasion où le
chirurgien doive faire plus grande reflexion, et apporter plus de
précaution aux choses qui concernent son art, c'est en celle où il s'agit
de juger si l'enfant qui est dans la matrice est vivant, ou bien s'il est
mort." There are few circumstances more painful to the feelings of an
accoucheur, than the uncertainty as to whether the child be alive or dead,
in a labour where the passage of the head is rendered unusually difficult
or dangerous for the mother, even with the aid of the forceps; whether the
difficulty be produced by want of proportion between the head and pelvis,
unusual rigidity of the os uteri, &c. Could he assure himself that it was
alive, he would feel justified in either trusting still longer to the
efforts of nature, or in applying the forceps, even although he knows that
the delivery cannot be effected without considerable difficulty and
suffering: whereas, if he could once feel satisfied that the child had
ceased to exist, he would have recourse to perforation, for the purpose of
diminishing the size of the head, and thus releasing the mother from the
dangers of her situation.

The increasing success which has attended the Cæsarean operation of late
years, adds still more to the importance of having the signs of the
child's life or death in utero carefully investigated and understood; for,
under such circumstances, it becomes a most serious question whether we
are always justified in destroying the life of the foetus by perforation,
when we might in all probability have saved it by resorting to another
means of delivery, which, formidable as it is, is now infinitely less so
than it was in former times. It becomes a question whether we ought not,
in certain cases to adopt the same indications for performing the Cæsarian
operation, as are used upon the Continent, and apply it not only to those
cases where the child cannot be delivered _par vias naturales_, but also
in those cases of minor pelvic obstruction, where, if we could feel sure
of the child's death, we should have recourse to perforation. Under
circumstances of this nature, the question becomes one of fearful
responsibility, the painfulness of which is not a little increased by the
uncertainty as to whether the child be alive or not. Mauriceau was the
first author who devoted a chapter expressly to the consideration of this
subject, and those few who have done the same since his time, have
borrowed largely from his observations.

A great number of symptoms have been enumerated as indicating the child's
death in utero, but for the most part they are deserving of very little
confidence, frequently occurring where the result of labour has shown the
child to be alive and strong, or _vice versâ_. The most practical
arrangement of these symptoms will, we think, be under the two following
heads: those which occur _before_ labour, and those which occur _during_
labour.

The symptoms of the child's death, which are usually enumerated as
occurring _before_ labour, are, cessation of the child's movements; the
abdomen undergoes no farther increase of size, but rather diminishes; the
uterus has no longer the tense elastic feel of pregnancy, but becomes
flaccid and moveable; the patient has a sensation of coldness and weight
in the abdomen, so that when she turns from one side to the other, she
feels as if a heavy weight rolled over to that part of the abdomen which
is lowest; the breasts are flabby, and sometimes there is a fetid slimy
discharge from the vagina. These changes are accompanied by some or all of
the following symptoms: the patient is seized with a sudden shivering,
languor, and debility; she loses her appetite and spirits; the stomach and
bowels become disordered; the breath is fetid, and the face pale, sallow,
and of a dark leaden colour under the eyes. All these symptoms taken
collectively will enable us to decide, with a tolerable degree of
certainty, that the child is dead: but scarcely any of them alone can be
trusted to. The most trust-worthy is the sensation of a heavy weight
rolling about the abdomen: when the female turns in bed, rises from her
chair, or in any way alters her position, this weight is felt as it were
tumbling down to that side which is lowest. A woman who is pregnant with a
living child, feels nothing of the sort; she may even dance or jump, and
yet she feels no more of a living foetus than she does of her own liver or
spleen. The living foetus obeys the laws of organic life; the dead foetus
those of gravity. When once the child has ceased to exist, it acts like
any other mass of inanimate matter, and pushes the uterus down to that
side which is lowest.

In most instances this symptom will be sufficient to make us suspect that
the child is dead, but it now and then occurs where the result of labour
proves the child to be alive; this must rather be looked upon as an
exception to the rule, for it is not of frequent occurrence. We have
observed it in two or three cases: it has been also noticed by Dr. E.
Kennedy, (_op. cit._;) and, therefore, cannot invariably be looked upon as
a certain sign of the child's death. We have observed it frequently in
cases threatening abortion at an early period: in many it has been
followed by premature expulsion, but in others the symptom has gradually
disappeared as the health improves, and the patient has eventually been
delivered of a living child at the full period.

In these cases, we should rather attribute the source of this symptom to a
loss of the firmness and tone peculiar to the uterine parietes during
pregnancy, and which depends upon the increased activity of the
circulation in them at this period: when this is considerably diminished,
the uterine parietes will necessarily become more flaccid, and, therefore,
less able to withstand the influence of gravity, or sustain the uterus in
its proper situation. The embryo itself during the first two or three
months is too small and too light to produce this symptom itself.

The sensation (to the mother) of the child's movements is as fallacious an
indication of the child's life as it is of pregnancy; nor can the absence
of this sensation be looked upon as a proof of its death. Women are very
liable to be misled in this respect; so much so, that it will be much
safer for the practitioner never to allow his diagnosis to be at all
influenced by their statements; the more so, as it applies equally to
mothers of large families as to primiparæ. Thus cases every now and then
occur where the patient declares her conviction that the child is dead;
that she has not felt it move for several days before labour; that she
feels altogether differently to what she did in any of her former
pregnancies, and yet she is delivered of a healthy living child. On the
other hand, we as frequently meet with cases where, up to the very
commencement of labour, the patient asserts that she has distinctly felt
the motion of the child, and yet she brings forth a child in such a state
of decomposition as proves beyond all doubt that it must have been dead
some eight, ten, or more days.

As the sound of the foetal heart is the surest sign of pregnancy, so it is
an equally certain proof of the child's life: but is the absence of this
sound, a certain symptom of its death? at the best it is a negative
evidence, and the value of it must entirely depend upon the skill of the
ausculator and the care with which he makes his examination. If, after
repeated and careful auscultation of the abdomen, the well-practised ear
can no where detect a trace of the foetal pulsations, it may be asserted
on very safe grounds that the foetus has ceased to live. This is more
particularly the case during the last weeks of pregnancy, when the
pulsations are stronger, and the bulk of the child, in proportion to that
of the liquor amnii being absolutely, as well as relatively, greater. The
distance between the heart and surface of the abdomen is less during the
last weeks of pregnancy also; the child's movements are not so free as at
an earlier period; and hence, if the foetal heart is beating, it will be
more easily discovered.

The uterine souffle affords us little aid in the diagnosis of the child's
death: it is frequently very distinct when the child is evidently alive;
and where it has been heard previous to its death, it will continue for
some hours afterwards, although with diminished strength and over a
smaller space.

During labour there are a variety of symptoms, by the aid of which we can
pronounce, with a very tolerable degree of certainty, whether the child is
alive or not; if alive, the foetal heart can invariably be detected; and,
for the reasons above stated, will be heard more distinctly than in the
earlier months of pregnancy. If, from the violence or duration of the
labour, or any other cause, the child is becoming exhausted, the
pulsations become weaker and slower until they stop; so that by the aid of
auscultation we possess distinct evidence of the child's life being
endangered, and of its complete extinction.

If the _head_ presents during labour, a firm elastic swelling (caput
succedaneum) will rise on that portion of it which first enters the
vagina: this is produced by the circulation in the presenting part of the
scalp being obstructed by the pressure which the os uteri and vagina exert
upon it, an effect which can only be produced upon the head of a living
child: where, on the other hand, the child is dead, the scalp will be felt
to be soft, flabby, and without swelling. This may be looked upon as a
very certain proof of the child's death in primiparæ, where the head is
advancing slowly, and where it is tightly encircled by the distended
vagina. But in multiparæ, where the soft passages have been dilated by
repeated labours, the pressure upon the head is so slight, and its passage
through them so rapid, that little or no swelling is produced: even in
these cases the finger of the accoucheur will easily distinguish the head
of a dead child by the loose yielding flabby feel of its integuments; the
cranial bones are more moveable, and overlap each other at the sutures
more than usual; their edges feel sharp, as if no longer covered by the
scalp; and frequently communicate a grating sensation when they rub
against each other. The great fontanelle is flaccid and loose; the bones,
which form it, appear falling together, from a want of sufficient contents
to keep them asunder, a circumstance which probably arises from the
circulation in the brain having ceased; and in those cases where the child
has already been dead some time, a crackling or crepitous sensation is
communicated to the finger from emphysema, the result of decomposition.

The only case in which the swelling of the head is capable of misleading
us, is in lingering difficult labours, where the child has been alive at
the beginning, the swelling has formed, but from the duration and severity
of the labour the child has died: wider such circumstances, a dead child
may be born with the usual swelling of the cranial integuments which is
observed in a living child. This can only happen where it has been
expelled almost immediately after its death, for in two or three hours the
swelling loses its former firm tense feel, and becomes so soft and
flaccid, as not to be easily mistaken.

If the face presents during labour, the flabby state of the lips will
instantly lead us to suspect that the child is dead: the tongue is also
flaccid and motionless. Whereas, in a living child the lips are firm and
full; if the face be approaching the os externum, a considerable swelling
will be felt on that side which presents; the tongue is firm, and
frequently moves upon the finger.

If the nates present, the state of the sphincter ani will be a sure guide
in ascertaining whether the child be alive or not. If it be alive, it will
be found closed, and will contract distinctly upon the finger; whereas, if
dead, it will be relaxed, and insensible to the stimulus of the finger.

In an arm presentation, where the child is alive, the arm will swell, and
grow livid or nearly black; but if it be dead, no swelling will be
observed, the arm will be very flabby, and where it has been dead some
time, the epidermis will peel off. In this case, as in head presentations,
the date of the child's death will more or less modify these appearances;
if it has not taken place until some time after the commencement of
labour, a dead child may be born exhibiting the swelling and
discolouration above-mentioned. The pulse in the wrist of the prolapsed
arm is no guide, as the very degree of pressure, which produces these
changes in its appearance, will be generally sufficient to render it
imperceptible.

In cases where the cord has prolapsed, we have certain evidence with
respect to the child's life: if alive the cord is firm, turgid, and
distinctly pulsating; if dead, it is flaccid, empty, and without
pulsation.

Fetid liquor amnii, and the discharge of the meconium, have also been
enumerated as signs of the child's death, which occur during labour. The
first affords no proof whatever, as cases not unfrequently occur in which
the liquor amnii is excessively fetid, and of a thick slimy consistence,
and yet the child is born alive and healthy.

The appearance of meconium during labour is a suspicious sign where the
nates do not present, and will at any rate justify the supposition, that
if the child be not actually dead, it is very weakly; in nates
presentations, however, this will not hold good, for the meconium is
constantly discharged during labour, where the child is in this position,
and yet it will be born alive and well.



CHAPTER IV.

MOLE PREGNANCY.

    _Nature and origin.--Varieties.--Diagnostic Symptoms.--Treatment._


When any cause has occurred to destroy the life of the embryo during the
early weeks of pregnancy, one of two results follows, either that
expulsion takes place sooner or later, or the membranes of the ovum become
remarkably changed, and continue to grow for some time longer, until at
length they form a fleshy fibrous mass, called _mole_, or _false
conception_.[47]

It is well known that the venous absorbing radicles of the chorion, which
give it that shaggy appearance during the first months of pregnancy are
the means by which the embryo is furnished with a due supply of
nourishment at this period: if the embryo should die from any cause, and
the uterus show no disposition to expel the ovum, the nourishment which
has been collected by the absorbing power of the chorion appears now to be
directed to the chorion itself, which therefore puts on a fleshy growth
and increases very rapidly in size. (Roederer, _Elementa Artis
Obstetricæ_, p. 738.)

In other instances, the thick fleshy character of the ovum is not produced
by a growth of substance, but is the result of hæmorrhage from rupture of
some of the vessels which run between the uterus and the ovum. In this
case, if the placental cells be already formed, they become distended with
the blood of the hæmorrhage which solidifies by coagulation; and not only
render the chorion or incipient placenta much thicker and more solid, but
give it also a lobulated tuberculated appearance: from the same reason,
the little funis, which is probably not an inch long, is greatly
distended, being in some cases as thick as the body of the embryo itself,
the blood having penetrated from the placental cells into the cellular
tissue of the chord. This is by no means an uncommon form of mole;
externally it is covered by the decidua, which appears to be in a natural
condition, and the inner surface of the cavity is lined by a fine
membrane, having all the usual characters of the amnion. The lobulated
appearance is chiefly seen from within, the amnion being raised by a
number of irregular convexities.

"When the blood is poured out from its containing vessels into the
substance or cells of the placenta, or between the membranes, gradually
coagulates, and assumes a very dark purple, and sometimes almost a
melanotic black colour: after a time, however, it begins to lose this
tint, the colouring matter gradually becomes removed, and the coagulum
successively assumes a chocolate brown, a reddish or brownish yellow hue;
and latterly, if time sufficient be allowed, it presents a pale yellowish
white or straw-coloured substance, the fibrinous portion of the coagulum
being then left alone."[48] This form of mole, as far as our own
observation goes, seldom attains any considerable size, rarely exceeding
four inches in length, and is usually expelled between the eighth and
twelfth week. The size and condition of the foetus varies a good deal; in
some cases it appears nearly healthy, although the cord is much thickened
and distended; this is probably owing to its having been expelled shortly
after its death, or to its having gone on to live a short time after the
injury which had caused hæmorrhage: in this way alone can we explain why
we occasionally meet with cases where the parietes of the ovum are much
thickened and solidified, and yet the embryo is in such a state of
integrity as to prove that its death must have been very recent. The
extravasation of blood between the ovum and uterus does not appear to be
sufficient to annihilate immediately the nutrition of the embryo, so that
the blood has had sufficient time to solidify before the ovum was
expelled. At other times the embryo exhibits evident marks of having been
dead some time: it is much smaller and younger in proportion to the size
of the ovum; sometimes it has disappeared entirely, a short rudiment of
the funis merely remaining to mark its previous existence.

"Should the embryo die (suppose in the first or second month) some days
before the ovum is discharged, it will sometimes be entirely dissolved, so
that when the secundines are delivered, there is nothing to be seen. In
the first month the embryo is so small and tender, that this dissolution
will be performed in twelve hours; in the second month, two, three, or
four days will suffice for this purpose." (_Smellie._)

Where the growth of the ovum proceeds after the destruction of the embryo,
it increases very rapidly in size, much more so than would be the case in
natural pregnancy, so that the uterus, when filled with a mole of this
sort, is as large at the third month as it would be in pregnancy at the
fifth.

Another form of mole is where the uterus is filled with a large mass of
vesicles of irregular size and shape like hydatids, which appear to be
the absorbing extremities of the veins of the chorion distended with a
serous fluid; it is difficult to distinguish these from real hydatids; the
more so, as Bremser asserts that he has occasionally met with real
hydatids among them. Perhaps the mode of their attachment will in some
degree assist the diagnosis: these vessicles, or _hydatids of the
placenta_, as they have been called, are attached over a large portion of
the uterus,--an arrangement we believe, not generally seen in real
hydatids, which are mostly attached to a single stalk or pedicle. Indeed,
it may be doubted if the masses of vesicles which are occasionally
expelled from the uterus are ever true acephalocysts, as they are
invariably connected with a blighted ovum, and are, therefore, formed as
before observed, by a dropsical state of the venous radicles of the
chorion.

A variety of other molar growths have also been enumerated by authors; in
fact, "the term _mole_ has been rather vaguely applied to almost every
shapeless mass which issued from the uterus, whether this proved to be
coagulated blood, detached tumours, or a blighted conception." (Churchill,
_on the Principal Diseases of Females_, p. 153.) Thus a fibrinous cast of
the uterus, which has been formed by a coagulum of blood, from which the
colouring matter has been drained, has been called a fibrous mole: these,
however, may easily be distinguished from real moles, which are invariably
the product of conception: from inattention also to this circumstance,
fungoid, bony, and calcareous tumours have been described as so many
species of moles.[49]

_Diagnostic symptoms._ The diagnosis of a mole pregnancy is exceedingly
obscure; in fact, for the first eight or ten weeks we know of no symptom
by which we can distinguish it from natural pregnancy. As the death of the
embryo is intimately connected with the first morbid changes in the
condition of the ovum, and in most cases precedes them, the earliest
symptoms which can excite our suspicions are those which indicate this
event: thus we shall find that the face becomes pale and chlorotic, the
digestion deranged, the breasts flaccid, with unusual lassitude, debility,
and depression of spirits; many of the sympathetic affections which belong
to early pregnancy, such as the morning sickness, nausea, &c. cease
suddenly; in some cases, an attack of hæmorrhage comes on, and may be
repeated several times, causing much loss of strength and exhaustion, and
attended with a good deal of pain, more especially if the uterus be about
to throw off its contents. In that form of mole where the parietes of the
ovum have been thickened and lobulated by masses of coagulated blood, the
uterus undergoes little or no more increase of size, but the mole,
especially the hydatic, continues to grow rapidly; and the unusual
increase in the size of the abdomen, as already mentioned, will be an
additional reason for suspicion. In all cases, hæmorrhage sooner or later
makes its appearance, the patient's health still farther declines,
leucorrhoea comes on, followed by oedema of the feet, general breaking up
of the health, and even incipient cachexia. Occasionally the discharge is
excessively putrid and offensive. Where it is of the hydatic species, we
can frequently ascertain its character by the expulsion of two or three
hydatids which have separated from the main mass, or by the escape of some
limpid colourless water resulting from the rupture of one or more of them.
The expulsion of the mole itself clears up all doubts.

The amount of hæmorrhage will chiefly depend upon the extent of surface by
which the mole is attached to the uterus: hence it is observed to be
greatest in cases of hydatic mole, from the large size of the mass to be
expelled: indeed, under these circumstances, it is frequently more profuse
than hæmorrhage from detachment of the placenta. The process of the
expulsion itself resembles that of an abortion: pain in the back, groins,
and lower part of the abdomen comes on, with more or less discharge of
blood; at length bearing down pains succeed, and the mass is expelled.

We cannot better describe the symptoms produced by the presence of a
hydatic mole, and the mode of its expulsion, than by quoting a case from
the work of Dr. Gooch, _on some of the most Important Diseases peculiar to
Women_.

"I was sent for to ----, a few miles from London, to see a lady, who,
having ceased to menstruate for one month, and becoming very sick,
concluded that she was pregnant. The next month she had a slow hæmorrhage
from the uterus, which had continued incessantly a month when I saw her:
she kept nothing on her stomach. On examining the uterus through the
vagina, its body felt considerably enlarged, and there was a round
circumscribed tumour in the front of the abdomen, reaching from the brim
of the pelvis nearly to the umbilicus. I saw her several times at
intervals of a fortnight, during which the hæmorrhage and the vomiting
continued unrelieved: the peculiarity about the case was the bulk of the
uterus, which was greater than it ought to be at this period of pregnancy;
it felt also less firm than the pregnant uterus, more like a thick bladder
full of fluid. Eleven weeks from the omission of the menstruation, she was
seized with profuse hæmorrhage; towards evening there came on strong
expelling pains, during which she discharged a vast quantity of something
which puzzled her attendants. The next morning I found her quite well--her
pain, hæmorrhage, and vomiting, having ceased. I was then taken into her
dressing-room, and shown a large wash-hand basin full of what looked like
myriads of little white currants floating in red-currant juice. They were
hydatids floating in bloody water."

_The treatment_ previous to the expulsion of the mole should be gently
alterative and tonic; the chylopoietic functions should be kept in regular
action, and the strength sustained. When hæmorrhage comes on, we must be
guided a good deal by the quantity lost, and by the effect which it has
upon the pulse. Generally speaking, when the pulse has been a good deal
reduced in strength and volume, we shall find the os uteri relaxed and
dilated, and in all probability a portion of the mass protruding into the
vagina, which may be hooked down by the fingers, and thus the expulsion of
the whole mass facilitated. For farther details regarding the management
of such cases, we must refer to the chapter on premature expulsion of the
ovum, between the symptoms and treatment of which, and of mole pregnancy,
there is a close analogy. The after treatment will always be a matter of
considerable importance, and will, in a great measure resemble that in
abortion or mis-carriage.

Patients who have suffered from a mole pregnancy generally have their
strength seriously reduced and their health much broken: hence, they are
liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long
series of troublesome and even dangerous affections, the recovery from
which will be slow and difficult, requiring a long course of tonic
medicines, and removal to the sea-coast or some watering-place where there
are chalybeate springs.



CHAPTER V.

EXTRA-UTERINE PREGNANCY.

    _Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance
    of the uterus._


The ovum when impregnated does not always quit the ovary and pass along
the Fallopian tube into the uterus. It may remain in the ovary and become
here developed; it may pass into the Fallopian tube and remain there; or
from some defect in the action of the fimbriated extremity of this canal,
it may escape into the cavity of the abdomen, and become attached to some
of the viscera. Hence, extra-uterine pregnancy has been divided into three
species, viz. _graviditas tuberia_, _ovaria_, and _ventralis_, according
to the situation which the ovum takes. A fourth has been also described by
M. Breschet, which he has called _graviditas in substantia uteri_, a
modification probably of tubarian pregnancy.

[Illustration: _a_ The uterus, its cavity laid open. _b_ Its parietes
thickened, as in natural pregnancy. _c_ A portion of decidua separated
from its inner surface. _d_ Bristles to show the direction of the
Fallopian tubes. _e_ Right Fallopian tube distended into a sac which has
burst, containing the extra-uterine ovum. _f_ The foetus. _g_ The chorion.
_h_ The ovaries; in the right one is a well marked corpus luteum. _i_ The
round ligament.]

This singular deviation from the usual course of conception is fortunately
of rare occurrence, for few cases terminate favourably. If it be in the
Fallopian tube or ovary, these become immensely distended into a species
of sac or cyst, to the sides of which the placenta adheres: as the ovum
increases, this at length gives way from excessive distension, and the
patient usually dies from internal hæmorrhage. In ventral pregnancy, the
sac is attached to the abdominal viscera, and is usually imbedded among
the convolutions of the intestines: hence the duration of extra-uterine
pregnancy will depend upon its situation; thus, if it be in the Fallopian
tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will
continue for five or six months; on the other hand, in ventral pregnancy
the foetus will not only be carried to the full term, but far beyond that
period, amounting to several years.[50]

Although the uterus does not receive the ovum into its cavity as it does
in natural conception, it nevertheless undergoes many of those changes
which are known to take place in regular pregnancy. The layer of
coagulable lymph, which is effused upon its internal surface, and which
forms the membrana decidua of Hunter, is present, and the uterus undergoes
a slight increase of volume. As the ovum increases, excruciating pains are
felt in the lower part of the abdomen, coming on at irregular intervals,
and of irregular duration; in some cases lasting for a short time, in
others continuing for twenty-four hours. These attacks of pain are
generally accompanied with very painful forcing and tenesmus, and not
unfrequently with a discharge of bloody mucus from the vagina. In tubarian
pregnancy, however, the case generally follows a much shorter course: the
patient is suddenly seized with an acute pain in the lower part of the
abdomen, followed by nausea and vomiting; she becomes faint and weak; the
abdomen evidently increases in size (from effusion of blood into the
cavity;) the debility becomes more alarming, and death quickly follows.

In ovarian pregnancy the fatal termination is merely postponed till a
later period, during which the patient has to undergo attacks of most
terrible suffering: at length, after a paroxysm more than usually severe,
and frequently attended with the sensation of something giving way in the
abdomen, faintings come on, speedily followed by death. During the attacks
there is obstinate constipation, which is attended with painful and
fruitless efforts to evacuate the bladder and rectum; the face is pale,
and expressive not only of the most acute suffering, but of great anxiety
and mental depression; nevertheless, in the intervals of the attacks she
feels easy, and appears well and cheerful.

The termination of a ventral pregnancy is very different; after a time the
foetus dies, and may either remain enclosed in the cyst for life, or it
may be discharged in portions by means of an abscess, either through the
intestines, uterus, vagina, or abdominal parietes. Cases have occurred
where it has come away by the bladder; in the former case, where it is
retained, it diminishes more or less in size, becomes hard and closely
packed together, and, in some instances, encrusted with a layer of
calcareous matter.

It is to our venerable friend, the late Dr. Heim, of Berlin, that we are
indebted for much curious and interesting knowledge respecting
extra-uterine pregnancy. Although the symptoms in the very early stages
are so obscure as to render it nearly impossible to detect its presence,
he has nevertheless observed some facts connected with it, which are
peculiar, and deserve to be noticed. No morning sickness has been observed
in cases of extra-uterine pregnancy, a circumstance which can easily be
accounted for, if we bear in mind the causes of morning sickness in
natural pregnancy: the patient could only lie on the affected side, and
the abdomen was observed to swell irregularly, not in the same manner as
in regular pregnancy.

In tubarian and ovarian pregnancy, the pain was in the pelvis, but in
ventral pregnancy it occupied more or less the whole abdomen, the parietes
of which were very tender upon pressure. In cases where the foetus died at
an early period, the symptoms gradually disappeared after a time,
especially when followed by the bursting of an abscess through the rectum
or any other part. One of the most remarkable facts which Dr. Heim
observed, was a peculiar whining tone of voice, with which the patient
expressed her sufferings during a paroxysm of pain; so peculiar, that when
once heard, the sound can never be mistaken. On several occasions Dr. Heim
was enabled by means of this symptom alone to decide confidently as to the
nature of the case the moment he entered the room, a fact which would
appear scarcely credible had not the results of the cases proved the
correctness of his assertion. A most interesting case of this sort
occurred, which he pronounced to be ventral pregnancy, and when it had
gone the full term gastrotomy was performed, a living child was extracted
but the unfortunate mother perished: she could not be induced to submit to
the operation until inflammation had come on, and she died in two days
after.

It must always remain a matter of great obscurity as to the immediate
_causes_ of extra-uterine pregnancy, more especially of the ovarian and
ventral species; and the more so as we are still ignorant of the mechanism
by which the fimbriated extremity of the Fallopian tube grasps the ovary
immediately over the impregnated vesicle of de Graaf at the moment of
conception. In many cases we are inclined to think that this function of
the Fallopian tube is destroyed by adhesions between it and the ovary, a
circumstance of not uncommon occurrence; but from the alteration in the
shape and size of these parts, as also from the extensive adhesions which
are usually found after death, in such cases it will ever be difficult,
and perhaps impossible, to prove it.

The _treatment_ of extra-uterine pregnancy must be chiefly guided by the
prevailing symptoms: where any portion of the abdomen is very tender to
the touch, leeches and warm fomentations will be required; the pain during
the attacks can only be alleviated by frequently repeated opiates; and
constipation must be carefully guarded against by laxatives and enemata
between the paroxysms. Where an effort is made by nature to discharge the
foetus by means of an abcess, the case will require all our care to
sustain the powers of the system through a long protracted struggle.
Portions of the foetus come away from time to time, and if the exit
afforded them be by way of the intestine, the suffering produced is very
great, particularly when any of the larger bones are passing. The presence
of such a mass of semi-decomposed animal matter in the abdomen is of
itself sufficient to injure the general health materially: hence it is
that patients, during the process of expulsion, suffer greatly from severe
attacks of fever, which recur from time to time. Where the abscess opens
through the abdominal parietes, the whole is completed with much greater
ease and safety to the patient: in some instances the tumour has been
opened, and a foetus with a large quantity of putrid pus has been removed.
(_Medical Obs. and Inquiries_, vol. ii. p. 369.)

A case of ventral pregnancy has recently come under our care, a short
account of which will enable the reader to understand the subject better
than a mere enumeration of symptoms; the more so as we believe it to have
been the first case of extra-uterine pregnancy in which the stethoscope
has been used.

The patient, æt. 32, and the mother of four children, was admitted, May
26, 1837, into St. Bartholomew's Hospital, under Dr. Latham, who kindly
consigned her to our charge. She considers herself to be six months
advanced in pregnancy; is continually suffering from attacks of acute pain
in the lower part of the abdomen, both at the sides and front, causing her
to moan from its great severity; this is accompanied with a constant
dragging pain on the right side, and in the loins: the attacks of
abdominal pain go off at intervals, leaving her comparatively easy. She is
pale, with an anxious expression of face. Pulse 120, and firm. Tongue
moist. Bowels very constipated.

The abdomen is as large as in common pregnancy at the sixth month, but
does not present the same uniform distension, being irregularly shaped. At
the left hypogastrium is a soft tympanitic prominence of considerable
extent, and appears, from its feel and also from auscultation, to consist
of a large portion of the intestines pushed over to that side: at the
inner edge of this tumour a solid mass, as large as the head of a six
months' foetus, can be felt. Between this and the median line of the
abdomen, and half way between the pubes and umbilicus, a small hard
knob-like and moveable prominence is felt immediately beneath the
abdominal parietes, and intensely painful to the touch. From this point,
quite to the right side, the abdomen has a solid irregular feel; below
this to the symphysis pubis, a very loud souffle is heard, synchronous
with the mother's pulse, having all the characters of the uterine souffle
in common pregnancy except its extraordinary loudness. Its limits,
superiorly, are remarkably defined; below a transverse line, drawn half
way between the umbilicus and pubes, it is heard in full strength,
whereas, immediately above it the sound ceases: it is also heard some way
to the right side. At the upper part of the right iliac region two
ridge-like prominences, like the extremities of a child, may be felt close
beneath the abdominal parietes. No trace of foetal pulsation can be heard
over any part of the abdomen, although it has been carefully ausculted
round to the loins: it was however distinctly heard the day before we saw
her, by two gentlemen who are proficients in the use of the stethoscope,
and whom we consider fully capable of judging in such a case.

On examining per vaginam, the os uteri is found high up and backwards,
barely within reach. Its edges are thick, soft, and closed; the cervix is
short, and seems less than half an inch. The anterior portion of the
inferior segment of the uterus feels somewhat firm and full, as if there
was something in the uterus. We were confirmed in this respect by our
friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country
at the time, and who examined the case with us. He was at first induced to
suppose that it was the head. We considered that it was the uterus more or
less anteverted, the fundus being pressed forwards and downwards, and the
os uteri backwards, by the extra-uterine cyst above; farther examinations
tended to confirm this view.

She states that the catamenia appeared last in November, during the middle
of which month she was attacked with inflammation of the bowels, for which
she was treated, and soon afterwards began to have the violent attacks of
pain of which she now complains. She felt the child move at the usual
time; it evidently formed the mass which occupies the lower part of the
abdomen, and its movements appeared unusually close to the surface. During
the last few days they have ceased altogether. The above-mentioned attacks
of pain have continued to recur ever since at short intervals and with
increasing severity.

As leeches had been applied without relief, and as the pulse was quick
and hard, she was ordered to be bled to eight ounces, and to take half a
grain of morphia immediately.

_June 2._--Has been in constant suffering, in spite of leeches and
morphia; bowels obstinately constipated, but moved at length by repeated
injections and doses of house medicine. Has not felt the motions of the
child since the intestines have become tympanitic: still, however, the
mass can be felt lying across the abdomen, half-way between the pubes and
umbilicus, commencing from about three inches to the left of the median
line, and extending to about four inches on the opposite side. On the left
side it feels firm and rounded, and so superficial, that it can almost be
grasped through the abdominal integuments. Face very pale and anxious.
Pulse 120.

_June 10._--Was easy and free from pain when we first saw her: the souffle
is heard over a smaller extent; in the centre of the space where it is
heard it is as remarkably loud as ever, but it gradually becomes
indistinct towards the circumference. As she was able to rise we examined
her standing: the os uteri is exceedingly high up to the left sacro-iliac
symphysis, so that it can scarcely be reached; the cervix is short, the
lips somewhat larger than usual, and the whole very firm and immoveable.
The anterior portion of the uterus, to be felt through the vaginal
parietes, is somewhat firmer and larger than usual: on pressing the tumour
in the left hypogastrium, this appeared to lie altogether anterior to the
uterus. Little motion is communicated to the os uteri when this is moved.

_June 20._--Has been in much suffering since last report; much emaciated;
complains of a fetid taste in the mouth; bowels inclined to be purged;
stools of a whitish purulent appearance; tongue clean; pulse tolerably
natural; has continued to pass portions of fibrinous matter from the
vagina, mixed with bloody mucus, since last report. The hard globular
swelling at the left side of the abdomen is more distinct at times: the
hand can almost pass round it: it has the precise feeling of the head; the
mass which lies across the abdomen is also more distinct: the souffle is
heard over a much smaller space and is diminished in strength.

_June 27._--Much the same, except that, after severe bearing down and
tenesmus, she has passed a considerable quantity of blood from the rectum
and vagina. The little prominences on the right side, presumed to be the
extremities, are remarkably distinct, like two heels or knees.

_July 18._--No material change has taken place since last report; she has
suffered from irregular attacks of pain, and has had repeated discharges
of blood from the vagina, which always give relief; is weaker than usual,
and feels exhausted from the continued character of the pain; abdomen less
swollen; the globular mass on the left side is lower and much nearer to
the median line; the little prominences on the right are also lower, and
nearer the median line; the whole mass appears much more compressed
together and nearer to the pubes; it is extremely painful on the left
side, and at the most painful spot the skin is red and inflamed; the
bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any
trace of souffle to be heard.

Shortly after this she left the hospital, and for some time continued to
enjoy tolerable health, occasionally suffering from severe paroxysms of
abdominal pain; the abdomen diminished considerably in size, and the
various prominences became indistinct.

In _May, 1839_, she was again admitted in a state of great exhaustion from
constant severe pain. The abdomen had diminished still more, and a portion
of the mass had descended between the uterus and rectum; the constipated
bowels were moved with great difficulty, but with much relief. The
symptoms gradually diminished, and she was discharged in the first week of
the following _August_.

In _January, 1840_, she returned to the hospital, all her former
sufferings being greatly aggravated. The abdomen had subsided still
farther; early in _February_ she passed a quantity of putrid purulent
matter from the rectum, after which the abdomen diminished considerably.
The pain appeared to be chiefly situated in the upper part of the rectum,
accompanied with severe bearing down, and on examining per vaginam the
mass was felt deep at the posterior part of the pelvic brim: the debility
and emaciation increased, and she died early in _February_. Our notes of
the post mortem examination were as follows:--

Much emaciated, abdomen concave, but on pressing it the tumour can be felt
at the brim of the pelvis. On opening the abdominal cavity, the mass was
found adhering firmly to the neighbouring intestines, and on the right
side to the soft linings of the pelvis: it was of an irregular form, with
spots of livid vascularity in different parts: on the upper and left side
of it, fetid purulent matter was seen exuding from a small orifice. The
uterus was below, its fundus pushed over to the left side. On separating
its adhesions, and attempting to raise the sac from the pelvis, the
half-softened parietes gave way, and the decomposed putty-like mass of the
foetus became visible; the cranial bones were at the left side; the feet
were still distinct on the right side; the whole was immersed in a
quantity of thick fetid pus, and there were no traces either of umbilical
cord or placenta.

Cases of ventral pregnancy have been recorded where the child has remained
in the mother's abdomen without producing any dangerous symptoms, and
where she has again become pregnant in the natural way. The earliest
instance of this sort was recorded so long ago as by Albucasis. A very
interesting case of this nature is described by Dr. Bard of New York.
(_Med. Obs. and Inquiries_, vol. ii. p. 369.) It was the patient's second
pregnancy; at the end of nine months she had pains, which after a time
went off; the tumour gradually diminished somewhat, and in about five
months after she conceived again, and in due time was delivered, after an
easy labour, of a healthy child. "Five days after delivery she was seized
with a violent fever, a purging, suppression, pain in the tumour, and
_profuse fetid sweats_:" an abscess formed in the abdomen, which was
opened, and a vast quantity of extremely fetid matter was discharged; the
opening was enlarged, and a foetus of the full size was extracted. Dr.
Bard "imagined the placenta and funis umbilicalis were dissolved in the
pus, of which there was a great quantity."

It becomes a question of deep interest whether it be really possible to
save the patient and the child in cases of ventral pregnancy, by
performing gastrotomy. The separation of the placenta from the walls of
the cyst can only be effected with much difficulty and hazard; indeed, we
are at a loss to conceive how it can be removed with any degree of safety,
where the child has been found alive. The attachment in these cases was
more than usually firm, and it has been left to undergo that process of
solution which has been described in Dr. Bard's case. In all the cases
where gastrotomy has been performed some time after the child's death,
little or no trace of the placenta has been found, but in its place a
quantity of ill-conditioned purulent matter, which was excessively fetid.

The fourth species of extra-uterine pregnancy, which M. Breschet has
described as taking place in the substance of the uterus, is of very rare
occurrence, four cases only having been recorded by him. (_Med. Chir.
Trans._ vol. xiii.) M. Breschet has attempted a variety of explanations of
this singular anomaly, but without success; and from the circumstance of
the cyst having always been found situated in the fundus to one side, the
Fallopian tube of which was closed at its uterine extremity, we think that
there can be little doubt of its having been a modification of tubarian
pregnancy, where the ovum had been obstructed at that portion of the
Fallopian tube where it passes obliquely through the wall of the uterus:
in one case the tube appears to have given way at this part, and the ovum
to have insinuated itself between the uterus and peritoneum. In these
cases the sac ruptured at about the same period as in tubarian pregnancy,
except in one instance, where she went five months. A rather inexplicable
case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds
(_Med. Obs. and Inquiries_, vol. iii.,) where a full grown foetus was
found enclosed in a large sac, which filled the abdominal cavity, and
which communicated inferiorly with the uterus. On tracing the umbilical
cord, "we were led," says Mr. Hay, "to a large aperture in the right side
of the inferior globular sac already mentioned, from which that which
contained the foetus seemed to have its origin. This inferior sac we now
found to be the uterus, containing a very thick placenta, which adhered
very firmly to about three-fourths of its internal surface, having the
navel string attached to its centre, and this centre corresponded nearly
with the centre of the fundus uteri. The placenta filled up the greatest
part of the aperture of communication between the uterus and sac. The
Fallopian tube on the left side was very small; the place of that on the
right was occupied by the beginning or orifice of the sac." (_Op. cit._)

This would seem to have been a case of pregnancy in the substance of the
uterus, and where a portion of the ovum had burst its way into the cavity
of the uterus lined with decidua, to which it adhered; the other portion,
containing the embryo, distended the uterine parietes in a contrary
direction, and thus formed the large sac which communicated with the
cavity of the uterus.



CHAPTER VI.

RETROVERSION OF THE UTERUS.

    _History.--Causes.--Symptoms.--Diagnosis.--Treatment.--Spontaneous
    terminations._


During the earlier months of pregnancy the uterus is liable, although
rarely, to a peculiar species of displacement, called _retroversion_, in
which the fundus is forced downwards and backwards into the hollow of the
sacrum, between the rectum and posterior wall of the vagina, and its os
and cervix are carried forwards and upwards behind the symphysis pubis.

[Illustration: _a a_ Half the bladder on each side turned over the spine
of the os ilium. _b_ Anterior extremity of the vertical incision by which
the bladder was opened. _c_ One turn of the rectum, which was seen at the
posterior end of the same incision. _W. Hunter._]

Retroversion of the uterus appears to have been known to the ancients, as
we find it alluded to by Hippocrates (_De Nat. Mulieb._ sect. 5.) and
Philumenus (_Histoire de la Chirurg._ par Dujardin and Peyrhille, t. ii.
p. 280.) Oetius, who has quoted the works of the celebrated Aspasia,
describes this displacement of the uterus very exactly, and gives rules
for introducing two fingers into the rectum, in order to remedy it. Rod. a
Castro, who wrote in the sixteenth century, in his work on the diseases of
women, quotes what Hippocrates had written on the subject of this
displacement; and it is astonishing that no farther notice was taken of it
until the eighteenth century, when it excited considerable attention among
accoucheurs. (_Martin le Jeune_, p. 137.) Gregoire appears to have been
the first who gave a good description of it; his pupil, Mr. W. Wall, on
his return to England, met with what he considered to be a case of this
displacement, and not being able to restore the uterus to its natural
position, requested the advice of Dr. W. Hunter. On passing his finger
between the os uteri and symphysis pubis, and thus removing, in some
degree, the pressure upon the neck of the bladder, a considerable quantity
of urine was discharged, but he was unable to return the uterus to its
natural situation, and the patient gradually sunk. The bladder was found
immensely distended; the lower part of it, "which is united with the
vagina and cervix uteri, and into which the ureters are inserted, was
raised up as high as the brim of the pelvis by a large round tumour, (viz.
the uterus,) which entirely filled up the whole cavity of the pelvis. The
os uteri made the summit of the tumour upon which the bladder rested, and
the fundus uteri was turned down towards the os coccygis and anus."
(_Medical Obs. and Inquiries_, vol. iv. 404.)

_Causes._ This displacement may also occur in the unimpregnated state,
either from the fundus being pushed into that position by some morbid
growth, or where this effect has been produced by the violent pressure of
the abdominal muscles in lifting heavy weights, under circumstances where
the uterus has been larger and heavier than usual;[51] but it is in the
early months of pregnancy that it is most likely to happen, because now
the fundus is both larger and heavier than before, and, therefore, more
liable to be affected by the pressure of the intestines and abdominal
muscles, and has not yet attained a sufficient size to prevent its
undergoing this displacement in the pelvis: this period is about the third
or fourth month, often before it, but never after it. (Burns's _Anatomy of
the Gravid Uterus_, p. 17.)

It has been supposed by many authors, especially Dr. Burns, that
distension of the bladder is, in many instances, the immediate cause of
retroversion, owing to the intimate connexion which exists between the
lower part of the uterus and this organ, inasmuch, "that whenever the
bladder rises by distension, the uterus must rise also." In the later
editions of his work on the principles of midwifery, he has considerably
modified this opinion, and from careful examination of the parts in situ,
in the third month, is not disposed to consider the distension of the
bladder as the cause, but the effect of retroversion. In every case which
has come under our own observation, the bladder has not been distended
until the retroversion had taken place, in consequence of which the os and
cervix uteri had been tilted up behind the symphysis pubis, and having
thus compressed its neck had caused the difficulty in passing water.[52]
Whenever any force is applied to the fundus uteri at this period of
pregnancy, either from external violence, or the action of the abdominal
muscles pressing the intestines and bladder against it, it will be pushed
against the rectum, in which case the rectum will be flattened at that
part against which the fundus rests; and if any mass of fæculent matter be
passing along the intestine, its course will be obstructed at this point,
and the rectum quickly become distended with an accumulation of fæces
above, by which means the fundus will not only be prevented from rising,
but in all probability be forced still lower down. If the force which has
originally pushed the fundus backwards be of sufficient degree and
duration to carry it past the promontory of the sacrum, the increase of
space which it will meet with in the hollow of the sacrum, and the
straining efforts which are induced by the displacement itself, contribute
powerfully to complete the mischief, and to bring the fundus so low into
the pelvic cavity as at length to turn it nearly upside down.

As soon as the fundus of the uterus is pressed with any degree of force
against the posterior parietes of the pelvis, its os and cervix will be
directed forwards and upwards against the symphysis pubis, and from the
pressure which they exert against the neck of the bladder, the patient
either experiences complete retention of urine, or, at any rate,
considerable difficulty in passing it; hence, therefore, we find, that
where retroversion has come on suddenly, the patient is generally sensible
of the pain produced by the displacement, before she has experienced any
difficulty in evacuating the bladder.

A modern French author of great experience, (_Martin le Jeune_, p. 178,)
in enumerating the causes of retroversion, appears to take a similar view
of the subject, and places retention of urine very far down in his list.
"Sudden and violent contractions of the abdominal muscles and diaphragm in
attempting to vomit, to evacuate the bowels or bladder, or to lift heavy
weights; the throes during an abortion at an early period of pregnancy;
strong mental emotions; retention of urine; tumours in the neighbourhood
of the fundus, which by their weight or pressure force it backwards
towards the sacrum, are the causes which may produce a retroversion of the
uterus."

Retroversion may also come on gradually, from "the uterus remaining too
long in that situation which is natural to it when unimpregnated, namely,
with its fundus inclined backwards. This may depend on various causes;
such as too great width of the pelvis, or the pressure of the ileum full
of fæces on the fore part of the uterus. In this case the weight of the
fundus must gradually produce a retroversion, and she will be sensible of
its progress from day to day." (Burns's _Anat. of the Gravid Uterus_. p.
18.)

It will thus be seen how peculiarly liable the uterus is to retroversion
during the early months of pregnancy. At this time, the fundus is not yet
free from the weight of the superincumbent coils of intestine; and if from
any cause its ascent out of the pelvis be delayed beyond the usual time,
its liability to retroversion is still farther increased; for, not only
does the size of the fundus press it still farther backward, but any
sudden contractions of the abdominal muscles, or external violence, act
upon it with increased effect.

The _symptoms_ of this displacement are as follow:--the patient is seized
with violent pain, bearing down, and sense of distension about the hollow
of the sacrum, with a feeling of dragging and even tearing about the
groins, produced by the violent stretching of the broad and round
ligaments; the bearing down is sometimes so severe and involuntary as to
resemble labour pains, and cases have occurred where it has been mistaken
for labour. With all this she finds herself unable to pass fæces or urine,
from the pressure of the fundus upon the rectum and of the os uteri upon
the neck of the bladder. Upon examination per vaginam, the altered
position and form of this canal instantly excite our suspicion: instead of
running nearly in a straight direction backwards and somewhat upwards, it
now takes a curved direction upwards and forwards behind the symphysis
pubis; the hollow of the sacrum is occupied with the globular and nearly
solid mass, (the fundus uteri,) which is evidently behind the vagina, the
posterior wall of this canal being felt between it and the finger; behind
the symphysis pubis, the vagina is more or less flattened, and its
anterior wall put violently upon the stretch, so much so that, according
to Richter, the orifice of the urethra is sometimes dragged up above the
pubic bones, (_Anfangsgründe der Wundarztneikunst_, vol. ii. p. 45:) the
os uteri is found high up behind the symphysis pubis, and in most cases
can be reached, although with much difficulty; sometimes we shall be able
to reach the posterior lip only, which is now the lowest: but "if the
retension of urine has been of some duration, it will be impossible to
reach the os uteri above the pubic bones with the finger. On examining per
rectum, we shall feel the same tumour pressing firmly upon it, and
preventing the farther passage of the finger, thus proving that the tumour
is situated between the rectum and the vagina; for, in such cases, the
bladder forms a considerable swelling below it, and prevents the finger
from passing up." (_Op. cit._)

"The uterus being situated in the centre of the pelvis, between the rectum
and bladder, its retroversion cannot take place without deranging the
functions of these organs: the symptoms thus produced come on rapidly when
the displacement is sudden, slowly when it is gradual. Their severity is
in proportion to the size of the uterus, the degree of retroversion, its
duration, and the various circumstances which increase the impaction of
the uterus in the cavity of the pelvis: they also determine the degree of
inflammation and gangrene of this organ and the neighbouring parts."
(_Martin le Jeune_, p. 178.) Hence we frequently observe in the earlier
stages of retroversion, before the displacement has become complete, that
the patient is able to relieve the bladder to a certain extent, although
very imperfectly, and that with some difficulty; a slight dribbling of
urine continues to a very advanced stage, when the bladder is enormously
distended, and upon the point of bursting: this is not so much the case
with the rectum, the passage of fæces being generally completely
obstructed at an early period, partly from the pressure of the fundus
against it, and partly from the solid nature of its contents. "When such
suppressions once begin they aggravate the evil, not merely by causing
pain, but by occasioning a load of accumulated fæces in the abdomen above
the uterus, which presses it still lower into the cavity of the pelvis, at
the same time that the distension of the bladder in this state draws up
that part of the vagina and cervix uteri with which it is connected, so as
to throw the fundus uteri still more directly downwards." (Dr. W. Hunter,
_Med. Obs. and Inquiries_, vol. iv. p. 406.) These conditions of the
bladder and rectum, and the retroversion of the uterus, act reciprocally
as cause and effect; for the continuance of the distension of the bladder
and the descent of the fæces from the part of the intestine above the
obstruction, must elevate still more the os uteri, and depress to a still
greater degree the fundus. The retroversion, on the other hand, increases
the affection of the bladder and rectum, from which the principal danger
of the disease arises. (Burns's _Anat. of the Gravid Uterus_.)

The _diagnosis_ of retroversion is, generally speaking, not very
difficult, the os uteri tilted up behind the symphysis pubis, and the
fundus forced downwards and backwards between the vagina and rectum, are
sufficiently characteristic of this displacement. We cannot agree with Dr.
Dewees that it can easily be mistaken for prolapsus uteri; in cases of
sudden prolapsus which has been caused by great violence, there will be,
it is true, intense pain in the pelvis, with sensation of forcing and
tearing in the direction of the broad and round ligaments; there will
also, probably, be inability to evacuate the rectum and bladder; but then
the examination, per vaginam, will present such a totally different
condition of parts as to preclude all possibility of mistake: the vagina
merely shortened, neither altered in direction or form; the os uteri at
the lower part of the tumour, which is in the vagina; the mobility of the
tumour itself, all conspire to show that the case is one of prolapsus not
retroversion.

We occasionally meet with cases of retroversion where the os uteri,
although carried more or less upwards and forwards, is not forced, to that
extreme height behind the symphysis pubis as is usually observed. Instead
of looking towards, or rather above, the symphysis, the os uteri itself
looks downwards, the neck or lower part of the body of the uterus being
bent upon the fundus like the neck of a retort.[53] If, under such
circumstances, we cannot satisfy ourselves as to the existence of
pregnancy, we might easily be led to form an erroneous diagnosis, and to
conclude that some tumour had forced itself down into the hollow of the
sacrum, between the rectum and vagina, and had thus pushed the uterus
upwards and forwards, above the brim of the pelvis. An extra-uterine ovum
of the ventral species may occupy this situation, but its slow and gradual
growth, its greater softness and elasticity, and the slight degree of
uterine displacement produced in its early stages, would enable us to
ascertain its real character. The same would hold good to a certain extent
with an ovarian tumour, although in all probability this would produce
more or less displacement of the uterus to one side.

The danger in retroversion of the uterus chiefly arises from the
distension or rupture of the bladder, and from the gangrenous inflammation
which may then take place, not only in it, but also in the uterus and
neighbouring parts. The very displacement itself is sometimes immediately
attended by alarming symptoms, such as faintness, vomiting, cold sweats,
weak irregular pulse, as seen in cases of inversion or strangulated
hernia. In some cases the suffering at first is but trifling, and only
increases in proportion to the degree with which the bladder is distended.

Retroversion not reduced may experience a spontaneous termination in two
ways, either by abortion being excited, after which the uterus, now
diminished in size, returns to its natural situation, or it may go on to
increase in this position until a more advanced period of pregnancy, when
if it be not capable of being replaced by the action of the pains,
sloughing takes place in the fundus, and the foetus is discharged, either
by the rectum or vagina, as in a case of ventral pregnancy.

In the _treatment_ of retroversion of the uterus, our object should be,
first, to remove the accumulated contents of the bladder and rectum, and
secondly, to endeavour to restore the uterus to its natural position. The
relief of the bladder must be our first aim, for here is the greatest
source of danger. The elastic catheter should always be used in these
cases, and greatly facilitates the operation of drawing off the water. The
altered direction of the urethra must be borne in mind; in many cases we
must pass the catheter nearly perpendicularly behind the symphysis pubis:
by pressing the uterus backwards, we shall diminish its pressure upon the
urethra, and thus enable the catheter to pass with great ease.[54]

"The catheter should be employed occasionally, and the bowels emptied
daily, either by medicines of a mild kind, or by injections: if this plan
do not succeed in restoring the fundus, we should then consider the
propriety of mechanically replacing it. To aid us in our judgment, we
should consider, first, the period of gestation; secondly, the degree of
development the uterus has undergone; thirdly, the nature and severity of
existing symptoms. The period of gestation ought almost always to
influence our conduct in this complaint, and we may lay it down as a
general rule, the nearer that period approaches four months, the greater
will be the necessity to act promptly in procuring the restoration of the
fundus: the reason for this is obvious, every day after this only
increases the difficulty of the restoration from the continually
augmenting size of the ovum. The degree of development should also be
taken into consideration, as some uteri are much more expanded at three
months, than others are at four. The extent or severity of symptoms must
ever be kept in view; as, for instance, where the suppression of urine is
complete, and not to be relieved by the catheter, in consequence of the
extreme difficulty and impossibility to pass it: here we must not
temporize too long, lest the bladder become inflamed, gangrenous, or
burst; for the bladder, from its very organization, cannot bear distension
beyond a certain degree, or beyond a certain time, without suffering
serious mischief." (Dewees, _Compend. Syst. of Midwifery, 6th Ed._ § 276.)
Our next step should be to relieve the rectum of its contents by emollient
enemata; this is not always very practicable, owing to the flattened state
of it: hence a glyster pipe of the ordinary sort is too large, and meets
with much resistance; in such cases it will be desirable to use a common
elastic catheter, or thin elastic tube without an ivory nozzle, which
will, therefore, better adapt itself to the form of the bowel. A few doses
of a saline laxative should be given to render the contents of the bowels
more fluid, and the enemata repeated until a sufficient evacuation has
been effected. Where the retroversion is not of long standing, and the
patient not far advanced in her pregnancy, these means are generally
sufficient; and the uterus, in the course of a few hours, will return to
its natural position, either spontaneously or with very slight assistance.
Where, however, the uterus is large and firmly impacted, where it has
already been displaced more than twenty-four hours, where the suffering
from the very beginning has been acute, independently of that produced by
the distended bladder, we cannot expect that the spontaneous replacement
will follow the mere removal of the accumulated urine and fæces; nor must
the uterus be suffered to remain in the state of retroversion, as not only
will its pressure on the neighbouring parts produce serious mischief, but
from the increasing growth of the ovum, every day will add to the
difficulty of moving it out of the pelvis. In determining upon the
artificial reposition of the uterus, it must be borne in mind that the
chief difficulty is to raise the fundus above the promontory of the
sacrum, for if we can once succeed in gaining this point, the rest will
follow of itself; our object, therefore, will be to raise the fundus
upwards and forwards, in a direction towards the umbilicus of the patient.
To effect this purpose various methods have been proposed: some have
recommended that, with a finger in the vagina, we should hook down the os
uteri, while with one or two fingers of the other hand passed into the
rectum, we endeavour to push the fundus out of the hollow of the sacrum.
Some object to any attempt being made through the rectum. (Naegelé,
_Erfahrungen und Abhandlungen_, p. 346.) We agree with Richter in the
utter inutility of attempting to bring down the os uteri; in most
instances we can barely reach it with the tip of the finger, and even were
we able to lay hold of it, we should run little or no chance of moving it
so long as the fundus is impacted in the hollow of the sacrum. The fingers
which are in the vagina must endeavour to raise the fundus, and in doing
so may be assisted by one or two fingers in the rectum according to
circumstances; the very effort to press per vaginam against the fundus,
necessarily puts the anterior wall of the vagina upon the stretch, and
thus tends of itself to bring the os uteri downward.[55] In all cases
where the reposition of the uterus is at all difficult, Professor Naegelé
recommends the introduction of the whole hand into the vagina, by which we
gain much greater power. Under such circumstances it is desirable to place
the patient upon her knees and elbows, as in a difficult case of turning,
because now the very weight of the fundus will dispose it to quit the
pelvis. The only difficulty which we shall meet with in thus using the
whole hand, is the violent straining and efforts to bear down, which the
patient is involuntarily compelled to make, from the presence of the hand
in the vagina. Dr. Dewees in such cases very judiciously recommends
bleeding to fainting, not only to obviate these efforts which would have
prevented our raising the fundus, but also to relax the soft parts as much
as possible. In our attempts to replace the uterus we must not be
discouraged by finding that at first no impression is made upon it; by
degrees it will begin to yield, and with a little more perserverance we
shall be enabled to push the fundus above the promontory of the sacrum.
(See Mr. Hooper's Case, _Med. Obs. and Inquiries_, vol. v. p. 104.)

Where the pain in the pelvis indicates considerable pressure of the uterus
upon the surrounding parts, arising probably from swelling and
engorgement with blood, the result of vascular excitement, a smart
bleeding will afford great relief; the size and firmness of the tumour are
diminished, the soft parts in which it is imbedded are relaxed, the
general turgor and sensibility are alleviated, and if the moment of
temporary prostration which it has produced be seized upon by the
practitioner, he will find that the reposition of the uterus, which was
before nearly impracticable, is now comparatively easy.

Where, however, the circumstances of the case are so unfavourable, and the
fundus so firmly impacted in the hollow of the sacrum as to resist the
above-mentioned means, Dr. Hunter proposed, "Whether it would not be
advisable, in such a case, to perforate the uterus with a small trocar or
any other proper instrument, in order to discharge the liquor amnii, and
thereby render the uterus so small and so lax as to admit of reduction."
(_Med. Obs. and Inq._ vol. iv. p. 406.) Dr. Hunter did not live to see
this plan carried into execution. In latter years, several cases of
otherwise irreducible retroversion have thus been successfully relieved:
the remedy, it is true, necessarily brings on premature expulsion of the
foetus sooner or later. Under such circumstances, this result cannot be
made a ground of objection. In cases of such severity as to require
paracentesis uteri, there can be little or no chance of the foetus being
alive; and even if it were, of what avail would this be, when almost
certain death is staring the mother in the face, unless relieved by this
operation?[56] Puncture of the bladder has also been tried where the urine
could not be drawn off.[57]

Cases have now and then been met with where the retroversion of the uterus
has continued to an advanced period of pregnancy without producing serious
injury to the patient: Dr. Merriman has even recorded some, where the
uterus has continued in this state up to the full term. Some of these had
been actually published as cases of ventral pregnancy; but for their
history he has shown that they evidently were cases of retroversion: the
patient had been subject to occasional suppressions of urine and
difficulty in passing fæces; these symptoms had gradually diminished as
pregnancy advanced; the os uteri could not be felt, or, if it were
capable of being reached, was found high up behind the pubes, the head of
the child forming a large hard tumour between the rectum and vagina. The
condition of the vagina afforded strong evidences of the nature of the
complaint: on introducing the finger in the usual direction, it was
stopped, as if in a cul-de-sac: but on passing it forwards, the vagina was
found pulled up behind the symphysis pubis. In some of these cases the
uterine contractions gradually restored the fundus to its natural
position: the os uteri descended from behind the symphysis, and the child
was born after long protracted suffering; in others, which have been
mistaken for ventral pregnancy, the fundus has inflamed and ulcerated, and
the child has been gradually discharged by piecemeal.



CHAPTER VII.

DURATION OF PREGNANCY.


There are few questions of great importance and interest respecting a
subject under our daily observation, about which such uncertainty and so
much diversity of opinion exists, as the duration of human pregnancy; and
yet, as is the case with the diagnosis of pregnancy, upon a correct
decision frequently depend happiness, character, legitimacy, and fortune.
In like manner it frequently happens, that the data upon which we have to
found our opinion are exceedingly doubtful and obscure; and to increase
the difficulties of the investigation still farther, we have not
uncommonly to contend with wilful deception and determined concealment.

The duration of pregnancy must ever remain a question of considerable
uncertainty so long as the data and modes of calculation vary so
exceedingly. "Some persons date from the time at which the monthly period
intermits; others begin to calculate from a fortnight after the
intermission; some reckon from the day on which the succeeding appearance
ought to have become manifest; some are inclined to include in their
calculation the entire last period of being regular; and others only date
from the day at which they were first sensible of the motions of the
infant."[58]

"A good deal of the confusion on this point seems to have arisen from
considering forty weeks and nine calendar months as one and the same
quantity of time, whereas, in fact, they differ by from five to eight
days. Nine calendar months make 275 days, or if February be included, only
272 or 273 days, that is thirty-nine weeks only instead of forty. Yet we
constantly find in books on law, and on medical jurisprudence, the
expression "nine months or forty weeks." Another source of confusion has
evidently had its origin in the indiscriminate use of lunar and solar
months, as the basis of computation in certain writings of authority."[59]

It is owing to this uncertainty that a considerable latitude has been
allowed by the codes of law in different countries for the duration of
pregnancy, in order to prevent the risk of deciding where the data are so
uncertain.

Experience has shown that the ordinary term of human pregnancy, wherever
it has been capable of being determined with any degree of accuracy, is
280 days or forty weeks; and this period seems to have been generally
allowed even from the remotest ages. As, however, it is so difficult to
fix the precise moment of conception, it has been customary in different
countries to allow a certain number of days beyond the usual time; thus
the Code Napoléon ordains 300 days as the extreme duration of pregnancy,
allowing twenty days over to make up for inaccuracy of reckoning. In
Prussia it is 301 days, or three weeks beyond the usual time. In this
country the limit of gestation is not so accurately determined by law, and
therefore gives rise occasionally to much discrepancy of opinion.

The grand question which this subject involves, is, whether a woman can
really go beyond the common period of gestation. A great number of authors
have considered that the _partus serotinus_, or over-term pregnancy, is
perfectly possible; but by far the majority use such an uncertain mode of
reckoning that little confidence can be placed in them.

Two questions here arise, the determining of which will greatly assist us
in forming a correct view of this intricate subject, viz. _first_, what
has been the duration of those cases of pregnancy where the moment of
conception has been satisfactorily ascertained? _secondly_, what are the
causes which determine the period at which labour usually comes on?

The circumstances under which it happens that we are able to ascertain the
precise date of impregnation occur so rarely, that it is nearly impossible
to collect any considerable number of such cases. Three have occurred
under our own notice, in which there could be little doubt as to the
accuracy of the information given, and in each of these the patient went a
few days short of the full period. One, a case of rape, was delivered on
the 260th day; in the two others, sexual intercourse had only occurred
once; in one case she went 264, in the other, 276 days. We could have
mentioned several others, but where even the slightest shadow of doubt as
to their accuracy has existed, we have rejected them as inconclusive.

The mode of calculating the duration of pregnancy, which is ordinarily
adopted, viz. by reckoning from the last appearance of the catamenia,
although the chief means which is afforded us for so doing, is
nevertheless much too vague and uncertain to ensure a decided result; for
although it is a well-known fact, that conception very frequently takes
place shortly after a menstrual period, there can be no doubt that it is
liable to occur at any part of the catamenial interval, and particularly
so shortly before the next appearance: hence, by this mode of reckoning,
we are not more justified in expecting labour in nine months time from
the last appearance of the catamenia, than at any part of the interval
between this and what would have been the next appearance.

Dr. Merriman, who has devoted much attention to this intricate but
important subject, says, "When I have been requested to calculate the time
at which the accession of labour might be expected, I have been very exact
in ascertaining the _last day_ on which any appearance of the catamenia
was distinguishable, and having reckoned 40 weeks from this day, assuming
that the _two hundred and eightieth_ day from the last period was to be
considered as the legitimate day of parturition" (_Synopsis of Difficult
Parturition_, p. xxiii. ed. 1838;) and gives a valuable table of "one
hundred and fifty mature children, calculated from, but not including, the
day on which the catamenia were last distinguishable." Of these,

   5 were born in the 37th week,
  16    ---    in the 38th,
  21    ---    in the 39th,
  46    ---    in the 40th,
  28    ---    in the 41st,
  18    ---    in the 42nd,
  11    ---    in the 43rd;

so that about one-third were born three weeks after the 280 days from the
last appearance of the catamenia; a circumstance which is perfectly easy
of explanation, from what we have just observed, without the pregnancy
having overstepped its usual duration: in other words, it would appear
that 28 of these cases had conceived one week, 18 two weeks, and 11 three
weeks after the last appearance of the catamenia.

The question therefore of the _partus serotinus_; as far as these data are
concerned, remains still undecided: of 10 cases which have occurred under
our own immediate notice, where the patients determined the commencement
of their pregnancy from other data than the last appearance of the
catamenia, a similar variation was observed, viz. that nearly one-third
went beyond 280 days, six of these individuals reckoned from their
marriage, and four from peculiar sensations connected with sexual
intercourse, which convinced them that impregnation had taken place: of
these, seven did not go beyond the 280th day, two having been delivered
upon that day, and three went beyond it, viz. to the 285th, 288th, and
291st days: the two former reckoned from their respective marriages; the
latter, who went 291 days, from her peculiar sensations.

The calculation from the date of marriage is liable to the same objections
as that taken from the last appearance of the catamenia; for if it had
been solemnized (as is usually the case where it is possible) shortly
after a menstrual period, and if conception did not take place until a
fortnight or three weeks afterwards, the patient's pregnancy would thus
have appeared to have lasted so much longer than the natural term. The
case, however, which is stated to have gone 291 days, does not come under
this head, for here the pregnancy really appears to have lasted 10 or 11
days beyond the full period, which cannot be accounted for in the way
above mentioned: we should not have ventured to quote this, if a similar
instance had not been recorded by Dr. Dewees. "The husband of a lady, who
was obliged to absent himself many months, in consequence of the
embarrassment of his affairs, returned, however, one night clandestinely,
and his visit was only known to his wife, her mother, and ourselves. The
consequence of this visit was the impregnation of his wife; and she was
delivered of a healthy child in 9 months and 13 days after this nocternal
visit. The lady was within a week of her menstrual period, which was not
interrupted, and which led her to hope she had suffered nothing from her
intercourse; but the interruption of the succeeding period gave rise to
the suspicion she was not safe, and which was afterwards realized by the
birth of a child."[60]

Although it is to be regretted that this case has been calculated in the
ordinary vague manner of calendar months, yet it is perfectly evident that
the pregnancy was longer than the ordinary duration. We shall, therefore,
endeavour to investigate the possibility of over-term pregnancy still more
closely by a consideration of the second question, viz. what are the
causes which determine the period at which labour usually comes on?

It is now ten years ago since we first surmised that "the reason why
labour usually terminates pregnancy at the 40th week is from the
recurrence of a menstrual period at a time during pregnancy when the
uterus, from its distension and weight of contents, is no longer able to
bear that increase of irritability which accompanies these periods without
being excited to throw off the ovum."

Under the head of PREMATURE EXPULSION, we shall have occasion to notice
the disposition to abortion which the uterus evinces at what, in the
unimpregnated state, would have been a menstrual period: for some months
after the commencement of pregnancy, a careful observer may distinctly
trace the periodical symptoms of uterine excitement coming on at certain
intervals, and it may be easily supposed that many causes for abortion act
with increased effect at these times. Where the patient has suffered from
dysmenorrhoea before pregnancy, these periods continue to be marked with
such an increase of uterine irritability as to render them for some time
exceedingly dangerous to the safety of the ovum. Even to a late period of
gestation, the uterus continues to indicate a slight increase of
irritability at these periods, although much more indistinctly; thus, in
cases of hæmorrhage before labour, especially where it arises from the
attachment of the placenta to the os uteri, it is usually observed to come
on, and to return, at what in the unimpregnated state would have been a
menstrual period. We mention these facts as illustrating what we presume
are the laws on which the duration of pregnancy depends, and also as being
capable of affording a satisfactory explanation of those seeming over-term
cases which are occasionally met with.

From this view of the subject it will be evident, that the period of the
menstrual interval at which conception takes place, will in great measure
influence the duration of the pregnancy afterwards; that where it has
occurred immediately after an appearance of the menses, the uterus will
have attained such a dilatation and weight of contents by the time the
ninth period has arrived, that it will not be able to pass through this
state of catamenial excitement without contraction, or, in other words,
labour coming on: hence it is that we find a considerable number of
labours fall short of the usual time, so much so that some authors have
even considered the natural term of human gestation to be 273 days or 39
weeks: for a somewhat similar reason we can explain why primiparæ seldom
go quite to the full term of gestation, the uterus being less capable of
undergoing the necessary increase of volume in a first pregnancy than it
is in succeeding ones.

On the other hand, where impregnation has taken place shortly before a
menstrual period, the uterus, especially if the patient has already had
several children, will probably not have attained such a volume and
development as to prevent its passing the ninth period without expelling
its contents, but may even go on to the next before this process takes
place: it is in this way that we would explain the cases related by Dr.
Dewees and Dr. Montgomery. We are aware that, under such a view of the
subject, the duration of time between the catamenial periods of each
individual should be taken into account, some women menstruating at very
short, and others at very long, intervals; but although this will affect
the number of periods during which the pregnancy will last, it will not
influence the actual duration of time, as this will more immediately
depend upon the size and weight of contents which the uterus has attained.

The valuable facts collected by M. Tessier respecting the variable
duration of pregnancy in animals, which have been quoted by some authors
in proof of the partus serotinus, are scarcely applicable to this question
in the human subject; the absence of menstruation, and the different
structure of the uterus, prevent our making any close comparison.



CHAPTER VIII.

PREMATURE EXPULSION OF THE FOETUS.

    _Abortion.--Miscarriage.--Premature labour.--Causes.--Symptoms.--
    Prophylactic measures.--Effects of repeated abortion.--Treatment._


The uterus does not always carry the ovum to the full term of pregnancy,
but expels it prematurely. This expulsion of its contents may occur at
different periods, and is characterized accordingly: thus, among most of
the Continental authors, it has been divided under three heads; those
cases which occur during the first sixteen weeks coming under the head of
_abortion_; those which occur between this period and the twenty-eighth
week are called _miscarriages_; and when they take place at the latter
period, until the full term of utero-gestation, they receive the name of
_premature labours_.

It is perhaps useful to distinguish those cases of premature expulsion
which occur before from those which occur after the fourth month, inasmuch
as they seldom prove dangerous before that time, from the diminutive size
of the ovum and from the slight degree of development which the uterine
vessels have undergone; whereas, after this period the hæmorrhage is more
severe, and the general disturbance to the system greater. In other
respects it will be more simple to divide premature expulsion of the ovum
under two heads only; those cases which happen before the twenty-eighth
week, or seventh month, being termed _abortions_, and after this period
(as before) _premature labours_. This division is highly important in a
practical point of view, since it marks the period before which the child
has little chance of being born alive; whereas, after this date it may
with care be reared.[61] A foetus may be expelled, at a very early stage
of pregnancy, not only alive but capable of moving its limbs briskly for a
short time afterwards, but it is unable to prolong its existence separate
from the mother beyond a few hours. Cases do occur now and then where a
child is born in the sixth month, and where it manages to struggle
through, but these are rare, and must rather be looked upon as exceptions
to the general rule.

Abortions usually occur from the eighth to the twelfth week, a period
which is decidedly the least dangerous for such accidents. "The liability
to abortion is greater in the early than in the later periods of
pregnancy; for as the union between the chorion and decidua is not well
confirmed, as the attachment of the latter to the internal face of the
uterus is proportionably slight, and as the extent of surface which the
ovum now presents is very small to that which it offers in the more
advanced state of pregnancy, and as it can of course be affected by
smaller causes, it will be seen that a separation will be more easily
induced, and prove much more injurious to the well-being of the embryo,
than a larger one at another stage." (Dewees, _Compendious System of
Midwifery_, § 929.) Abortions coming on at a later period, viz. from the
sixteenth to the twenty-eighth week, which corresponds to the second
division, or _miscarriages_, of the continental authors, are not only more
dangerous than abortions at an early stage, for the reasons
above-mentioned, but also than premature labours, as in this last division
the uterus has attained such a size as to make the process rather resemble
that of natural labour at the full term.

_Causes._ Premature expulsion may be induced by a great variety of causes,
which may be brought under the two following heads: those which act
indirectly, by destroying the life of the embryo, and those which act
directly on the uterus itself. These various causes may be general or
local; the process of nutrition for the growth and development of the
embryo may be defective and scanty, from general debility or disease:
hence, whatever depresses the tone of the patient's health renders her
liable to abortion by causing the death of the embryo. Thus, dyspepsia and
derangement of the chylopoietic viscera; debilitating evacuations;
depressing passions of the mind; bad or insufficient nourishment; intense
pain, as in toothach; severe suffering from existing disease, especially
where the health is much broken down by some chronic affection; syphilis,
and febrile attacks, all act as indirect causes of abortion.[62]
Salivation from mercury not unfrequently has a similar effect; in some
instances, however, febrile affections appear to act much more directly,
stimulating the uterus to powerful contractions and rapid expulsion of its
contents. The symptoms which indicate the death of the child have already
been detailed in the chapter upon that subject.

The period which may elapse between the death and the expulsion of the
embryo varies exceedingly: in the early months the one usually follows the
other pretty quickly, owing probably to the slight attachment of the ovum
to the uterus; during the middle third of pregnancy the interval may be of
considerable duration, and cases every now and then occur where the foetus
is retained, not only several weeks, but even some months after its death;
whereas, during the latter third of pregnancy, expulsion follows the death
of the child after a short interval, seldom exceeding two or three days;
for now the weight of the dead foetus speedily irritates the uterus to
contraction, and, as has been observed by Smellie, the membranes, running
gradually into putrefaction, and being now unable to bear the weight of
the liquor amnii, burst, and expulsion soon follows.

Among the causes which act locally in inducing premature expulsion by
first destroying the child, may be enumerated external violence applied to
the abdomen, such as blows, falls, and other violent concussions; these
act indirectly by producing separation of the ovum from the uterus, and
thus destroying the life of the child. Under the same head may be classed
all violent exertions, as lifting heavy weights, straining to reach
something high above the head, &c. The mere act of walking, when carried
to such an extent as to induce exhaustion, will suffice, in weakly
delicate females, to bring on expulsion; sudden and violent action of the
abdominal muscles, when excited by a half-involuntary effort to save
herself from falling, or receiving any other injury, may produce a similar
effect: if the foetus be so young that its movements cannot be felt by the
mother, she feels from this moment more or less pain in the pelvis, with a
sensation of weight and bearing down; and this, in all probability, will
be followed by a discharge of blood from the vagina: where pregnancy has
sufficiently advanced for the motions of the foetus to be perceptible, the
mother will frequently feel them in an unusually violent degree for a
short time immediately after the injury, and then they cease entirely.

Premature expulsion may also be induced immediately without the previous
death of the child, by causes which directly excite the uterus to action:
thus, various violent mental emotions, as rage, joy, horror, may act in
this manner, although they may also act more indirectly; sudden exposure
to cold, as sudden immersion in cold water, will occasionally produce it
instantly. Irritation in the intestinal canal will directly excite uterine
contraction; hence an attack of dysentery is frequently a cause of
abortion, and we not unfrequently meet with patients who are liable to
this affection in every pregnancy: a similar effect may be produced by the
improper use of drastic purgatives, which irritate the lower bowels, viz.
aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited
to contract from the peculiar action of secale cornutum. On the other
hand, a loaded state of the bowels equally predisposes to abortion, by
impeding the free return of blood from the pelvis. A state of general
plethora acts in the same manner; and this is more particularly the case
if it takes place at what would, in the unimpregnated state, have been a
menstrual period; for, occurring in conjunction with the increased
vascular action which prevails at these periods in the uterine system, it
produces, as it were, an apoplectic state of the uterine sinuses, which
form the maternal portion of the placenta; blood is extravasated between
the ovum and uterus; their connexion is more or less destroyed, and the
death of the foetus becomes unavoidable: hence, in these cases the
expulsion may result either from this latter circumstance, or from the
uterus being irritated to contract by the effused blood between itself and
the membranes.

In patients who have suffered from attacks of dysmenorrhoea in the
unimpregnated state, the irritable uterus, when pregnant, is very apt to
contract upon its contents and expel them. This usually happens at what
would have been a menstrual period, and not unfrequently takes place so
soon after impregnation as merely to be looked upon as an unusually severe
attack, the little ovum having been imperceptibly expelled among the
discharges. Under this head must be brought those cases of spasmodic
affection of the uterus, which Dr. Burns has described, and where, from
the diminutive size of the ovum, the case has rather resembled one of
menorrhagia. Cases of abortion are also mentioned by authors where the
uterus is stated to be incapable of undergoing the necessary dilatation
and increase of size which pregnancy requires; but we are strongly
disposed to refer them to the above head of great uterine irritability, as
we neither know of any diagnostic marks which will enable us to detect
this condition during life, nor are we aware of any physical condition of
the uterus short of actual disease, to be detected after death, which can
produce this inability.

The uterus may be also excited to expel the foetus, without its previous
death by local causes, as acute leucorrhoea, or other inflammatory
affections of the vagina, by inflammation and other affections of the
bladder, as calculus, &c. Too frequent sexual intercourse during the early
months of pregnancy is peculiarly liable to excite abortion: this is
especially observed among primiparæ of the better ranks, where, from
luxurious living, &c., there is but little physical strength in proportion
to the great irritability of the system: hence we find that a fifth, or
even a fourth, of these females abort in their first pregnancies. In
conclusion we may briefly state that the same circumstances which in the
unimpregnated condition produce menstrual derangement and other disorders
of the uterine system, now act as so many causes of abortion.

The sudden cessation of the breeding symptoms, with sense of weight and
coldness in the lower part of the belly, flaccid breasts, pain in the back
and loins, and discharge of blood from the uterus, are pretty sure signs
of abortion: they are those which are "produced by separation of the ovum
and contraction of the uterus," (_Burns_;) the one is attended by
hæmorrhage, the other by pain. Although these are two chief symptoms which
characterize a case of threatened abortion, and although they must
necessarily be present more or less in every instance where premature
expulsion actually happens, still neither of them, either separately or
conjointly, can be considered as a certain proof that the uterus will
carry its contents no longer. Cases not unfrequently happen where patients
have repeated attacks of hæmorrhage during the early months of pregnancy,
and sometimes to a considerable amount, without any apparent disturbance
to the process of gestation, and are delivered of a living healthy child
at the full term: on the other hand, we have known instances where the
pain of the back was severe, and where, on assuming the erect posture even
for a minute, the sense of weight and bearing down in the lower part of
the abdomen was so great as to make the patient fear that the ovum was on
the point of coming away; still even these threatening symptoms have
gradually subsided, and the pregnancy has continued its natural period.
Puzos considered that neither pain nor hæmorrhage were necessarily
followed by expulsion. (_Mém. de l'Acad. de Chir._ vol. i. p. 203.) When,
however, both occur together, and to a considerable extent, the case must
be looked upon as one of at least doubtful if not unfavourable
termination. Where pain comes on at regular intervals, with hardness of
the uterus, and dilatation of its mouth, this is a serious symptom, for it
shows that the uterus will no longer retain its contents, but is evidently
preparing to expel them.

The part of the ovum at which the separation of it from the uterus has
taken place, not only determines which of the above symptoms will appear
first, but also the probability of expulsion. "When a considerable
separation takes place, as must be the case when it commences at the upper
parts of the uterus, pain will more likely occur than when it happens near
the neck; hence we sometimes have pain before the blood issues externally.
The uterus in this instance suffers irritation from partial distension
from the blood insinuating itself behind the ovum; contraction ensues; the
blood is thus forced downwards, and is made to separate the attachment
between the ovum and the uterus in its course, until it finally gains an
outlet at the os tincæ. In consequence of the uterus being excited to
contraction, the friendly coagula which may have formed from time to time
are driven away, and the bleeding each time is renewed and accompanied
most probably with increased separation of the ovum, until at last from
its extent the ovum becomes almost an extraneous body, and is finally cast
off. Hence a separation at or near the os uteri will not be so dangerous,
and in all probability there will be hæmorrhage without pain, which is
the contrary when it takes place near the fundus." (Dewees, _Compend.
System of Midwifery_, § 981, 982.) The pain during the abortion is
sometimes exceedingly severe, and not unlike that of dysmenorrhoea: this
is probably owing to the violent contractions of the uterus, which are
required to dilate the os and cervix before the ovum can pass: they are
frequently attended with nausea, vomiting, and fainting, and sometimes
with more or less general fever and local inflammatory action; the pain is
generally attended with much irritability of the bladder, and frequent
desire to pass water; the pulse is mostly quick and small, and where there
is arterial excitement, it is sharp and resists the finger.

_Treatment._ The treatment of premature expulsion consists in, 1, that
which is intended to guard the patient against its occurrence, or
_prophylactic_; and 2, in that which is required _during an attack_.

A knowledge of the various causes of premature expulsion will materially
assist us in the prophylactic treatment; under all circumstances, even
where there is not the remotest fear of such an accident coming on, it is
nevertheless highly important to pay strict attention to the state of the
stomach and bowels, for these are almost always more or less influenced by
the presence of pregnancy; the vomiting and sickness must be relieved in
the manner already pointed out under the chapter on the TREATMENT OF
PREGNANCY; the bowels, if constipated, must be moved by the mildest
laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and
thus all sources of irritation in the primæ viæ prevented as far as
possible. The patient must carefully avoid every thing which may excite
the circulation, such as violent affections of the mind, rich indigestible
and stimulating food, violent exertion, &c. The diet should be light,
nourishing, and moderate; heavy meals must be forbidden, and especially
suppers; she should keep early hours, take gentle and regular exercise,
and in fact, endeavour by every means in her power to raise her health to
a full degree of tone and regularity. In those patients who have already
miscarried in their previous pregnancies, these precautions must be
enforced with double vigilence; for the system becomes exceedingly
irritable, and the uterus soon acquires, as it were, a habit of retaining
its contents only to a certain period, and then prematurely expelling
them. When this is the case, it becomes exceedingly difficult, and is
often actually impossible, to make it carry the ovum to the full term of
utero-gestation, and, despite of the greatest care, the symptoms of
premature expulsion will come on at about the same time at which they
occurred in former pregnancies, and sometimes to the very same week.

In the treatment of such cases, where there is so much liability to
abortion, we must first examine the precise condition of the circulation,
and ascertain whether it be above or below the natural standard of
strength; for as abortion may arise from very opposite conditions of the
circulation, our treatment must consequently vary. If there be signs of
arterial excitement, a small bleeding may be necessary; it unloads the
congested vessels, diminishes the force of the circulation, and therefore
also the chance of an extravasation of blood between the uterus and ovum;
the bowels must be kept open by cooling saline laxatives, and the
circulation may be still farther controlled, by the use of nitre two or
three times a day. The diet must be spare; she must take regular exercise
in the open air, wear light clothing, dress loosely, and sleep upon a hard
mattress.

In these cases we are often warned that congestion of the uterine vessels
is present, by pain and throbbing, and sense of fulness in the groins;
leeches applied to these parts give much relief, and frequently render
venesection unnecessary. Tight lacing ought to be strictly prohibited in
all cases of pregnancy, particularly where there is a disposition to
plethora: among other bad effects, it prevents the proper development of
the breasts, the nipples are pressed so flat as to be nearly useless, the
child being unable to get sufficient hold of them: this may in some degree
be avoided, by putting thick ivory rings upon the breasts, and thus
shielding the nipples from injurious pressure. It will, however, be much
better to have the dress made loosely, to allow for the development of the
breasts, which takes place during pregnancy; for there can be little
doubt, that irritation of these glands is very liable to be followed by a
corresponding state in the uterus.

The common but erroneous notion that it is necessary to take an extra
quantity of nourishment for the support of the child as well as of the
mother must be strenuously opposed. Nature contradicts it in the most
striking manner; for, by the nausea and sickness which most women
experience during the first half of their pregnancy, she raises an
effectual obstacle to any error of this kind. "It certainly cannot be
intended for any other purpose, since it is not only almost universal, but
highly important when it occurs, as it would seem to add much to the
security of the foetus; for it is a remark as familiar as it is well
grounded, that _very sick women rarely miscarry_; while on the contrary,
women of very full habits are disposed to abortion, if exempt from this
severe, but as it would seem, important process." (Dewees, _on Children_,
§ 45.)

Where the case has become one of habitual abortion, the patient's only
chance will be by living separate from her husband for twelve or more
months: the uterus, not being exposed to any sexual excitement during this
period, becomes less irritable, and it gradually loses the disposition
which it has acquired of expelling its contents prematurely. In such a
case, when pregnancy has again commenced, it requires to be watched most
narrowly; every possible source of irritation must be removed by the
strictest attention to diet and regimen, and the patient must make up her
mind to be entirely subservient to the rules laid down by her medical
attendant. Although the chances are against her escaping without premature
expulsion, still we are not to despair, experience showing that cases
every now and then occur where the patient has gone the full term of
pregnancy in safety, in spite of repeated previous abortions. Dr. Young of
Edinburgh, in his lectures on midwifery, describes a case where the
patient actually miscarried thirteen times, and yet bore a living child
the fourteenth time.

On the other hand, where the condition of the patient evinces a state of
strength considerably below the natural standard, we find a very different
set of symptoms to those which have been just described, requiring
opposite treatment: the face is pale and even sallow; the pulse is soft,
small, and irritable; the tongue pale and flabby; the digestion impaired;
the bowels torpid; and the extremities cold: fatigue, or rather a sense of
exhaustion, is induced by the slightest exertion, and this is attended
with dull, heavy, dragging pain about the pelvis and loins, and a feeling
as if the contents of the abdomen required more support, and were disposed
to prolapse either by the rectum or vagina, on her maintaining an upright
posture for any length of time.

Even at a very early period of pregnancy, there is the sensation of a
weight in the lower part of the abdomen, falling over to that side which
is lowest, as we described among the signs of the death of the foetus at a
later period, resulting in all probability from a loss of tone and
firmness in the uterus. In this state, if nothing be done to restore the
mother's strength, the embryo will inevitably perish, and expulsion
follow, sooner or later, as a necessary result.

In all cases where pregnancy occurs, in a weakly delicate woman, measures
should be taken to increase the general tone of health, in order to fit
her for going through this process safely, by removing her to the country,
or to the sea-side, or to some watering place, where she will have the
opportunity of drinking a mild chalybeate, and enjoying a purer air. Where
it is even hazardous to move her, she should be put upon a course of mild
chalybeates. The food should be light and nourishing, and a glass or two
of wine or mild ale, may generally be taken with advantage. Where she can
bear it, tepid salt-water bathing, or sponging, will have the best
effects.

"For a number of years, (says Mr. White of Manchester,) I have been
convinced of the good effects of cold bathing, not only in preventing
miscarriages when every other method has been likely to fail, but other
disorders which are incident to pregnant women, and generally attendant
upon a weak lax fibre. I don't mean the cold bath in the greatest
extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing
in a tub in the patient's house, with the water a little warmed. I have
frequently advised my patients to bathe every other day, at a time when
the stomach is not overloaded, and not to stay at all in the water; to
begin this process as early as possible, even before they have conceived,
as there will be then no danger from the surprise, and continue it during
the whole term of pregnancy; and several have bathed till within a few
days of their delivery." (White, _on Lying-in Women_, p. 70.) Where
exercise can be taken without fear, it should be done regularly but
cautiously, so as not to induce fatigue or exhaustion, which is the very
effect we must be so careful to avoid; in fact, every means and
opportunity should be used of recruiting the powers and the vigour of the
system. In proportion as the strength increases, so does the irritability
diminish; the uterus becomes less sensitive to external impressions, and
can, therefore, bear its gradual development without being excited to
contraction; the foetus receives its due supply of nourishment; the
feeling of relaxation and deficient support of weight, and bearing down,
go off as health returns; and by thus keeping up the powers of the system
to the proper standard, it will be enabled to continue the process of
pregnancy to the full term.

Although some women recover very quickly after an abortion, and appear for
the time to suffer but little from its effects, they seldom escape with
impunity, more especially if it has been repeated more than once: anæmia,
with its varied train of anomalous symptoms and concomitant gastric and
cerebral disturbance, profuse leucorrhoea, menorrhagia, and dismenorrhoea,
are some of the more direct results of repeated abortion; we may also
enumerate prolapsus uteri, inflammation of the cervix, with induration and
scirrhus, as the more remote effects.

In the treatment of a case where expulsion is threatened, our object will
be either to stop that process in time to save the life of the foetus, or
if this cannot be attained, to carry it through, in such a manner, as to
expose the mother to as little danger and injury as possible.[63] In the
first instance, we must be guided nearly by the same rules as in the
prophylactic treatment: if there be considerable arterial excitement, and
evidence of general plethora, a small bleeding will be useful in restoring
a calm to the circulation; the most perfect quiet of body and mind must be
insisted upon; the patient should lie upon a hard mattress, and be covered
with as little clothing as is consistent with safety; she must refrain
from all exertion, and strictly maintaining the horizontal posture for a
considerable time. The indications for our treatment will be, 1. to remove
every thing which may, in any degree excite the circulation, and, 2. to
prevent the contraction of the uterus. Stimulants of every description,
and animal food must be forbidden; the bowels must be opened by gentle
saline laxatives; and if the pulse still betrays any sharp or resisting
feel to the finger, small doses of nitre may be taken as already
recommended. When the circulation has become perfectly calm, and every
trace of excitement allayed, opiates will prove of inestimable value: they
stop any disposition to uterine contraction, and remove the pain in the
back and loins which this will cause. The form which we prefer is the
Liquor Opii Sedativus, as being more sure in producing a sedative effect
than common laudanum, while at the same time, it produces less irritation
and derangement in the stomach and bowels.

A moderate discharge of blood from the vagina, although showing that a
separation has taken place between the ovum and the uterus, cannot be
looked upon as an unfavourable sign, for it relieves the pelvic vessels,
diminishes the pain in the back, and makes the patient feel more light and
comfortable; but if it be at all brisk, and continues so after the
employment of the above remedies, if also there be heat and throbbing in
the region of the uterus, it will be necessary to apply cloths wrung out
of cold water to the lower part of the abdomen and vulva, and to the
groins and sacrum; and this treatment must be continued in full force
until the symptoms of congestion have abated, and the discharge lessened
or stopped.

If the hæmorrhage be really profuse, it shows that the separation of the
ovum from the uterus must be of considerable extent; and as there will be
no chance of preserving the life of the foetus under such circumstances,
the expulsion of the ovum is no longer to be avoided, but rather to be
promoted; our attention therefore must now be directed to assist the
uterus in the evacuation of its contents, with as little injury and danger
to the mother as possible. It is, however, no easy matter to decide with
certainty when we must give up all hope of preserving the ovum, for a
large quantity of blood may be lost without expulsion being a necessary
consequence. Uterine contractions may have even taken place, and yet by
careful management the mischief may be sometimes averted, and the patient
be enabled to go her full time. Even where they have been of sufficient
force and duration to dilate the os uteri, we are not justified in
discontinuing remedial measures unless the flooding has seriously affected
the patient's strength, and the ovum be actually projecting through the os
uteri. "We might often prevent abortion (says Baudelocque) if we were
perfectly acquainted with its cause, even when the labour is already
begun. A very plethoric woman felt the pains of childbirth towards the
seventh month of her pregnancy, and the labour was very far advanced when
I was called to her assistance, since the os uteri was then larger than
half a crown; two little bleedings restored a calm, so much that the next
day the orifice in question was closed again, and the woman went the usual
time. Food of easy digestion prudently administered quieted a labour not
less advanced in another woman, where it was suspected to be the
consequence of a total privation of every species of nourishment for
several successive days. Delivery did not take place till two months and a
half afterwards, and at the full time. Emollient glysters and a very
gentle cathartic procured the same advantage to a third woman, in whom
labour pains came on between the sixth and seventh months of pregnancy,
after a colic of several days' continuance, accompanied with diarrhoea and
tenesmus." (_Baudelocque_,) § 2232. Nor is it always easy to decide
whether it be the ovum or not which we feel protruding through the os
uteri. "When the abortion is in the second or third month, the
practitioner must bear in mind that it may have been retention of the
menses, and, therefore, what he feels in the os uteri may either be an
ovum or a coagulum of blood. To decide this point he must keep his finger
in contact with the substance lying in the os uteri, and wait for the
accession of a pain (for where clots come away, pains like those of labour
are present,) and ascertain whether the presenting mass becomes tense,
advances lower, and increases somewhat in size; this will be the case
where it is the ovum pressing through the os uteri. On the other hand, if
it be a coagulum, which it is well known assumes a fibrous structure, it
will neither become tense nor descend lower, but be rather compressed.
Generally speaking, the ovum feels like a soft bladder, and at its lower
end is rather round than pointed, whereas, a plug of coagulum feels
harder, more solid, and less compressible, and is more or less pointed at
its lower end, becoming broader higher up, so that we generally find that
the coagulum has taken a complete cast of the uterine cavity. If we try to
move the uterus by pressing against this part, it will instantly yield to
the pressure of the finger, if it be the ovum; whereas, the extremity of a
coagulum under these circumstances is so firmly fixed, that when pressed
against by the finger the uterus will move also. When abortion happens at
a later period of pregnancy, we shall be able to feel the different parts
of the child as the os uteri generally dilates, viz. the feet, or perhaps
the sharp edges of bones, although we cannot distinguish the form of the
head from the cranial bones being so compressed and strongly overlapping
each other." (Hohl, _on Obstetric Exploration_.)

Although expulsion must be looked upon as the only means of placing the
patient in a state of safety, where the symptoms have advanced so far as
to preclude all hopes of preserving the life of the foetus, there are so
many steps of this process to be gone through before it can be entirely
completed, that more or less time must necessarily be required for that
purpose. The ovum must be completely separated from its attachments to the
uterus, and the contractions of that organ must have been of sufficient
strength and duration to produce such a degree of dilatation of its mouth
and neck as to allow the ovum to pass; but before this can be effected,
such a quantity of blood may have been lost as greatly to endanger the
life of the patient. Hence we must use such means as shall enable us to
control the hæmorrhage, whilst we give the os uteri time to dilate
sufficiently: this object will be gained most effectually by plugging the
vagina. The best mode of performing this operation is that recommended by
Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to
fill the vagina without producing uneasiness, must be wrung out of pretty
sharp vinegar, and introduced into the passage up to the os uteri; the
blood, in filling the cells of the sponge, coagulates rapidly, and forms a
firm clot, which completely seals up the vagina without producing any of
those unpleasant effects which are produced by the insertion of a napkin
rolled up for the purpose. A hard unyielding mass of this nature
frequently produces so much tension, pain of back, and irresistible
efforts to bear down, as to render it incapable of being borne for any
length of time. The sponge plug may be borne for hours without
inconvenience; we may either leave it to be expelled with the ovum, or
after awhile remove it for the purpose of ascertaining what progress has
been made. If the os uteri be still undilated, and the hæmorrhage going
on, the plug must be returned. It is however by no means a remedy to be
used in every case of hæmorrhage, for in most instances the treatment
already mentioned will be sufficient to keep it within safe bounds. Where,
however, the flooding has become very alarming, and the os uteri still
remains firm and but little dilated, the plug will prove an invaluable
remedy; and so long as the os uteri remains in this condition, and the
uterus itself shows no disposition to contract, we may safely trust to
perfect rest, cold applications, and the plug. Opium, which in the early
stages of the attack is so useful in keeping off contractions of the
uterus, will now for this very reason be contra-indicated; it will
diminish the power of the uterus, and interfere with the process of
expulsion.

The acetate of lead has been extolled as a powerful remedy for stopping
hæmorrhage, more especially by Dr. Dewees, who states that "in many cases
it seems to exert a control over the bleeding vessels as prompt as the
ergot of rye does upon the uterine fibre." (_System of Midwifery_, §
1045.) We have never tried this remedy in premature expulsion, having
found the means of treatment above mentioned sufficient; the authority
however of such an author demands respect, the more so as it is known to
be a valuable remedy in certain forms of menorrhagia.

Where a considerable quantity of blood has been lost, and the patient is
much reduced, we must endeavour not only to excite the contractile power
of the uterus, but also to assist this organ in the expulsion of its
contents: syncope in these cases is a dangerous symptom, because, as the
patient is in the horizontal posture, it will seldom be induced except by
a serious loss of blood; although we must not therefore allow her to flood
until she faints, still, however, when the pulse has become considerably
affected, the os uteri dilates more readily, and in this way facilitates
the expulsion; we must no longer trust to the plug, for the whole system
is beginning to sympathize and grow irritable, the pulse grows quicker and
smaller, and the stomach rejects its contents. Although vomiting as well
as syncope are symptoms which we cannot safely wait for, they are
nevertheless means which nature adopts to relieve herself from the
impending danger: by syncope she not only produces greater dilatability of
the os uteri, but also, by causing a temporary cessation of the heart's
action, she favours the coagulation of blood, and thus checks the
discharge; whereas, by the involuntary effort of muscles which she excites
by the action of vomiting, the ovum is more speedily separated and
expelled.

Where it becomes evident that expulsion cannot be prevented, it is our
duty to promote this process before nature has had recourse to the means
just mentioned. The ergot of rye is here a valuable remedy, for by
inducing or increasing the contractions of the uterus we shorten the
process and diminish the danger: the powder given in cold water is
decidedly the best form in which it can be given; in infusion its powers
seem to be injured by the heat of the water, and in tincture by the action
of the spirit: the addition of about half its quantity of borax renders
its action more powerful and certain. Borax has been long considered in
Germany to possess a specific power in exciting uterine contraction, but
it was first recommended for that purpose in this country by Dr. Copland.
(_Dict. Pract. Med._ art ABORTION.) A scruple or half a drachm of ergot
powder with ten grains of borax may be given in cinnamon water, and this
repeated every hour for several times.

In all cases threatening premature expulsion, wherever there has been much
pain and discharge, the napkins which come from the patient should be
carefully examined by her medical attendant, for otherwise the ovum may
escape among the coagula and not be perceived. Where the separation is
nearly complete, a portion of it protrudes at the os uteri; and this we
can sometimes hook down with one or two fingers, and bring away: a still
better mode is recommended by Levret, viz. of throwing up a pretty
powerful stream of warm water by means of a syringe. Dr. Dewees has
recommended a wire crotchet, which he has used with very good effect.
(_Op. cit._ § 1011.)[64] We ought not, however, to be in a hurry to bring
away the ovum, for when the uterine contractions have been of sufficient
strength to dilate the os uteri, it will generally come away of itself.
One objection to the wire crotchet is, that it tears the membranes, and
lets out the liquor amnii, and perhaps the embryo.[65] This is by all
means to be avoided; the larger the body which is to be expelled, the more
powerfully and effectually does the uterus contract upon it: hence,
therefore, if the membranes of a three or four months' ovum be imprudently
pierced with a view of hastening the expulsion, the liquor amnii and
embryo escape, but the secundines remain and require protracted efforts of
the uterus to expel them, during which time the sufferings of the patient
are prolonged, and the hæmorrhage kept up; whereas, if the ovum had
remained whole, it would have been expelled more easily and quickly. On
the other hand, where the foetus has already attained a considerable size
(fifth month,) the plan recommended by Puzos of rupturing the membranes is
very desirable; by this means the size of the uterus is reduced by the
escape of liquor amnii, and thus the hæmorrhage checked; and the foetus
remaining in the uterus is of sufficient weight and bulk to excite
contractions to expel itself and the membranes.

The treatment after abortion varies considerably: in many cases it will be
merely necessary for the patient to remain in bed for a few days
afterwards; but where she has been much reduced, a mild course of tonics
will be necessary, in order to prevent that disposition to leucorrhoea and
menstrual derangement which is so common a result: this, where it is
possible, should be combined with removal into the country, or to the
sea-side, or, what is still better to a watering place, where there are
mineral springs of chalybeate character. For the treatment of anæmia we
must refer our readers to the chapter on HÆMORRHAGE.



PART III.

EUTOCIA, OR NATURAL PARTURITION.



CHAPTER I.

STAGES OF LABOUR.

    _Preparatory stage.--Precursory symptoms.--First contractions.--Action
    of the pains.--Auscultation during the pains.--Effect of the pains
    upon the pulse.--Symptoms to be observed during and between the
    pains.--Character of a true pain.--Formation of the bag of liquor
    amnii.--Rigour at the end of the first stage.--Show.--Duration of the
    first stage.--Description of the second stage.--Straining pains.--
    Dilatation of the perineum.--Expulsion of the child.--Third stage.--
    Expulsion of the placenta.--Twins._


Parturition may be divided into two great orders, _Eutocia_ and
_Dystocia_, the one signifying natural labour which follows a favourable
course both for the mother and her child; the other signifying faulty or
irregular labour, the course of which is unfavourable.

We may define eutocia to be the safe expulsion of the mature foetus and
its secundines by the natural powers destined for that purpose. No
function exhibits such infinite varieties, within the limits of health and
safety to the mother and her offspring, as that of parturition; no two
labours, even in the same individual are exactly alike; still, however,
the great objects of the process will be the same, viz. 1st. the
preparation of the passages and the foetus for its expulsion; 2dly, the
expulsion of the foetus; and 3dly, the expulsion of the placenta and
membranes.

That we may form a clearer and more comprehensive view of this process,
labour has usually been divided into stages or periods, marked by the
changes just now alluded to: hence it is generally said to consist of
three stages; the first, or preparatory stage, commencing with the first
perceptible contractions of the uterus, and terminating in the full
dilatation of the os uteri; the second, or stage of expulsion, terminating
with the birth of the child; and the third, consisting of the expulsion of
the placenta.

_Preparatory stage._--_Precursory symptoms._ For some time before the
commencement of actual labour, a variety of changes are taking place which
must be looked upon as the precursors of this process: during the last
weeks of pregnancy, nature appears, as it were, to be preparing for the
great change which is at hand, and to be making such arrangements as shall
enable it to be completed with the least possible danger both for the
mother and her child.

One of the earliest warnings which we have of approaching labour is an
alteration in the form of the abdominal tumour; the cervix uteri has by
this time (especially in primiparæ) entirely disappeared; the presenting
part of the child has therefore descended to the lowest part of the
uterus; the fundus has sunk lower and more forwards; and from the
diaphragm being enabled to act with greater freedom, the respiration is
performed with more ease and comfort to the patient; she therefore feels
more capable of moving about, and is in better health and spirits than for
some time previously. Upon examination per vaginam, the head will be found
deep in the cavity of the pelvis, covered by the lower and anterior
segment of the uterus; the os uteri is still closed, and situated in the
upper part of the hollow of the sacrum, forming merely a small circular
depression. In women who have already had children, a portion of the
cervix uteri is still remaining; it is thick and bulky; and in some cases,
where the uterus has been greatly distended in several successive
pregnancies, it is nearly as long as in the unimpregnated state; the os
tincæ or os uteri externum is open, its edge irregular from former
labours; the upper extremity of the canal of the cervix is contracted, and
forms the os uteri internum; it has been closed during the greater part of
pregnancy, but usually is now sufficiently open to admit the finger; the
os uteri is neither so high up nor so far backwards in the pelvis as in
primiparæ, and is reached with greater ease; whereas, the head of the
child, instead of being felt in the cavity of the pelvis, generally
remains at the brim until labour is more advanced.

_First contractions._ The first contractions of the uterus (in a state of
health) are so slight as scarcely to be noticed by the patient: they
create a sensation of equable pressure and general tightness round the
abdomen, and during the contraction the uterus feels somewhat firmer, but
they are neither attended with pain, nor do they appear at first to have
any effect upon the os uteri; these precursory contractions generally come
on a day or two before actual labour commences, and sometimes are felt at
intervals for one or two weeks. Where the uterus has been exposed to any
source of irritation, and especially where there is a disposition to
rheumatic affection of this organ, they may produce much suffering and
give rise to one form of what are called _false pains_, hereafter to be
described. "The first contractions, says M. Leroux (_Sur les Pertes de
Sang_, § 41.,) are feeble, and communicate no sensation to the patient; in
order to discover them we must hold our hand upon the abdomen, and if we
feel the globe of the uterus raise itself and become hard, this is a true
contraction. These contractions gradually increase until they excite pain:
but pain is not essential to a contraction; it depends on the distension
and compression of the nerves produced by the resistance of the body upon
which the uterus acts, and increases in severity in proportion to the
degree of resistance and contraction."

In proportion as the lower part of the uterus descends into the cavity of
the pelvis, so does it exert a degree of pressure on the neighbouring
parts; the capacity of the bladder and rectum is diminished; and being
therefore unable to contain the usual quantity of urine and fæces, and
being probably rendered more irritable by the pressure above-mentioned,
the patient experiences frequent calls to pass water and evacuate the
bowels, which is sometimes effected with considerable difficulty: in some
instances she is obliged to lean forward, or support the abdomen, in order
to take the weight of the child off the neck of the bladder before she can
empty it: the same cause occasionally requires the use of the catheter,
and sometimes renders the introduction of it a matter of considerable
difficulty.

As these various changes make their appearance, the patient becomes
restless and anxious; she cannot remain long in the same posture; the
slight precursory contractions which have been just described, are
becoming stronger, and begin to produce a sensation of pain; the os uteri
(in primiparæ) opens somewhat, its edge at first is exceedingly thin, and
feels almost membranous; by degrees however it swells, grows thick and
cushiony, and is now more dilatable.

_Action of the pains._ The os uteri does not dilate merely by the
mechanical stretching which the pressure of the membranes and presenting
part exert upon it; it dilates in consequence of its circular fibres being
no longer able to maintain that state of contraction which they had
preserved during pregnancy; they are overpowered by the longitudinal
fibres of the uterus, which, by their contractions, pull open the os uteri
equally in every direction.

The vagina also swells and grows more cushiony, and this is followed by a
copious secretion of colourless and nearly inodorous mucus. "The more
albuminous it is the better, and it is always a good sign when lumps of
albuminous matter come away from time to time; the thicker, softer, and
more cushiony the os uteri is, the more mucus does it secrete." (Wigand,
_Geburt des Menschen_, vol. ii. p. 292.) The thin hard os uteri does not
dilate, its fibres are all in close contact, and like a well-twisted cord
will not yield; whereas, when they are separated from each other by the
swelling of the os uteri, they easily yield to the dilating force which is
applied to them. Besides serving the purpose of lubricating the passage,
the secretion of mucus is of great importance as a topical depletion, for,
by thus unloading the congested vessels, they diminish the vascularity and
heat of the part, and render it more capable of dilatation. "If, on the
other hand, the entrance of the vagina is small, the neighbouring parts
cool, dry, inelastic, and as if tightly stretched over the bones; if the
finger, in spite of being well oiled and carefully introduced, produces
pain upon the gentlest attempt to examine, we may expect a tedious and
difficult labour." (_Op. cit._ p. 190.)

The patient is now no longer able to conceal her pains when they come on.
If she be in the act of conversing she stops short, and remains silent
until the severity of the pain is over; if she be walking about her room
she is obliged to stand still for the time, and rest against or hold by
something until the pain has gone off. The true labour pains are situated
in the back and loins; they come on at regular intervals, rise gradually
up to a certain pitch of intensity, and abate as gradually; it is a dull,
heavy, deep sort of pain, producing occasionally a low moan from the
patient: not sharp or twinging, which would elicit a very different
expression of suffering from her.

_Auscultation during the pains._ "If we direct our attention to the
changes of tone which the uterine pulsations present during auscultation,
we shall find them generally stronger, more distinct and varied in tone
during labour; and this is especially the case just before a pain comes
on. Even if the patient wished to conceal her pains, this phenomenon, and
more especially the rapidity of the beats, would enable us to ascertain
the truth. The moment a pain begins, and even before the patient herself
is aware of it, we hear a sudden short rushing sound, which appears to
proceed from the liquor amnii, and to be partly produced by the movement
of the child, which seems to anticipate the coming on of the contraction:
nearly at the same moment all the tones of the uterine pulsations become
stronger; other tones, which have not been heard before, and which are of
a piping resonant character, now become audible, and seem to vibrate
through the stethoscope, like the sound of a string which has been struck
and drawn tighter while in the act of vibrating. The whole tone of the
uterine circulation rises in point of pitch. Shortly after this, viz. as
the pain becomes stronger and more general, the uterine sound seems as it
were to become more and more distant, until at length it becomes very
dull, or altogether inaudible. But as soon as the pain has reached its
height and gradually declines, the sound is again heard as full as at the
beginning of the pain, and resumes its former tone, which in the intervals
between the pains is as it was during pregnancy, except somewhat louder.
This is the course of things if the pain be a true one, and attain its
full intensity: where the pains are false or irregular it is very
different; the uterine sound either remains unaltered, or increases only
for an instant, or its seeming increase of distance, as above mentioned,
is not observed." (_Die Geburtshülfliche Exploration_, von Dr. A. T. Hohl,
erster theil, s. 105.)

_Effect of the pains upon the pulse._ It is curious to observe the effect
which a regular pain has upon the rapidity of the mother's pulse; as the
former comes on and goes off, so does the other increase or diminish. "The
increasing rapidity of the pulse announces the commencement of the pain;
it rises and attains its _summum_ with it; and as the pain subsides so
does the pulse gradually resume the rate which it had during the
intervals; a similar ebb and flow may be heard in the uterine souffle. The
more regular the pain is, and the more distinctly it rises to its full
extent, the more marked, regular, and distinct, is this change in it. We
may also invert the order of things, and say, the more distinctly the
rapidity of the pulse comes on and announces the pain, the more regularly
it rises and attains a certain height, which it maintains, and then
gradually subsides; in like proportion will the pain be more perfect,
attain its full extent more completely, and act more efficaciously upon
the regular progress of the labour. Where however the rapidity of the
beats subsides before it had scarcely begun to increase, the pain is too
weak; or where the rapidity rises by sudden starts, the pain is a hurried
one; and in either case its effect will be imperfect." (Hohl, _op. cit._
vol. i. p. 108.) In order that we may ascertain these changes correctly,
we ought to note the rapidity of the pulse during each successive quarter
of a minute as directed by M. Hohl; thus, in a pain which lasts two
minutes, the increase and diminution in the rapidity of the pulse may be
as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it
increases, so that shortly before the birth of the child we shall find
that what was the rate of the pulse during the height of the pains at the
beginning is now the rate of it during the intervals.

_Symptoms to be observed during and between the pains._ When a pain comes
on, the uterus grows hard and tense; if the fundus be somewhat to one
side, as is not unfrequently the case, it now gradually moves, so that the
median line of the uterus corresponds with that of the patient's body; the
various prominences of the child are no longer to be felt, the whole is
now firm and unyielding; the os uteri is put tightly upon the stretch, the
membranes which were loose become tense and are firmly pressed against it,
and the presenting part is rendered indistinct: as the pain gradually
subsides, the uterus becomes softer, and yields to the pressure of the
hand; the different parts of the child which project, as also its
movements, can now be felt more distinctly; the patient is free from pain,
and feels herself in an agreeable state of tranquillity, which is
frequently attended by a short refreshing doze; the os uteri, which has
become somewhat more dilated during the last pain, is now soft and loose,
so that we can hook the finger into it and move it about; the tight
bladder of membranes becomes relaxed and flaccid, and retracts more or
less into the uterus, so that we shall now be able to introduce the finger
into the os uteri and feel the presenting part through the membranes;
while the presenting part of the child, which during the pain was fixed,
can be moved somewhat by the finger.

_Characters of a true pain._ In examining the course of a true pain we
shall find that the contractions of the uterus do not begin in the fundus,
but in the os uteri, and pass from the one to the other. (Wigand, _op.
cit._ vol. ii. p. 197.) Every pain which commences in the fundus is
abnormal, and either arises from some derangement in the uterine action,
or is sympathetic with some irritation not immediately connected with the
uterus, as from colic, constipation, &c. We very seldom find that a
contraction of the uterus, which has commenced in the fundus, passes into
the cervix and os uteri, and becomes a genuine effective pain; usually
speaking, the contraction is confined to the circumference of the fundus,
without detruding the foetus at all. When a genuine pain comes on, so far
from the head being pressed against the os uteri, it at first rises
upwards, and sometimes gets even out of reach of the finger, whilst the os
uteri itself is filled with the bladder of membranes: if it had commenced
in the fundus instead of the inferior segment of the uterus, so far from
the head being drawn up at the first coming on of the pain, it would have
been forcibly pushed down against the os uteri. In the course of a few
seconds the contraction gradually spreads over the whole uterus, and is
felt especially in the fundus; the head which had been raised somewhat
from the os uteri is now again pushed downwards to it, and seems to act as
a wedge for the purpose of dilating it; it is not until the whole uterus
is beginning to contract that the patient has a sensation of pain. We may,
therefore, consider that a genuine uterine contraction consists of certain
phenomena which occur in the following order: first, the os uteri grows
tight, and the presenting part rises somewhat from it; then the rest of
the uterus, especially the fundus, becoming hard, the patient has a
sensation of pain, and the presenting part of the child advances. The
period of time necessary for all these changes varies not only in
different individuals, but in the same individual in different labours,
and in different stages of the same labour.

"The more completely the os uteri is opposite the fundus, and the more
the axis of the uterus corresponds with that of the pelvis, the sooner are
the pains, _cæteris paribus_, capable of dilating the os uteri."
(_Wigand_, vol. ii. p. 273.) The cushiony state of the vagina and os
uteri, and the free secretion of thick albuminous mucus from these parts,
as already mentioned, will be of great importance in ensuring their easy
dilatation. Where this secretion is either absent, or very scanty, the
passages become dry, hot, and tender, from no relief being afforded to the
congested vessels by its effusion; and _vice versâ_, where there is a
febrile state of the circulation and considerable topical excitement, the
secretion is sparing, or, perhaps, stops entirely. This state may arise
from a variety of causes, such as from general plethora, too warm
clothing, bad ventilation, derangement and irritation of the primæ viæ,
and abuse of spirituous and other stimulating liquors: it may arise from
constipation, or may be induced by rough and too frequent examination. The
patient becomes flushed, excited, and feverish, with a hot skin, dry
tongue, thirst, and headach; the uterine contractions become irregular,
they produce much suffering, and but very little advance in the progress
of the labour; the passages are in a state of inflammation, and more
especially the os uteri, which is much swollen and excessively tender. The
process of labour is completely interrupted, and can only be restored to a
healthy condition by bleeding, warm bath, laxatives, and enemata.

_Formation of the bag of the liquor amnii._ When the os uteri has dilated
more or less, a quantity of liquor amnii begins to collect between the
head and the membranes, so that when a pain comes on they form a tense,
elastic, and conical bag, which presses firmly against the os uteri, and
protrudes through it into the vagina, and from its form and elastic nature
greatly facilitates the speedy dilatation of it. If the edge of the os
uteri be still thin, it will become so tense during the pain, and the bag
of membranes will press so firmly against it, that we shall have some
difficulty for the moment in distinguishing the one from the other. As the
labour advances, the intervals between the pains become shorter, whereas
the pains themselves are of longer duration and more effective. In this
way pain succeeds pain until the os uteri, at length, attains its full
degree of dilatation; if the membranes have not yet ruptured, we may now
expect them to burst with every succeeding pain.

_Rigour at the end of the first stage._ At this moment the patient is
occasionally seized with a sudden and violent fit of shivering, so much so
as to make the teeth chatter, and even communicate a tremulous motion to
the bed itself; this is not the result of cold, nor is it relieved by the
application of external warmth; and, in many cases, the patient will
express her surprise that she should shiver thus violently, and yet not
feel cold. It appears to be a modification of convulsive action, excited
by sympathy between the os uteri on its becoming fully dilated, and
certain muscles in other parts of the body.

_Show._ On examination at this stage of the process, streaks of blood will
be found in the mucus which soils the finger, and sometimes it amounts to
a slight discharge of blood: this appearance is called by midwives "_a
show_," as it usually indicates that the os uteri is nearly or fully
dilated. It is produced by a separation of the membranes from the vicinity
of the os uteri, and consequent rupture of any little vascular twigs which
may have passed from the uterus to them.

The full dilatation of the os uteri terminates the _first stage_ of
labour. During this stage, the action of the pains does not appear to have
been so much for the expulsion of the child, as for preparing it as well
as the passages for this purpose, viz. by so arranging and regulating the
different forces of the uterus, and at the same time by giving the child
such a position (_i. e._ with its long axis parallel to that of the
uterus,) and the os uteri such a degree of dilatation, as shall ensure its
expulsion with the greatest possible ease and safety.

_Duration of the first stage._ The duration of the first stage of labour
varies exceedingly, both in primiparæ and those who have had several
children; nor is it at all easy to determine with precision the exact
moment when labour commences. The sensation of pain to the patient is no
guide whatever, for what is attended with much suffering in one patient is
scarcely sufficient to excite the notice of another. The dilatation of the
os uteri as marking its commencement, must also be taken with some
caution: in primiparæ, where it generally remains closed until the
contractions are becoming painful, it would obviously be wrong to date the
commencement of labour from the moment that the os uteri opens, as regular
uterine contractions have been evidently present for some hours
previously, although not of sufficient force to produce actual pain. On
the other hand, in women who have already had several children, the os
uteri is found open some days and even weeks before labour comes on. As a
general rule, we may state that regular and genuine contractions of the
uterus, sufficiently powerful to produce pain, seldom require more than
six hours to effect the full dilatation of the os uteri; in many cases a
much shorter time will be sufficient; whereas, in others, the first stage
of labour may last for more than quadruple this period before it is
completed: in neither can it be considered as abnormal; and we usually
find that where the pains of the first stage have been slow and lingering,
they become remarkably quick and active during the second stage. This
agrees with the experience of Dr. Churchill, in his report of the Western
Lying-in Hospital at Dublin, viz. that, "no evil consequences resulted,
and they (the labours where the first stage was so protracted) were
amongst those in whom the remaining stages of labour were shortest."

The first stage terminates with the full dilatation of the os uteri; the
rupture of the membranes is a change which is necessarily more or less
uncertain, as to the precise period of labour at which it takes place.
Thus, in primiparæ, it frequently occurs before the first stage is
completed; whereas in other cases the membranes sometimes do not give way
until the head approaches or has even passed through the os externum;
generally speaking, however, they burst at this period of the labour, and
usually effect a remarkable change in the whole process. The pains are now
of longer duration and more powerful, the intervals between them are
shorter, and yet, although the suffering is actually more severe, it is
more tolerable to the patient than that of the first stage. During the
first stage they are chiefly confined to one spot in the loins; and as
they must necessarily continue for some hours without any distinct
evidence of the labour being advanced by them, the patient feels
discouraged and gets a little impatient at the endurance of so much
apparently useless suffering: but as soon as the gush of liquor amnii
takes place, she feels that a great alteration has been produced; the
abdomen becomes smaller: the pains assume a very different character, and
every thing combines to assure her that she has made progress, and
encourages her to patience and resolution.

_Description of second stage._ The os uteri has now disappeared entirely,
so that the vagina and uterus form one continuous canal, and is thus
admirably adapted for the easy passage of the head: the anterior lip,
however, dilates much more slowly than the other parts of it, and this is
especially the case in primiparæ, for, being pressed between the head and
pelvis it becomes oedematous, and swells to a considerable size: if the
pains be strong, it is pushed down more or less before the head, and may
be frequently felt beneath the symphysis pubis, and occasionally it is
detruded so far as to be visible between the labia. According to Wigand,
the swelling of the anterior lip sometimes attains such a size as makes it
liable to be mistaken for the bladder of the membranes (_op. cit._ vol.
ii. p. 308;) it seldom produces much obstacle to the advance of the head,
and with a little patience gradually disappears of itself. All attempts to
push it up above the head are objectionable, because, in the first place,
the finger cannot reach sufficiently high to effect this object, and
therefore the swelling descends again to its former situation; and,
secondly, the efforts to push it up only tend to inflame it and increase
the swelling. Those who imagine that they can push up the anterior lip of
the os uteri above the head deceive themselves; and even if they do
succeed, it merely shows that had they let it alone, it would have gone up
very shortly of itself.

_Straining pains._ As the head enters the vagina, not only do the
contractions of the uterus become much more powerful, but now another set
of forces are called into action, and the half involuntary efforts of the
abdominal and other muscles come to aid the uterus in expelling its
contents. The sole object of this stage is the expulsion of the child, and
even the vagina by its contractions contributes to effect it. The head is
therefore subjected to considerable pressure; hence we may now feel the
cranial bones overlapping each other at the sutures, and the fontanelles
diminished in size; and, from the tightness with which the head is
embraced by the vagina, the circulation in the scalp is more or less
impeded, and a large oedematous swelling, called _caput succedaneum_,
forms on that part of the head which presents.

Each pain is attended with a violent and irresistible impulse to bear
down, and every muscle which can assist in effecting this object is now
brought into play. The tone of the patient's voice, the expression of her
face, the hurried breathing and sudden inspiration, stopping short the
moment a pain comes on, in order that she may add still greater power to
the efforts which she is about to make, all betoken a very different
process to that of the first stage, and one which requires a powerful
struggle of muscular strength and energy for its completion. Hence it is
that the sound of the patient's voice during the pain is frequently of
itself sufficient to inform us how far labour is advanced, for "we never
see the really powerful straining pains come on (the head may be never so
low in the pelvis,) so long as the os uteri is not fully dilated."
(Wigand, _op. cit._ vol. ii. p. 310.) This is a wise provision of Nature,
for by this means it prevents the danger of laceration to which the os
uteri would be otherwise exposed, and shows the importance of not
permitting a patient to strain and bear down until the os uteri be fully
dilated. In those cases where a patient has been induced to exert herself
prematurely, the efforts being voluntary are never so powerful, and soon
produce much fatigue.

Several reasons have been assigned why the straining pains should come on
at this stage. It cannot be owing to the pressure of the head upon the
parts of the pelvis, as has been supposed and especially the rectum, thus
producing the sensation of a violent desire to evacuate the bowels,
because, in almost every case of first labour, the head for several days
before the actual commencement of labour is sufficiently deep in the
pelvis to produce these effects. It evidently arises from a sympathetic
connexion "between the os uteri and vagina on the one hand, and the
abdominal and other muscles on the other. We see this connexion most
distinctly in those difficult labours where the head is pushed down deeply
in the pelvis even to the very outlet, and where the os uteri which is but
little dilated is protruded before it. In such cases we never see the
really powerful and continued action of the abdominal muscles excited,
let the head press never so forcibly upon the rectum; but as soon as the
os uteri (perhaps after much suffering) has retracted over the head, the
whole auxiliary action of the abdominal muscles commences." (_Ibid._ vol.
ii. p. 467.)

There is the same relation between these muscles and the vagina, as there
is between them and the rectum: the moment the vagina becomes distended,
it begins to contract upon the distending body, and like the rectum
excites them to strong and involuntary action. The tenesmus of dysentery
is a sympathetic action of the same nature; the rectum is highly irritated
by the acrid nature of its contents, and excites an irresistible
disposition to bear down. The patient wishes for the next pain and yet she
dreads it, from the suffering it creates, and the tremendous effort which
it compels her to make; the pulse is quicker, and is not only so during
the intervals, but undergoes a greater increase of rapidity during the
pains themselves than in the first stage; the face becomes red, swollen,
and bathed in perspiration; the breath is hurried; the lips are apart; the
eyes are wild; every thing betokens a state of the highest excitement.
When a pain comes on, she catches hold of whatever she can reach, plants
her feet upon any thing which is firm, and, by thus fixing her
extremities, she is enabled to bear down with greater power and effect.
During the struggle the face often changes its expression surprisingly, so
much so, that even her own attendants would scarcely recognise her.

_Dilatation of the perineum._ As pain succeeds pain, gradually increasing
both in force as well as duration, the head descends along the vagina, and
begins to press against the perineum; the rectum becomes flattened; the
sphincter ani dilated, and therefore any fæcal matter which may have been
lodging there is unavoidably expelled; the anterior wall of the rectum is
pressed close against the anus, and where the pressure is very great, even
protrudes somewhat through it; the hæmorrhoidal veins are frequently much
distended, and form a roll of cushiony swelling around the anus. A small
quantity of liquor amnii dribbles away from time to time, but is neither
during a pain, nor during the absence of a pain, for in the former case
the pressure of the head acts as a plug and prevents its escape, and in
the latter there is no uterine contraction present to expel it: the liquor
amnii dribbles away only at the moment when a pain is coming on or going
off.

_Expulsion of the child._ As the head descends farther it begins to press
more powerfully on the perineum, and during each pain pushes it out like a
large ball; and then, as a contraction goes off, and the resiliency of the
soft parts regain their superiority, it retires again. The breadth of the
perineum (viz. from the anus to the vulva) increases, whilst it diminishes
considerably in thickness, especially towards its anterior margin. Whilst
passing through the inferior aperture or outlet of the pelvis, the head
advances more or less forwards under the pubic arch, and begins to distend
the os externum; during a pain it separates the labia, and protrudes
between them, and again retires as the pain goes off; a larger and larger
portion of the head gradually forces itself through the os externum as
this dilates; the perineum becomes still thinner, so that at length it is
scarcely thicker than parchment. When more of the head has passed through,
it does not now recede when the pain goes off; the os externum and
perineum are at their greatest distension, for the largest diameter of the
head, which is presented to the os externum is now encircled by it; the
next pain brings the head into the world.

This is the moment of greatest pain, and the patient is frequently quite
wild and frantic with suffering; it approaches to a species of insanity,
and shows itself in the most quiet and gentle dispositions. The laws in
Germany have made great allowances for any act of violence committed
during these moments of phrenzy, and wisely and mercifully consider that
the patient at the time was labouring under a species of temporary
insanity. Even the act of child-murder, when satisfactorily proved to have
taken place at this moment, is treated with considerable leniency. This
state of mind is sometimes manifested in a slighter degree by actions and
words so contrary to the general habit and nature of the patient, as to
prove that she could not have been under the proper control of her reason
at the moment. It is a question how far this state of mind may arise from
intense suffering, or how far the circulation of the brain may be affected
by the pressure which is exerted upon the abdominal viscera.

A short cessation of pain succeeds the birth of the head. The violent
distension of the os externum has ceased for a time, and the patient feels
comparatively easy; but in the course of a few minutes the pains return as
before, although not quite so severe: first, the shoulder, which is turned
forwards, passes under the pubic arch, followed by the other which sweeps
over the perineum. The rest of the child is expelled with comparative
ease, and as soon as its pelvis has passed through the os externum, a gush
of the remaining liquor amnii, which had been retained in the upper
portions of the uterus, follows; the whole abdomen instantly sinks and
becomes flaccid, while the uterus contracts into a firm globe upon the
placenta, which is shortly to be expelled. A most delightful and perfect
calm succeeds, and the sense of freedom from suffering, and joy for the
termination of her trial, are expressed in the liveliest terms of
gratitude.

_Third stage._--_Expulsion of the placenta._ The period between the birth
of the child and expulsion of the placenta varies considerably. Sometimes
it follows the child very rapidly, so that, apparently, they are both
expelled by the same effort of uterine action; at others, the interval is
more considerable. There is generally an interval of ten or fifteen
minutes, and then pains of a totally different character make their
appearance: these are supposed to denote the separation of the placenta
from the uterus, and, from their being usually attended with discharge of
more or less blood, have been termed _dolores cruenti_ by many of the
foreign writers. The expulsion of the placenta is attended with little or
no suffering; it descends into the vagina inverted, _i. e._ with its
foetal or amniotic surface turned outwards: whether or not this is
produced by pulling at the cord is perhaps a question.

_Twins._ If there be twins, the placenta of the first child is seldom
expelled until after the birth of the second child. The membranes of the
second ovum become distended with liquor amnii, project into the vagina
and burst as in a common single labour; the passages have been
sufficiently dilated and prepared by the birth of the first child, so
that, when the uterus begins to contract, the expulsion of the second will
be readily and easily effected. The uterus may resume its efforts for this
purpose in twenty minutes after the birth of the first child, or it may
remain quiescent for several hours without at all disturbing the regular
and natural course of the process which will be precisely the same as in
the previous case.

The placentæ of twins are usually expelled together, forming one large
placentary mass; their vessels, however, are distinct from each other, so
that with care one placenta can be peeled away from the other. In other
cases, they are separated from each other by an intervening space of
membranes; and in one rare instance of triplet placentæ the umbilical
arteries of two placentæ anastomosed with each other, before dividing into
smaller branches.

Upon the expulsion of the placenta, the uterus, being now emptied of its
contents, contracts into a firm hard ball, which may be felt behind the
symphysis pubes, or sometimes a little to one side, of about the size of a
full grown foetal head. This state of hard contraction gradually
disappears, and a discharge of blood called lochia follows, which having
continued for a few days becomes colourless, and at length ceases
altogether. For a description of the changes which the uterus and passages
undergo in returning to their former condition as in the unimpregnated
state, we refer to the chapter on the FEMALE ORGANS OF GENERATION.



CHAPTER II.

TREATMENT OF NATURAL LABOUR.

    _State of the bowels.--Form and size of the uterus.--True and spurious
    pains.--Treatment of spurious pains.--Management of the first stage.--
    Examination.--Position of patient during labour.--Prognosis as to the
    duration of labour.--Diet during labour.--Supporting the perineum.--
    Treatment of perineal laceration.--Cord round the child's neck.--Birth
    of the child, and ligature of the cord.--Importance of ascertaining
    that the uterus is contracted after labour.--Management of the
    placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and
    abscess.--Excoriated nipples.--Diet during lactation.--Management of
    lochia.--After-pains._


This is a subject of great extent as well as importance, because it
comprehends the whole mass of rules for the management of a woman, not
only just previous to and during, but also after, her confinement. On
nothing does the course of a natural labour depend so much, as upon the
careful removal of every source of irritation which may tend in any way to
derange or interrupt the regular progress of that series of changes or
phenomena which constitutes the great process of normal parturition. It
will be necessary that the reader should have made himself thoroughly
master of the subjects discussed in the last chapter, before commencing
those of the present one. With each change there mentioned, the state of
the system and its functions should be carefully watched, and every slight
deviation from the natural course of things checked by appropriate
dietetic or medical treatment. Hence, therefore, the more a woman can
follow her usual avocations, and take that degree of exercise to which she
has been accustomed at other times, the better; for by so doing the
circulation is equalized, the digestion is kept in full activity, and the
tone and general strength of the system maintained.

It would almost seem, by rendering a woman more capable of moving about
during the last weeks of pregnancy (which has already been shown to be
produced by the sinking of the fundus, enabling the respiration to act
more freely,) that Nature intended she should use exercise at this period,
and thus prepare her, by increased health and strength, for a process
which requires so much suffering and exertion.

Her hours should be regular and early, her meals light and moderate, and
by agreeable and cheerful occupation she should fit herself, both in body
and mind, to meet the coming trial.

_State of the bowels._ Attention to the state of the bowels is of first
importance, and must never be neglected. It is a subject nevertheless upon
which women are remarkably careless, and they will frequently, when not
attended to, allow labour to come on with their bowels in a very loaded
and highly improper condition.

There is, perhaps, no one circumstance which is found to exert such a
prejudicial influence on the course of a natural labour, in so many
different ways, as deranged and constipated bowels. Where the contents are
of an unhealthy character, the irritation which they produce in the
intestinal canal is quickly transmitted to the uterus, and tends not a
little to pervert and derange the due and healthy action of this organ:
hence arises one of the most fertile sources of spurious pains, a subject
which will shortly come under our consideration. Where the bowels are
loaded, in consequence of the pressure upon the ascending cava,
considerable obstruction to the free return of blood from the pelvic
viscera is produced, the vessels of which become considerably engorged. No
organ feels these effects more than the uterus: from the immensely dilated
condition of its veins, a state of local plethora is engendered, which,
from the congested state of the uterine parietes, considerably interferes
with the free and regular action of its fibres, and not unfrequently
predisposes to hæmorrhage.

Moreover, the rectum being distended with fæces, diminishes proportionally
the capacity of the pelvis, and prevents the ready descent of the head
into it; occasionally it forms, at the beginning of labour, a solid
cylinder of indurated fæces, so hard, as, at the first touch, almost to
induce the suspicion of a projecting sacrum. As a measure of common
cleanliness, the bowels ought always to be attended to before labour, for,
besides the more serious effects now enumerated, the labour may be
rendered exceedingly filthy for the patient, and not less disgusting for
the practitioner; for, as the sphincter ani loses all power of contraction
when the head advances deeper into the pelvis, it follows that whatever
fæcal matter may have been lodging in the rectum will now be unconsciously
pressed out.

Hence, therefore, for the last few days of pregnancy, the bowels should be
regularly opened (unless they are so spontaneously, which is seldom the
case) by castor oil or other mild laxatives: and if labour has already
commenced before this measure has been taken, and if, therefore, there is
not sufficient time for the operation of the medicine, an enema should be
given.[66] In Germany it is a rule to throw up some chamomile infusion at
the commencement of every labour, by which means the process is rendered
more cleanly than is frequently the case in this country; and also, for
the reasons already given, the early stage is less apt to be tedious from
spurious and ineffective pains.

_Form and size of the uterus._ The more regular the first precursory pains
are, the more symmetrical and uniform will be the shape of the uterus; and
again, on the other hand, the more uniform its shape, the more regularly
and effectively will it act.

It is these slight but early contractions, which, although they produce
little or no effect upon the os uteri, exert a very important influence
over the first half of labour; for it is by their action, in great
measure, that the form of the uterus is determined, as also the correct
position of the child. Hence, therefore, some practitioners lay
considerable stress on ascertaining the precise form of the abdomen as a
means of determining what sort of labour the patient will have.

In a woman pregnant for the first time, and in a state of perfect health,
the uterus is of an oval or rather elliptical form at the beginning of
labour: when seen in profile, the abdomen presents nearly a uniform degree
of convexity. In this state the child lies with its long axis parallel to
that of the uterus, that is, with its head or inferior extremity turned
towards the brim of the pelvis; and if the fundus has already sunk in the
manner above-mentioned, the practitioner may very confidently
prognosticate that the head presents, even before making an examination
per vaginam.

In a perfectly healthy primipara there is scarcely any inclination of the
uterus either to one side or forwards, its median line corresponding with
that of the abdomen: whereas, in the multipara, the axis of the uterus is
seldom straight, inclining more or less to one side, or, from the greater
relaxation of the abdominal parietes, being somewhat pendulous. The size
of the uterus should also be taken into consideration, especially in first
pregnancies; a large uterus shows that either its parietes are gorged with
too much blood, or that its cavity is distended with an unusual quantity
of liquor amnii, or that the child is very large, or that there are twins.
Whatever may be the cause of the distension, it interferes with the
regular and effective contractions of the uterus, and tends to make the
labour (at least the first part of it) tedious. A moderate sized uterus is
much more capable of active exertion, for its fibres not being put so much
upon the stretch are enabled to contract better.

_True and false pains._ If the patient is already beginning to suffer
pains, it is of great importance to ascertain whether they be genuine or
spurious; upon the correct diagnosis of which, the favourable or
unfavourable course of the labour not unfrequently in great measure
depends.

A genuine labour pain comes on at tolerably regular intervals, rises
gradually to a certain degree of intensity, remains at that point for a
few seconds, and then subsides as gradually; the body and the fundus of
the uterus increase in hardness, and the os uteri in tenseness, in
proportion as the pain rises, and vice versâ; the pain is seated in the
back and loins, and is of a dull aching character: but with the spurious
pains it is quite the reverse; they come on and go off suddenly and
irregularly, the pain is in the abdomen, and produces a sharp twinging
sensation, and the hardness of the uterus and tenseness of its mouth bear
no proportion to the pain.

Spurious labour pains are the early contractions of the uterus perverted
and rendered irregular, spasmodic, and painful by irritation, congestion,
or inflammatory action; they sometimes come on several days before actual
labour commences, and if not recognised and removed, may expose the
patient to considerable suffering and exhaustion. Derangement of the
stomach and bowels is one of the most frequent causes of spurious pains,
for by the irritation which is thus produced, the uterus is almost sure to
sympathize, and to have its action more or less disordered. This may arise
from unhealthy irritating contents of the bowels producing spasmodic,
griping, and colicky pains, or from diarrhoea with tenesmus arising from
exposure to cold, or from irritation caused by the pressure of the gravid
womb. Spurious labour pains of this character also frequently occur in
patients who are accustomed to indulge in the luxuries of the table, or in
the lower classes, who are addicted to the use of spirituous liquors.
Constipation has been already mentioned as a cause of this condition. The
state of plethora, congestion, or inflammation, acting as a cause of
spurious pains, may arise from various sources: it is frequently observed
in strong healthy young women, especially those pregnant for the first
time; the pains do not assume the proper character of genuine labour
pains, and exhaust the patient by continued but useless suffering. The os
uteri probably dilates somewhat, but its edge remains thin and tense, and
the pains appear to have no effect in dilating it any farther. The mucous
secretion of the vagina is not of the character described at the beginning
of labour in the preceding chapter. The pulse is strong and more or less
excited, and the flushed face, and generally increased heat of skin
indicate the condition upon which those symptoms depend. The inflammatory
form of spurious labour pains is not unfrequently of the rheumatic
character, a condition which has not been much noticed in this country,
but which is capable of exerting a very considerable influence upon the
course and progress of the labour. It is usually produced by exposure to
cold and the other common causes of rheumatism in other parts of the body,
and is generally accompanied with more or less derangement of the stomach
and bowels. In this state each contraction of the uterine fibres is
attended with much suffering, although the contraction itself may be so
slight as to produce little or no effect upon the os uteri. Most of these
conditions, in a severe degree, form that species of dystocia which arises
from a faulty state of the expelling powers, for the farther consideration
of which we must refer to our chapter upon that subject. In a minor degree
they produce these slight derangements of uterine action, which we are now
considering under the name of _spurious pains_.

_Treatment of spurious pains._ The indications of treatment depend in
great measure upon the cause; and we cannot impress it too strongly on the
young practitioner, as a rule never to be lost sight of, that, whatever is
wrong in the state of the circulation or of the bowels must be first
rectified before having recourse to opiates. Where the stomach is much
deranged at the beginning of labour, nature frequently induces spontaneous
vomiting, with considerable relief to the patient, and mitigation of the
pains; if not a gentle emetic may be administered. Where the bowels are
loaded, the treatment already mentioned must be put into practice, after
which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine
in peppermint water, or gr x of Dover's powder may be given. When there is
diarrhoea with a good deal of griping and tenesmus, a dose of castor oil
with Liquor Opii Sedativus in any aromatic water may be administered; and
if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder
may be also given at night. If there be a plethoric or even inflammatory
condition, the lancet will be of the greatest service; it reduces the
temperature of the body, relaxes the soft parts, brings on copious
secretion of mucus, and by relieving the congested state of the uterine
parietes, enables the fibres to contract with more regularity and effect.
In the rheumatic form, laxatives followed by diaphoretics, the warm bath,
and even venesection will be necessary.

By thus treating the spurious pains according to their cause, they will
usually subside readily enough, and be either followed immediately by
pains of a more genuine and effective character, or leave the patient
perfectly free for several hours, or perhaps even days. It is by
inattention to, or ignorance of, these conditions, that patients have been
allowed to remain for several days in suffering, during which they have
been treated as if they had been in natural labour, until at length they
have become so exhausted that, when labour really made its appearance,
they were incapable of undergoing the exertions which this process
demands.

_Management of the first stage._ The preparatory pains of labour, which
form the first stage, do not require that the patient should take to her
bed at this early period; and this is especially the case in primiparæ,
where the first stage is usually somewhat tedious. Until nearly the end of
the first stage, she ought rather to be induced to suppose that actual
labour has scarcely yet commenced, and that she may still sit up or walk
about the room as best suits her feelings, taking care at the same time
that every thing is in readiness against the moment when it shall become
necessary for her to lie down. A nurse who understands her business will
of course duly arrange all these matters, but it behoves the accoucheur,
nevertheless, to pay attention to these little details, and to see that
every thing is properly prepared: that the bed is ready, and guarded
either by several folds of sheeting, or by a leather for the purpose, to
prevent the blood and other discharges during labour from soaking into the
bedding beneath; this must be done either on the right side or at the foot
of the bed, in order that the patient may be better within the reach of
the accoucheur: that the patient should be partially undressed, and
covered with her dressing-gown: that all the linen should be well aired:
that there should be towels, napkins, hot and cold water in readiness, and
also a bottle of vinegar, and one of spirit in the room, in case of
hemorrhage, suspended animation in the child, &c. &c. These and many other
arrangements of less importance are by no means beneath his attention, and
require but a moment's glance to assure him that every thing is properly
prepared.

By encouraging the patient to sit up as long as she can, or even to move
about occasionally, the pains are rendered more tolerable as well as more
effective; the time passes more agreeably and quickly; and by the time
that it has become necessary for her to lie down, the labour has made so
much progress that the rest of its course seems to be much quicker than
was at first expected. On the contrary, where the practitioner at an early
period of the first stage, informs her that she must stay up no longer,
that she must go to bed and remain lying on her left side, her mind is
solely occupied with her pains, which become wearying and irksome; the
time passes heavily away; she becomes impatient and therefore dispirited;
and is much disappointed, that, after remaining in this state for some
time, the termination of the labour appears to be as far off as ever.
Nothing eases the pains of the first stage, or increases their effect, so
much as frequent change of position and moving about; when, however, they
are severe or of long continuance, and the patient becomes fatigued, she
will require rest, and this opportunity, afforded by her lying down,
should be seized for the purpose of making an examination.

_Examination._ The manner in which this operation should be proposed to
the patient cannot be too delicate: it should, as Dr. Dewees has justly
observed, always if possible be done by means of a third person, such as
the nurse or any elderly female friend who happens to be present. If the
accoucheur has proposed it with that degree of gentleness and good feeling
which it ought to behove every one to show under such circumstances, he
will rarely, if ever, experience the slightest unwillingness to accede to
his request: the better the patient's rank in life is, the more docile
will she prove at these times, and the more resolute to undergo whatever
she is told it is necessary to submit to. The object of an examination is
to determine whether the child presents rightly, whether the labour is far
advanced, and to form some degree of prognosis as to its course and
duration, &c.: these are points which are of such importance as well as
interest to ascertain, that the dread which a patient feels at undergoing
an operation so repugnant to her feelings is generally merged more or less
in the intense anxiety to know if all is right.

An examination at an early period of labour is important in many respects.
We ascertain the condition of the vagina, whether it be soft, cool,
relaxed, and well lubricated with mucus, as described at the beginning of
the last chapter; whether the os uteri be dilated; whether its edge be
thin and tense, or already becoming soft, cushiony, and yielding; whether
the membranes are ruptured; whether the presentation be a natural one, and
whether the pelvis be rightly formed. In cases where the umbilical cord is
prolapsed, it is particularly desirable to ascertain the existence of this
displacement as early in labour as possible.

It is usually directed to examine during a pain, because at this moment we
feel the os uteri tense, and therefore more distinct to the finger; but it
is far better to examine during the interval between the pain: the os
uteri being now relaxed, admits the finger more easily; the membranes
being loose are not so liable to be ruptured; and, from their not being
distended, we shall feel the presenting part more distinctly.

Wherever the os uteri is nearly or fully dilated, or from its condition
and the effect which the pains have upon it shows a disposition to dilate
with rapidity, the patient should go to bed, as we cannot be sure when the
membranes may rupture, more especially in primiparæ, in whom this usually
takes place early. It is equally desirable, also, in those who have
already had children, that the patient should be upon her bed at this
moment; because, if the pains be strong, and the os uteri yielding, the
head is apt to follow the discharge of the liquor amnii, and sudden
expulsion of the child might result at a moment when the patient is
unprepared for such an occurrence.

The accoucheur should always examine when the membranes give way, because
not only will he be able to feel the presenting part now more distinctly,
but if the cord has prolapsed, a coil of it will come down into the
vagina and cannot escape his notice; in fact, if there is any thing
unusual about the presentation, he will be now able to distinguish it with
greater certainty. In women who have had large families, the head remains
very high in the pelvis until this moment, so that it is frequently
extremely difficult to reach it and to ascertain its position: the same is
observed with presentations of the nates and of the shoulder, which seldom
descend into the pelvis until the liquor amnii escapes.

_Position of the patient during labour._ The position which the patient
should take during the actual process of labour has been a subject of
considerable discussion, and even at the present day varies exceedingly in
different countries. In the earliest periods of history, women appear to
have been delivered in a sitting posture, as is described in the first
chapter of _Exodus_: this mode was revived in comparatively modern times;
thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined
back, which he preferred to a common bed. Labour chairs were brought into
very general use upon the Continent in the beginning of the last century
by Hendrick van Deventer of Dort in Holland, and although they have been
in great measure discontinued in modern times, there are still some
districts of Germany where they continue to be used. It is a species of
chaise percée furnished with straps, cushions, &c. by which the patient
can fix her extremities, and thus enable the abdominal muscles to act with
the greatest power. This is the very reason which renders labour chairs
objectionable. The presenting part of the child is forced through the soft
passage with great violence, before they have had time to yield and to
dilate sufficiently; hence it has been noticed that lacerations of the
perineum are of very frequent occurrence in those countries where labour
chairs have been in general use. In some remote parts of Ireland, and also
of Germany, the patient sits upon the knees of another person, and this
office of substitute for a labour chair is usually performed by her
husband. Labour chairs, as far as we are acquainted with their history,
were never used in this country, nor have they been used for the last
century in France, where the patients are usually delivered in the supine
posture, on a small bed upon the floor, which has not inaptly been termed
_lit de misére_. A modification of the labour chair is the labour cushion
first used by Nuger, and afterwards by the late Professor von Siebold of
Berlin and Professor Carus of Dresden; it is a species of mattress, with a
hollow beneath the nates of the patient for receiving the discharges which
take place during the labour. The patient is compelled to lie upon her
back during the greater part of labour, and thus maintain the same posture
for some time, which must necessarily become irksome and even painful to
her. In this country and in Germany the patient is delivered upon a common
bed, prepared for the purpose as above mentioned: in England she is placed
upon her left side, the nates projecting to the edge of the bed, for the
greater convenience of the accoucheur: in Germany, except in Vienna and
Heidelberg, where the English midwifery has in great measure been
introduced by Boer and Naegelé, the patient is delivered upon her
back.[67] In former times the supine posture was also used in this
country, but for about a century the position on the left side has been
preferred; the patient lies more comfortably to her own feelings; her face
is turned from the practitioner who sits behind her, and who, from this
posture, is able to examine or to perform any other necessary manipulation
without her feelings being annoyed by seeing what is going forward. It is
decidedly the easiest position during the last moments of tremendous
suffering and exertion; when the presenting part is passing she is not
able to exert an undue degree of violence, and from the knees being kept
together, there is less danger of the perineum being torn. The left side
seems moreover to be the natural position for a woman at the moment of
parturition, for if accidental circumstances have occurred, such as sudden
labour, &c. by which she is deprived of all assistance at this moment, she
will almost invariably be found upon the ground lying on her side
supporting herself with one hand. In some cases she will remain during
these moments upon her knees, into which posture she has gradually dropped
from that of standing: in by far the majority of cases she will take the
position upon her side, as above mentioned.

So long as the os uteri is not fully dilated, the patient is not
involuntarily compelled to strain and bear down: hence it is important to
caution patients, more especially primiparæ, not to be induced by an
ignorant nurse or friend to exert themselves improperly during the first
stage of labour, for not only is the process of dilatation considerably
impeded, and much exhaustion produced, but frequently severe febrile or
inflammatory action excited, which may lead to serious results after
labour. All attempts to accelerate the course of a natural labour,
especially the first stage, either on the part of the patient by premature
straining, or on the part of the practitioner by attempts to dilate the os
uteri and passages, or by giving her stimuli, &c. cannot be too strictly
forbidden. It is a mode of practice which has long since been strongly
condemned by the highest authorities in midwifery, except in Scotland, and
which may very easily lead to most mischievous results. Quick rapid
labours are by no means desirable, for they are seldom safe; nor is it
possible to limit this or that stage (especially the first) to any given
duration of time.

No conscientious practitioner, who has clear and enlarged views of the
process and mechanism of natural labour, would feel himself justified in
interfering with its course, merely because some portion of it has
extended beyond a certain fixed period; but would rather guide his conduct
by the habit and strength of the individual, and by the effects which the
labour has upon her. We have before stated, that no two labours are alike;
we may also add, that no two individuals are similarly affected by the
same degree and duration of labour, nor indeed are any two labours exactly
alike in the same person: hence it will be evident, that what to one
patient would prove a protracted and exhausting labour, to another would
be nothing more than a perfectly regular labour, natural both in its
character and progress. Among other injurious effects which premature
efforts on the part of the patient will have, is, that the membranes are
liable to give way too soon--this is by all means to be avoided, for
nothing is so likely to render the first stage protracted as the
occurrence of this accident; the course of the labour frequently undergoes
an immediate change; the pains lose their regular and effective character;
the os uteri remains thin, tense, and unyielding, and the process of
dilatation is greatly retarded.

_Prognosis as to the duration of labour._ There are few subjects upon
which an accoucheur is so frequently importuned, or about which it is so
difficult to give a decided opinion, as the probable duration of labour.
It is natural enough that both she and her friends should be anxious to
know how long this process of suffering is likely to last: nothing,
however, is more hazardous than a prognosis in these cases; and we would
warn our junior brethren to be cautious how they commit themselves by
venturing an opinion, which the result of the labour may prove to have
been founded upon guess-work or ignorance. The character of the labour
during the second stage, is frequently very different to that of the
first, so that the mode in which the labour commences is by no means a
criterion for its latter part. A labour which has commenced briskly and
regularly, and with every promise of a rapid progress and termination,
frequently becomes exceedingly lingering during the second stage, so that
the expelling powers may, perhaps, even fail altogether in making the head
pass through the os externum; whereas, on the other hand, a labour, the
first stage of which has been slow and protracted, frequently experiences
a complete alteration of character, and advances with a degree of
quickness and energy, which could scarcely have been anticipated from the
manner in which it commenced. In primiparæ, especially, it is particularly
difficult to foretell, with any thing like certainty, the duration of
labour: hence it is, that unguarded assertions in this respect are not
only liable to disappoint the patient, but destroy her confidence in the
practitioner.

_Wigand's views._ The celebrated Wigand of Hamburgh considered that the
form of the vagina would frequently furnish the means of a pretty certain
prognosis, as to the duration of labour: thus, if it were wide and
yielding throughout its whole length, the labour would be quick, both at
its beginning and termination; if, on the other hand, it were small,
rigid, and contracted throughout, the labour might be expected to be of a
very opposite character. If on examination the vagina is found roomy and
well dilated at its upper part, but contracted and rigid near the os
externum, the labour will be probably quick and easy during the first
half, but slow and difficult afterwards; on the contrary, where the os
externum is yielding and wide, but the upper portion of the vagina narrow,
the labour may be expected to be slow at first, but to be brisk and active
afterwards. We have already stated, that the course of labour varies in
every possible way; in some cases the same peculiar character of labour
shows itself through two or three successive generations: hence it has
been observed, that very tedious or very violent and rapid labours
sometimes seems to be hereditary; the mother, daughters, and
grand-daughters, being all remarkable for their lingering or rapid
labours.

_Diet during labour._ The diet of the patient during labour should be
simple and unirritating; if every thing is going on naturally and briskly,
some gruel or tea, with or without a little biscuit or bread and butter,
will be quite sufficient; but if the process is becoming tedious and
exhausting, some beef-tea, broth, or any other mild nourishment of this
sort will be required to support the strength.

During the first stage of labour there is no need for the practitioner to
be constantly in the room, nor even during the early part of the second,
unless the pains are very violent and protrusive; for, by taking frequent
opportunities of quitting the patient for a few minutes, she is left more
free from restraint, and the presence of the practitioner becomes less
irksome when it is really necessary; whereas, if he continues at the
bed-side, she is justified in expecting that the labour must be advancing
rapidly to demand so unremitting an attendance, and, therefore, becomes
disappointed and impatient to find that his presence has been of so little
use to her. The conversation should be light and cheerful, and every means
taken to encourage her and keep up her spirits.

_Supporting the perineum._ As the head approaches the os externum our
attention must be directed to giving the perineum such a degree of
support, as shall secure it from any serious degree of laceration during
its passage. The greatest danger of ruptured perineum is in primiparæ, for
the soft parts never having been subjected to such a degree of dilatation
before, do not yield so readily as in multiparæ. The anterior margin of
the perineum, called _frænulum_, is, we believe almost invariably ruptured
in every first case; but the laceration ought not to extend farther. The
more gradual the advance of the head is through the os externum, the
better will be the dilatation of the soft parts: hence therefore, when the
pains are violent, and the head is thrust with great force against the
perineum, it will be desirable to restrain it in some degree, until the
parts shall have had sufficient time to yield; on the other hand, where
the pains are more gradual, the perineum and os externum may receive the
whole dilating force of the head, and every succeeding pain will show that
a progressive advance is taking place.

The increasing thinness of the perineum itself, and the frænulum becoming
tense during the height of a pain, may be looked upon as warnings that the
expulsion of the head is not far distant, and now the support of the hand
will be needed to prevent laceration; for this purpose the position on the
left side is peculiarly convenient, besides having the additional
advantage of relaxing the external parts more completely. If the pains be
violent, and the impulse to strain very considerable, we must desire the
patient to lie as passive as she can, and do her best not to bear down,
for otherwise the head is sometimes driven through the os externum with a
single effort, and the mischief done in spite of all our care.

The support of the perineum has been variously directed by different
authors; we prefer using the left hand, because then we have the right at
liberty for any manipulations which may be necessary, such as examining if
the cord be round the child's neck, &c. &c. It is awkward at first,
because it requires the hand to be considerably twisted, and makes the
wrist ache a good deal; but a very little practice soon conquers this
slight difficulty, and the superiority of the mode will then be apparent.
As our object is not merely to support the perineum, but to direct the
head as much forwards under the pubic arch as possible, in order that the
anterior portions of the os externum should undergo their share of
dilatation, and thus in some measure spare the perineum, the chief
pressure should be applied near to the sphincter ani, gradually
diminishing it up to the frænulum perinei in front: for this purpose the
left hand protected by a napkin (partly for the sake of cleanliness and
partly for the purpose of having a firmer hold upon the parts, and
preventing it slipping) should now be applied with the palm in the
vicinity of the sphincter ani, so that the tips of the fingers should
project somewhat beyond the frænulum; the whole should be laid as flat and
close to the part as possible. In order that we may be sure of the hand
being applied exactly along the raphe of the perineum, we should guide it
by the examining finger of the right hand, bearing in mind, that when we
place this against the posterior margin of the os externum, and bring the
middle finger of the left hand in contact with it, we shall hold the left
hand in the desired direction.

It is desirable also to hold the examining finger of the right hand
against the frænulum perinei when a pain comes on, because then we know
exactly when the tension of the perineum is becoming such as to endanger
its integrity, and when the head is about to pass out. Until this moment
the frænulum is seldom on the stretch, although the rest of the perineum
is: hence we need not apply our support until now, and thus give the parts
the full benefit of the dilating force, which the head exerts upon them,
until the very last instant. To relax them still farther, the patient's
knees ought not to be separated by a pillow or cushion placed between
them, as is usually done, although it must be confessed that in some cases
she is relieved by it.

In applying the left hand to support the perineum, it should be placed
somewhat more backward than the spot which we intend to support: for by
this means we are enabled to push the soft parts somewhat forwards, and
thus relax them. By this means, also, we not only direct the head against
the other parts of the os externum but avoid the danger of its perforating
the perineum. When the moment of greatest distension arrives, the process
cannot be too slow; we must therefore desire the patient not to bear down,
and endeavour, if possible, to make the head remain in the state of
_crowning_ until the next pain comes on: the os externum having been held
for some moments at its utmost dilatation, permits the head to pass with
greater ease and safety. As the globe of the head passes forwards and
emerges through the os externum, we feel the posterior portions of the
perineum become soft and lax, while the forehead, followed by the face,
and lastly the chin glide over the anterior margin of it.

The passage of the head is not the only moment of danger to the perineum,
for laceration is even still more liable to be produced during the
expulsion of the shoulders; any slight rupture of the anterior edge is now
apt to be converted into a considerable laceration, unless the support be
continued until the thorax be expelled. We have already stated that the
frænulum perinei is generally torn through in the first labour; but the
laceration ought not, if possible, to extend farther, because serious
injury may be produced either to the vagina, or even to the sphincter
rectum. To say, however, that laceration of the perineum need never
happen, would be preposterous; because cases every now and then occur,
where, from the contracted and unyielding state of the os externum, and
from the size of the child, it is nearly impossible that the perineum can
escape without injury; fortunately, although considerable lacerations are
by no means uncommon, they are seldom observed to extend into the
sphincter ani, the direction of the rent being usually to one side. Under
the ordinary circumstances of perineal laceration, little more than mere
attention to cleanliness is required; for the parts contract so
astonishingly after labour, that what was a wide rent of an inch and a
half long, in a couple of days will be scarcely more than two or three
lines in length. Rest, great cleanliness, and gentle-relaxed bowels,
constitute the chief treatment.

_Treatment of perineal laceration._ Where, however, the laceration extends
into the rectum, the case becomes exceedingly troublesome and difficult to
cure, and the patient is liable to be rendered a miserable object for
life; for the action of the sphincter being entirely destroyed, she is
unable to retain fæces or flatus in the rectum; besides which, from the
injury to the posterior wall of the vagina, prolapsus uteri is an almost
certain consequence. In these cases the slightest movement of the thighs
upon each other alters the position of the lips of the wound, and thus
tears it open afresh, so that at length the edges of the wound become
callous and refuse to heal. A great deal in these cases depends upon the
patience and good conduct of the patient herself; for if she have the
resolution to lie perfectly still for at least a week, she will have every
chance of a perfect cure. If there be much swelling of the edges, and a
disposition to slough, a warm poultice of chamomile flowers should be
applied, and the bowels kept in a nearly liquid state by gentle and
repeated doses of salines, in order to prevent distension of the rectum
when the evacuation is passing; she should preserve the supine posture,
and have her knees confined together by a piece of tape, as is done with
patients after the operation of lithotomy. Straps of adhesive plaster are
seldom or never of any use, but if the rent be very severe a suture or two
may be required. The great fault in applying these means for bringing the
edges of the wound together is the attempting to unite them throughout
their whole length; for by so doing the tension of the parts is increased,
and therefore there is less disposition to unite; and even if we succeed
in effecting complete union of the whole wound, the perineum is so
contracted and unyielding from the cicatrisation, that it can scarcely
escape a repetition of the injury in succeeding labours. It is, therefore,
much better that we should content ourselves with uniting merely the
posterior half of the laceration; the parts heal much more readily, and
the os externum is left of a sufficient size to escape all danger of
laceration on future occasions.

Where the edges have become callous and refused to unite, they require to
be pared and brought together again; this, however, does not always
succeed, and the case becomes very difficult and protracted: under these
circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is
well worthy of attention. Having pared off the callous edges of the wound,
he brings them into the closest opposition by transfixing them with
needles in several places, as is done for the operation of hare-lip; and
in order to isolate the wound as much as possible from the surrounding
parts, and prevent any tension, he makes a free incision through the
integuments, parallel with the wound, at a little distance from it, and
nearly of the same length; by this means, every cause which might tend to
separate the edges is removed; whilst the parallel cuts, being fresh
incised wounds, soon close by granulation.[68]

It sometimes, although rarely, happens that the perineum, instead of being
torn from before backwards, is perforated through its centre by the head,
so that the child is not born through the os externum, but through a
lacerated opening in the body of the perineum. This accident may arise
from a variety of circumstances: the direction of the pelvic outlet may be
faulty, or the inclined plane formed by the lower part of the sacrum, by
the sacro-sciatic ligaments, &c. may be insufficient to guide the head
forwards under the pubic arch; or the perineum may be unusually broad; in
which cases the power of the uterus being directed against the centre of
it, the head becomes enveloped in a bag of protruded perineum; and if the
pains are violent, and the head not properly supported, it at length
bursts its way through the centre without even injuring the frænulum. The
treatment of this form of ruptured perineum is the same as that of the
more common species; the bowels must be kept open, and a fomentation of
chamomile flowers applied to the wound, which, from the gradual
contraction of the surrounding parts after labour, diminishes remarkably,
so that in the course of a short time it will have entirely or nearly
closed.[69]

Besides the above-mentioned advantages in supporting the perineum, we may
mention another which is not generally noticed, and which is sometimes of
considerable service. In cases where the head has completely descended
upon the perineum, and begins to protrude somewhat through the os
externum, the pains occasionally fail at this moment, the labour becomes
very lingering, while the advance of the head and state of the parts show
that two or three active pains would bring the child into the world; firm
pressure applied at the lower end of the sacrum, in a direction forwards,
materially adds to the effect of each pain in bringing the head through
the os externum, and seems also to excite the patient to make a more
powerful effort with the abdominal muscles. On several occasions we have
thus assisted the expulsion of the head, when otherwise the labour would
have been very protracted, or would have even required the forceps to
disengage it. Madame La Chappelle is the only authority in midwifery, as
far as we know, that has noticed this fact.

_Cord round the child's neck._ As soon as the head is born, we must
examine whether the cord be twisted round the child's neck; and here the
advantage of supporting the perineum with the left hand becomes evident:
it is ready to support the shoulders when they begin to pass, while the
right hand is at liberty to perform any manipulations which may be
necessary. If it be important to support the head during its passage over
the perineum, still more so will it be to support the shoulders; for if a
small laceration has already been produced, it is invariably converted
into a wide rent at this moment, if great care be not taken: indeed, we
are justified in saying that most of the cases of severe perineal rupture
are produced by the shoulders, not by the head.

_Passage of the shoulders._ If the pains cease for a time, or the child be
large, the shoulders do not pass immediately: in this position the face
swells and grows purple from the pressure upon the neck, although it does
not necessarily result from the cord being round it; if, however, we find
that this is the case, we can in most instances loosen it somewhat by the
finger, and as the shoulders advance, slip it first over one and then the
other: we must recollect that the shoulder, which is forwards, passes out
first, and that, therefore, we must slip the cord over it first.

It is seldom necessary to assist the shoulders by applying any extractive
force to the head, for in the course of a minute or two the uterus
generally resumes its activity and expels it: on the other hand, when the
shoulders pass through the os externum, the right hand should be in
readiness to prevent the body of the child from being born too rapidly:
the uterus can scarcely be emptied of its contents too gradually, for by
this means it contracts equably, powerfully, and permanently, and throws
off the placenta without difficulty; whereas, if suddenly evacuated, it
frequently becomes powerless for a time, or if contraction does take
place, it is so irregular and incomplete as to endanger partial
separation, retention of the placenta, and hæmorrhage.[70] If, however,
the cord be twisted exceedingly tight round the child's neck, and imbedded
so deeply into the skin, as to render it impossible to push the coil over
the shoulder, it may become necessary to divide it in order to let the
child pass, in which case the practitioner must seize the divided ends as
well as he can, and apply a ligature the instant the child is born. We
believe that this is rarely, if ever, necessary; for in proportion as the
child advances, so does the fundus descend, and thus relieves, in some
measure, the tension to which the cord is exposed. This subject, however,
belongs rather to the third species of dystocia, to which we must
therefore refer.

_Birth of the child and ligature of the cord._ As soon as the child is
born, we must place it in such a position as will enable it to breathe
with ease. The sudden exposure to the external air is generally
sufficient to excite respiration; if not, a gentle pat on the nates, or
blowing suddenly in the face, will usually succeed: if, however, the child
still remains insensible, recourse must be had to those means which are
recommended under the head of _Asphyxia neonatorum_. The cord should not
be tied until it has ceased to beat, for unless the circulation be well
established in its new course, the breathing is apt to stop, and the child
relapse into insensibility: the cord should be tied about three inches
distant from the umbilicus; it should be applied tightly, because
otherwise it is apt to become loose, as the cord grows flaccid. In tying
the ligature, one hand should be supported against the other to prevent
giving the cord any jerk in case the ligature breaks; we are able also by
this means to tie it more firmly.

The cord should be divided at some little distance from the ligature, so
as to prevent all chance of its slipping off, and it should be done with a
pair of blunt scissors, by which means the vessels of the cord are so
bruised as to be rendered nearly impervious. There is no need to apply two
ligatures; in fact it is better not, for, as Dr. Dewees justly observes,
"the evacuation from the open extremity of the cord will yield two or
three ounces of blood, which favours the contraction of the uterus and
expulsion of the placenta." It has been recommended, in case of twins, to
apply a second ligature, to prevent all chance of the second child
bleeding through the cord of the first. There is, however, no connexion
between the two placentæ, although they usually form what appears to be
one mass. We only know of one case where the umbilical arteries of one
cord anastomosed with those of the other, an anormality of very rare
occurrence: still, however, it is better to apply a second ligature upon
the cord, where we find that twins are present, as a precaution: and also
to prevent it being said, in case the second child is still-born, that it
had died from no ligature having been applied upon the placental extremity
of the cord. It has been questioned whether it was really necessary to tie
the cord before separating the child from the mother, from the well known
fact that nothing of the sort is required in animals; and that, in cases
of rapid labour, where the child has been unexpectedly dashed upon the
floor and the cord broken, no hæmorrhage has resulted. This arises from
the bruised and lacerated condition of the cord under these circumstances:
animals not only bite the cord, but also draw it through their teeth
several times, so as to contuse the vessels for a considerable extent;
whereas, if it was merely divided with a sharp instrument, there is no
doubt but that the new-born animal would quickly bleed to death.[71]

_Importance of ascertaining that the uterus is contracted._ As soon as the
child is separated from its mother and removed, or even sooner, if this
process has gone on slowly, we ascertain if the uterus has contracted:
this we shall know by its feeling like a large hard ball behind the
symphysis pubis: if there be one rule more important than another, it is
this, for without it we cannot be certain of the patient's safety for a
single minute: so long as we feel the fundus to be hard, we know that the
uterus is contracting, and that it will expel the placenta quickly, and
ensure the patient against hæmorrhage; but if it be soft and relaxed, she
cannot be considered safe even if their be no hæmorrhage; for the placenta
may have been separated, and may be lying across the os uteri, or the os
uteri itself may be contracted, or blocked up with coagula, so as to
prevent the blood from escaping; it therefore collects in the cavity of
the uterus in large quantities, to the imminent danger of the patient.
Even where the uterus has contracted, the patient is not permanently safe,
for it may again relax and grow soft, and hæmorrhage come on.

_Management of the placenta._ The placenta sometimes follows the child
immediately, and occasionally is expelled by the same pain; usually,
however, a few minutes intervene, during which time the uterus remains
more or less in a state of inaction; it then begins to contract, and the
dull and peculiar pains which characterize the separation of the placenta
are now felt. The interval after the birth of the child varies
considerably, and depends in many cases on the degree of rapidity with
which the uterus has been emptied: hence in some cases we feel the fundus
hard almost immediately, whereas, in others some considerable period
elapses before it resumes its state of activity, a period which, if any
separation of the placenta has already taken place, will be attended with
the greatest danger. The occurrence of pains indicates fresh contractions,
and therefore we should now examine to ascertain if the placenta has been
detached. As a general rule it may be stated, that if we can reach the
insertion of the cord with our finger we may presume that the placenta is
ready to be expelled; if not, that it is still partially or wholly
attached to the uterus. So long as this latter is the case, the less we
meddle with the cord the better, for by pulling at it we only excite the
os uteri to contract, and thus seriously impede its removal.

Where some time has elapsed without any symptoms of contraction coming on,
we may excite the uterus by circular friction of the abdomen, fanning the
face, or by sprinkling a little water upon it, &c.: if, however, the
uterus is hard and yet the placenta not within reach, we may pull slightly
at the cord, pressing it at the same time back with the fore-finger into
the hollow of the sacrum; we thus bring it down in the direction of the
pelvic axis, and generally succeed in moving it into the vagina. No
violent effort should be made, as this would probably tear it off from its
insertion into the placenta, but, by keeping a gentle pressure upon it,
the placenta will slowly pass through the os uteri, and then come away
without farther difficulty. Following the axis of the vagina, we now guide
it downwards and forwards; and when it approaches the os externum, it
should be seized with the finger and thumb, and rotated several times: the
membranes are thus twisted into a rope, and are less liable to be torn in
separating from the uterus. The uterus being now completely emptied,
contracts into a hard ball of about the size of a child's head. If,
however (whether before or after the expulsion of the placenta) the uterus
grows soft and swells, if the patient becomes pale and restless, and
complains of faintness, sickness, load at the præcordia, darkness before
the eyes, &c. we may be sure that hæmorrhage is going on. We refer to the
chapter upon uterine hæmorrhage for the measures to be adopted.

_Twins._ Where there are twins, the above rules for ensuring the safe
expulsion of the placenta require to be still more strictly observed: the
uterus has been more distended, the mass of placenta is larger, and is
attached to a much greater extent of surface than where there has been
only one child: hence there is not only a greater liability to hæmorrhage,
but if it does take place, will probably be much more dangerous. We cannot
be too cautious how we extract the placentæ of twins: from the size of the
mass, the uterus remains larger, and therefore less contracted: hence, if
we venture to pull at the cord before being able to reach the placenta
with our finger, we shall feel it yield; but this is not from the placentæ
being detached and coming away, but from the fundus itself being pulled
down with it--a state which would rapidly pass into inversion if the force
were continued. In order to detach the mass more equally, we should twist
the two cords together; by so doing there is less danger of their giving
way. The same rotating movement should be used when the placentæ approach
the os externum; the two bags of membranes are thus twisted together, and
come away entire: if this be not attended to, the membranes are torn,
portions of them are left adherent to the uterus, and come away some days
afterwards in a half putrid state producing a fetid discharge, and
sometimes considerable fever.

_Treatment after labour._ As soon as the placenta is expelled, the soiled
and wetted sheet should be removed and a warm napkin applied to the
external parts: the patient should remain thus for half an hour or more,
and enjoy a little rest, or even a short sleep: by this time the nurse
will have washed and dressed the child, and be ready to attend to the
mother. The external parts should be sponged with warm water, her linen
changed, and a broad bandage pinned firmly round the abdomen to give it
the necessary degree of support. Where there has been great abdominal
distension and more than one child, it is sometimes advisable to apply the
bandage immediately after the birth of the first, in order to assist the
uterus in expelling the second, and in contracting afterwards. The
bandage, therefore, should be gradually tightened as the abdomen
diminishes in size: without this precaution the removal of so much
pressure from the abdominal circulation will be sometimes attended with
alarming faintings. A similar effect may be produced by the patient
incautiously sitting up in bed to take any refreshment which may be
offered to her at this moment; she should be warned, more especially if
she be a primipara, not to raise herself from the horizontal posture for a
few hours after labour; at any rate, not until the bandage has been
properly applied: from inattention to this point, cases have occurred
where, on the patient's sitting up immediately after labour, she has
fallen back in a faint from which she never recovered; in other cases it
has been attended by profuse hæmorrhage, which has instantly proved fatal.
"The influence of position," says Dr. Meigs, "in determining the momentum
of blood in the vessels is well known to the Profession, but there are few
cases where it is of more consequence to pay a profound regard to this
influence than in the parturient woman. A uterus may be a good deal
relaxed or atonic, and yet not bleed, if the woman lie still with the head
low; whereas, upon sitting up suddenly, such is the rush of blood down the
column of the aorta, the hypogastric and the uterine and spermatic
arteries, that the resistance afforded by a feeble contraction is
instantly overthrown, and volumes of blood escape with an almost
unrestrained impetuosity: the vessels of the brain under such
circumstances become rapidly drained, and the patient falls back in a
state of syncope, which now and then proves immediately fatal."
(_Philadelphia Practice of Midwifery_, by Charles D. Meigs, M. D. p. 192.)
Even if all these directions have been strictly obeyed, if every thing has
gone well, and the uterus is firmly contracted, we are not sure of its
remaining so: after the lapse of many hours it may again relax, and
flooding come on, its power of contraction being impaired either by the
exhaustion of the previous labour, the warmth of the bed, &c. It will,
therefore, be desirable to adopt such measures, as will ensure the
patient against this occurrence: in most cases it will be sufficient to
keep the room moderately cool, and ensure a due degree of ventilation; but
where the uterus has shown a disposition to relax, we know of nothing
which guards the patient so effectually against hæmorrhage after labour,
and enables us to leave her with so much confidence, as putting the child
to her breast. The sympathetic connexion between the breast and the uterus
is now well known; nor are there any means so certain of producing
permanent uterine contraction as this natural act: it is a duty which
nature instinctively prompts the mother to perform, not only for the
preservation of her child, but for the safety of herself. We, therefore,
make it a rule, whenever the patient intends to suckle her child (a duty
which is performed more frequently now than it was a few years ago,) to
have it put to the breast before quitting the house: the first excitement
of the mother's feelings towards her offspring is a favourable moment for
the performance of this act, the erectile tissue of the nipple becomes
turgid, the child takes the breast with ease, and the effect upon the
uterus is not less certain than complete; even if the child sucks fairly
well for only five minutes we feel satisfied, for we cannot call to mind a
single case of hæmorrhage after the effects of this operation.

_Lactation._ When the wet clothing has been removed, and fresh linen
substituted, the patient should be left to enjoy perfect quiet both of
body and mind, in order that she may have some sleep, for "the refreshment
of sleep seems to be the most powerful natural means of inducing full
contraction of the uterus."[72] After this, the child should be placed at
her side, in order that it may enjoy the warmth of her body, and make
another trial of taking the breast. That new-born animals are not able to
maintain a sufficient degree of warmth, is seen by the care with which a
bird shelters her young beneath her wings, and by the manner in which
kittens, puppies, &c. crawl close to the mother's abdomen to enjoy that
degree of heat which of themselves they are unable to produce. Dr. Edwards
has shown that the animal heat of a new-born infant is several degrees
below that of the adult: the mother's breast is, therefore, the natural
place for it, where it can not only enjoy the necessary warmth, but take
that nourishment which has been destined for its support at this early
period. A child is capable of sucking the moment it is born; indeed, we
would say, better at this moment than later, for the power of instinct in
it is fully as great as in other animals; whereas, if not put to the
breast soon after birth, but fed instead, it quickly loses it. A vigorous
healthy child immediately seeks its mother's breast, and if it does not
find it, sucks at every thing which touches its mouth, even its own little
hand or finger when presented to it: so strong is this instinct, that, on
more than one occasion, we have known the child suck at the finger of the
medical attendant when the head had only just cleared the os externum.

It has been, and even still is, a very general practice not to apply the
child to the breast until the second or third day, upon the plea that
there is no milk: a more erroneous and mischievous plan of treatment could
not be devised, for it is a fruitful source of much injury as well of
suffering both to the mother and her child. The child should be put to the
breast, "whether there be signs of milk or not." (White, _on Lying-in
Women_.) There is always more or less thin watery fluid called _colostrum_
which is admirably adapted to form the first nourishment of the infant; it
is slightly purgative, and, therefore, well fitted to unload the bowels of
the viscid green mucus, called _meconium_, which fills them. The colostrum
has been variously described by authors; some speak of it as a thin watery
fluid, others as a thick creamy milk: this difference depends in great
measure upon the interval between the birth of the child and its
application to the breast: where this has taken place early, as we have
just recommended, the colostrum has almost always the thin watery
appearance above mentioned; whereas, if some period of time has been
allowed to pass before the child is applied, the breast begins to secrete
a fluid containing a larger proportion of caseous matter, or, in other
words a more perfect milk, which not being drawn off, the watery part of
it is absorbed, leaving the thicker portion to be removed by the process
of sucking. Instead of giving the child this bland and natural fluid when
in a state best fitted for its delicate digestive organs, it is but too
frequently the practice to make it swallow some soft sugar, or a
tea-spoonful of castor oil, and follow this up with a little gruel. The
effects of such treatment upon a stomach which has never yet received food
may be easily imagined; the digestive function becomes deranged, pain is
excited, acid is secreted, gas is disengaged, flatulence, diarrhoea, &c.
are the result, with all those manifestations of gastric irritation, such
as strophulus, aphthæ, colic, &c. from which new-born children are made to
suffer so severely.

Besides the above advantages in applying the child thus early to the
breast, there are others of even greater importance which require to be
mentioned. The breast is not yet distended; it is soft and conical, and
therefore in a most favourable condition for being drawn; the child can
seize the nipple and draw it out with ease, and by thus straightening the
lactiferous tubes it commands a ready flow of their contents. By the
gentle irritation of sucking, an earlier secretion of milk is excited, and
being drawn off as fast as it is formed, the breast is never distended by
an accumulation of milk. On the other hand, where some time has elapsed
before putting the child to the breast, it will have in great measure lost
the instinctive desire to suck; the breasts have become distended and
painful; instead of being soft and conical, they are now hard and
flattened, the nipple is shortened, or even sunken in; and if the child
does succeed in drawing it out, it is at the expense of severe suffering
to the mother. The process of sucking in this state of the breast is very
difficult; a considerable effort is required to elongate the nipple, and
the thin delicate skin which covers it is abraded; excoriations and deep
fissures round the base of it are produced, and each application of the
child is one of absolute torture. In many cases, partly from having been
fed, and partly from the difficulty it meets with, the child refuses the
breast altogether; in others, the suffering is so severe as to oblige the
mother to discontinue the attempt. The breasts now increase in size and
hardness, producing great pain from their weight and tension; hard painful
knots from the distended tubes and vessels are felt in different parts,
and the pain and dragging extends to the axillæ, the glands of which are
also swollen and painful.

_Milk fever and abscess._ By this time, or even earlier, the patient will
in all probability have been attacked with a smart shivering fit followed
by a hot and then a sweating stage, and accompanied with headach and
febrile excitement of the circulation. This is the _febris lactea_, or
_milk fever_, an affection which, at one time, was very generally supposed
to be necessary for establishing the secretion of milk: experience,
however, has shown that it chiefly results from neglect in not putting the
child to the breast sufficiently early; the secreted milk has been in part
absorbed into the system, fever has been induced, and the patient has been
relieved by the natural crisis of a sweating stage. The febrile excitement
will be considerably moderated, and the tension of the breasts relieved,
by the action of saline laxatives: the shoulders which are usually kept
warm for the purpose of promoting the secretion of milk, should now be
clothed more lightly; the relief, however, is but too frequently partial,
the breasts still remain large and painful; the process of suckling is
just as difficult as before, and the indurated spots increase in hardness,
sensibility, and extent; throbbing and darting pain is felt in the part,
the skin over it becomes hot and red, and at length presents that shining
glazy look which but too surely indicates the formation of matter beneath,
a circumstance which is still farther proved by the oedematous feel of the
part, or by the presence of actual fluctuation.[73]

Where the breast is capable of being drawn, whether by the child or by
artificial means, the application of a cold evaporating lotion, and the
frequent exhibition of saline laxatives, will generally suffice to check
the determination of blood to the breast, and diminish the secretion of
milk; but where these means fail to reduce its size and hardness, it
should be frequently rubbed with volatile liniment, and then enveloped in
a hot linseed-meal poultice: this may be advantageously made with Goulard,
and changed every two or three hours, keeping up a brisk action upon the
bowels, as before-mentioned.[74]

If there be much febrile excitement of the circulation, bleeding may be
sometimes required: we have rarely, however, found it necessary, having
been almost always able to exert a sufficient effect by means of nitre
with small doses of Vin. Antimonii and Sp. Æth. Nitr. Leeches seldom give
more that temporary relief, and that only when applied in large
quantities; in which case so much irritation and inflammation is produced
by their bites as not unfrequently to counteract the benefit arising from
the loss of blood. The patient should preserve the horizontal posture, or
at least have the breast well supported by a soft handkerchief, as
otherwise its weight will produce much painful dragging. It is not always
easy to detect the fluctuation, particularly when it is seated deep
beneath the fascia, which invests the mammary gland; but wherever it is
tolerably distinct, especially in the upper parts of the gland, the
abscess should be let out early, otherwise it will burrow through a large
extent of the breast, and destroy a considerable portion of the gland;
whereas, if it be felt below the nipple, it may be allowed to approach
nearer to the surface and point, by which means it will not be necessary
to make the incision so large or so deep, a point which is worthy of
attention, as otherwise considerable-sized milk tubes and even
blood-vessels may be divided. Dr. Burns has mentioned a case of fatal
hæmorrhage from this cause. In either case, whether the opening has been
made artificially or spontaneously, the breast should be constantly
enveloped in a hot poultice of linseed meal: if this be made with boiling
water it forms a gelatinous mass, which retains its heat for a very
considerable time, and not only acts as a fomentation, but gives great
relief by softening the indurated portions and diminishing the tension. If
the patient can bear it, the breast ought to be drawn by a glass for that
purpose: this is much better than the breast-pump, being simple and easy
of application. Where little or no milk comes, it is useless to persevere,
as we should only expose the patient to much unnecessary pain, and the
breast to a good deal of irritation.

It rarely happens that the breast recovers so far as to enable the mother
to nurse with it, and she will therefore be obliged to nourish the child
entirely from the other, which generally bears the double duty without
inconvenience: in some cases, however, there has been so much fever, and
the process of inflammation and its consequences has been so long, that it
is neither possible nor advisable to keep up or recall the secretions. In
succeeding labours great attention must be paid to a breast which has been
thus injured, and every disposition to distension and accumulation of milk
carefully watched.

By the time a mammary abscess has been fairly opened, the strength of the
patient is considerably lowered, not only from the quantity of discharge,
but also from the nature of the previous symptoms and treatment; her food
should now be more nutritious, she should take a little wine or porter;
and if the appetite be delicate, two pills, consisting of equal parts of
Extr. Gentianæ and Extr. Hyoscyami should be given night and morning; she
will thus be enabled to sleep better, and the general irritability arising
from her state of weakness will be relieved. If, however, the appetite
fail entirely, and she has a pale flabby tongue, or if it is brown and dry
in the centre; if the bowels are deranged, and she has a disposition to
profuse perspiration, with much pain in the front or summit of the head,
and other signs of debility, the Hydr. c. Cretâ and Dover's powder should
be given at night followed by a rhubarb and manna draught the next
morning, and if these have acted sufficiently, she may be put upon the use
of quinine and sulphuric acid with Tinct. of Hyoscyamus two or three times
during the day.

_Excoriated nipples._ When the nipples are merely excoriated, or there are
fissures in them, they should be bathed with tepid Lotio Plumbi or a
solution of Zinci Sulph. in rose water, which must be carefully washed off
before applying the child to them. If they are too tender to permit being
drawn by the child, they should be covered by the shield, to which is
attached a cow's udder or some form of artificial nipple, through which
the child can draw the milk without pain to the mother; the udder should
be kept very clean, and there should be one or two spare ones soaking in
water, in order that they may be changed from time to time. Excoriation of
the nipples frequently arise from the extreme thinness of the skin which
covers them, and from their unnatural softness. Whatever renders the
nipples soft and tender, makes the operation of sucking difficult, because
the child can draw them out too easily: we should rather be careful to
have them firm, and less sensitive of irritation, just as they would be
if they had not always been covered by the dress from the earliest
childhood, and thus rendered perfectly unfit to perform the office
designed them by nature. The best means of attaining this end is to expose
them frequently to the air during the latter months of pregnancy, and by
dabbing them occasionally with cold water mixed with a little lavender
water or eau de Cologne. (_Boer._)[75]

It is important that the child should be suckled at regular intervals of
about three hours during the day; and if this be done the last thing at
night, and the first thing in the morning, there will be no need of giving
it the breast during the night. With a little perseverance on the part of
the mother, the child soon learns not to require the breast at this time,
which ensures her a good night, and spares her much trouble and annoyance.
Those mothers who are obliged to suckle their children at all hours of the
night to pacify their screaming, have brought the trouble upon their own
heads, for if, instead of dosing the children with castor oil, and feeding
them for the first day or two after birth, they had put them to the breast
at once, the derangement of stomach and bowels which is the cause of this
restlessness would have been avoided.

_Diet during lactation._ Attention should be also paid to the diet of the
mother, for upon this subject much erroneous opinion prevails. If she be
strong and healthy, her food should be entirely farinaceous for the first
three or four days, using gruel, tapioca, farinaceous powder, arrow root,
&c. with a due admixture of milk; if there are no symptoms to forbid it,
an egg may now be taken in the morning, and she may gradually proceed from
chicken, &c. to the stronger meats, as her general condition and appetite
point out. Where she is naturally delicate, or has been weakened by a
sickly pregnancy, &c. it will be advisable to allow her chicken broth, and
weak beef-tea from an earlier period.

"Serious mischief is frequently done by the mother attempting to remedy
every temporary diminution of milk, by increasing the quantity of her
food, or by imagining that some stimulating drink will answer this
valuable end. Owing to some trifling disturbance in the system of a
temporary kind, the secretion of milk may be for the moment suspended or
diminished. An attempt is made to recall it by an increase of food, by
which a slight inconvenience is converted into a permanent derangement of
the system, or a fever of even a dangerous character may be generated; or
owing to a false theory, or imperfect observation, it has been supposed
that certain liquors have a control over the secretion of milk, and hence
the too free use of certain combinations, into which ardent or fermented
spirits too largely enter. We must not, however, be supposed to deny the
influence of certain solid as well as fluid substances upon the secretion
of milk, for we well know, that unless the body be properly supported,
there must soon be a diminution of milk. We only mean to insist that it is
the nutritious, and not the stimulating part of the diet, which is
subservient to the plentiful and healthful formation of this fluid. In
proof of this we need only observe, that we have often been consulted upon
the subject of the failure of milk, where an anxious mother herself, or a
hireling nurse, was concerned, and had been informed by them that they had
tried every thing with a hope of improving it, such as rich food, porter,
ale, beer, &c. without success, or it was followed, perhaps, by a
diminution of it. In such cases we have often succeeded in producing a
plentiful supply of milk, by adopting the opposite plan of treatment, for
it must be borne in mind, as an important truth, that this failure
proceeds more frequently from an over, than from an under, quantity of
food or of drink. It is a fact well-known to all who have paid attention
to the consequences of arterial excitement, that when it amounts to even
moderate fever, the milk almost immediately diminishes in quantity; and
also when this action is diminished by suitable remedies (provided it has
not continued too long,) that the secretion of milk again becomes more
abundant. Upon this principle we have frequently prescribed evacuants and
abstinence to promote the secretion of milk." (Dewees, _on Children_.)

Where the mother does not intend to nurse her child, a different plan of
treatment must be adopted: the shoulders should be lightly covered, cold
evaporating lotions applied to the breasts, and the bowels freely opened
by saline laxatives, her diet must be abstemious until the fulness of the
breasts subsides, and she ought not to take much fluid: where there is a
disposition to febrile action, an antimonial may be advantageously
combined with the salines. In most instances the milk is thus checked
without any inconvenience, but every now and then much illness and
suffering is produced before this can be effected. Wherever, therefore, it
is possible for the patient to suckle, the practitioner should urge the
importance of it in the strongest terms.

"A very serious evil from a woman neglecting this imperious duty is the
probability of her becoming more frequently pregnant than the constitution
of most females can sustain without permanent injury. A woman who suckles
her children has generally an interval of a year and a half or two years
between each confinement; but she who without an adequate cause for the
omission does not nurse, must expect to bear a child every twelve months,
and must reconcile her mind to a shattered constitution and early old
age." (Conquest's _Outlines_.)

_Management of the lochia._ The management of the lochia constitutes also
an important part of the treatment of a natural labour, for the patient's
health will be materially affected by any alteration either in its
quantity or quality. The lochia usually continues to be a sanguineous
discharge for about three days, becoming paler, thin, watery, and of a
brownish hue, and gradually disappears: a free lochial discharge for the
first forty-eight hours, at least, is one of the greatest safeguards
against the different forms of puerperal fever and inflammation which are
so justly dreaded by the practitioner, and nothing tends to ensure this
desirable object so much as the early application of the child to the
breast. It may seem paradoxical to assert, that what prevents hæmorrhage
after labour should promote the lochial discharge: we do not attempt to
explain why such is the case, but merely mention it as a fact repeatedly
observed. As the lochia is secreted from the internal surface of the
uterus, it will continue to accumulate in this cavity and that of the
vagina so long as the patient remains in the horizontal posture, the
direction of the vagina preventing its spontaneous escape: it will,
therefore, be desirable to favour its discharge by occasionally altering
the position of the patient, and thus prevent its becoming offensive,
which it would readily do from the temperature at which it is kept by the
surrounding parts, from being in contact with the external air, and from
its muco-sanguineous character. In the same way it frequently happens that
small coagula of blood lodge in the uterus and rapidly grow putrid. In
either case much irritation and fever are produced by their presence in
the passages, and serious symptoms would soon result if they were allowed
to continue there. Hence we make it a rule, that whenever the patient
requires to evacuate the bladder, she should do it by kneeling: by this
means the position of the vagina is altered, and the accumulated
discharges and coagula readily drain away and produce the greatest relief.
Wherever the patient complains of abdominal pain, and the lochia has
become scanty and somewhat offensive, it will be advisable to wash out the
vagina with a warm water injection: for the farther treatment of these
symptoms, we must refer the reader to the chapter on PUERPERAL FEVER.

_After-pains._ When coagula have remained or formed in the uterus after
labour, these irritate it by their presence, and excite it to contract:
pains therefore of a crampy spasmodic character are produced, which have
received the name of _after-pains_. Women who have already borne children
are more liable to them than primiparæ. They vary considerably in degree:
in some cases they are scarcely sufficient to excite attention; in others
they rise to great intensity, and may even be mistaken for inflammation;
indeed, they occasionally pass into this condition. During these pains the
uterus is evidently in a state of contraction, for the fundus feels hard,
and for the moment it is more or less painful to the touch: the patient
has also pain in the back like a labour pain.

After-pains do not only arise from coagula in the cavity of the uterus
irritating it to contraction, but also from little plugs of coagulated
blood, which fill the sinuses opening upon the internal surface of the
uterus. After awhile they excite contractions, by which they are squeezed
out and come away in the discharges: this fact was first pointed out by
Dr. Burton in 1751. Having to introduce his hand into the uterus for the
purpose of removing a portion of the placenta, he felt several of these
little oblong fibrinous masses exuding from the orifices of the uterine
sinuses, whenever he at all stretched the uterus by opening his hand;
these proved to be so many fibrinous casts of the above vessels, the blood
having been retained and coagulated in them, when the uterus contracted
after the birth of the child. When the uterus has been slowly emptied
during labour, it contracts gradually and uniformly, and forces the blood
from its numerous sinuses into the rest of the circulation; but where its
contents have been suddenly removed, the contraction is unequal, and a
portion of the blood is retained, which coagulates as described. This fact
affords an additional argument in favour of putting the child early to the
breast: the active contraction of the uterus, which is thereby induced,
effectually expels the coagula from its sinuses: hence we see that where a
patient suckles shortly after labour, she seldom (_cæteris paribus_) has
severe after-pains; but where this has been delayed until the second or
third day, the first application of the child to the breast is sure to
induce a sharp attack; the truth of the old adage, that "the child brings
after-pains," is thus verified.

After-pains must be looked upon as an important agent in preventing those
attacks of inflammation and fever which arise from the retention of putrid
coagula and lochia: they ought not therefore to be checked, unless their
severity is such as really demands it: hence the custom of giving an
opiate after _every_ labour cannot be too strongly reprobated, for by this
means those uterine contractions are suspended, by which nature would have
rid herself of the offending cause: nor do we consider ourselves justified
in giving an opiate where after-pains are severe, until by change of
posture, &c. we are satisfied that no accumulation exists in the passages.
"Wherefore," says Burton, "we must not be too forward in giving strong
opiates and other internal medicines, which may take them off while this
grumous blood is lodged within these sinuses. I doubt not but those
patients who die from the eighth to the fourteenth day, whose uterus has
been inflamed with the symptoms above-mentioned, have been injured by the
too free use of opiates." (_Essay towards a complete new System of
Midwifery_, by J. Burton, M. D. p. 342.) We do not deny that a mild
sedative is frequently of great benefit after labour: it calms the
irritability of the system and procures sleep: these effects will be much
better obtained by a little extract of hyoscyamus, lettuce, or hop. Where
an opiate is really necessary, twenty minims of Liq. Opii Sed. in any
aromatic water will be as good a form as any.[76]



CHAPTER III.

MECHANISM OF PARTURITION.

    _Cranial presentations--first and second positions.--Face
    presentations--first and second positions.--Nates presentations._


If we were asked to point out the basis on which the principles of
practical midwifery should be founded, we would answer, on an accurate
knowledge of the manner in which the child presents, and passes through
the pelvis and soft parts during labour. In confirmation of this remark,
we may observe, that almost every great improvement in midwifery practice
which has taken place during the last century, has resulted from farther
investigation into this difficult field of inquiry, and from the gradual
addition of new facts to our knowledge respecting this interesting
process.

Unless a practitioner be thoroughly acquainted with every step in the
mechanism of a natural labour, how can he be expected to understand and
detect with certainty any deviation from its usual course, still less make
use of those means which may be required under the particular
circumstances of the case; and yet, strange to say, there are few subjects
which, generally speaking, have excited so little attention, and upon
which such incorrect opinions have prevailed even up to the present time.
The investigation is confessedly one of considerable difficulty, and as it
was more easy to calculate how the head ought to pass in this or that
position through the pelvis than to ascertain how it really did pass,
ingenuity has been taxed, and theories have been invented, and positions
of the child without number have been described, which have never existed
in nature, and which have only added to the difficulty and perplexity of
the subject.

We consider that to form an accurate diagnosis in these cases, requires
the highest perfection of the _tactus eruditus_, which can only be
acquired by long practice and patient observation: and it is chiefly from
this circumstance that we can explain why such gross errors and vague
notions should have existed about a process of every day occurrence, and
why, with but few exceptions, they should have been transmitted from one
author to another even up to the present time. In the last century, when
it was so much the fashion to resolve every physiological process into a
mathematical problem, it was scarcely deemed necessary to spend much time
in actual observation and examination; the proportions between the head
and pelvis were ascertained, their angles were measured, and their curves
determined, and from these data it was inferred, what must be the course
which nature would follow; few attempted the slow but surer method of
ascertaining by patient research the real facts connected with the process
of parturition.

When the long axis of the child's body corresponds with that of the
uterus, the child (provided the passages are normal) can be born in that
position: it matters little, as far as the labour is concerned, which
extremity of the child presents, so long as this is the case; but where
the long axis of its body does not correspond with that of the uterus, the
child must evidently lie more or less across, and will present with the
arm or shoulder, a position in which it cannot be born. In stating this,
we wish it to be understood, that we merely refer to the full grown living
foetus, and not to one which is premature, or which has been some time
dead in the uterus, as these follow no rule whatever, hence the positions
of the child at the commencement of labour resolve themselves into two
divisions, viz. where the median line of the child's body is parallel with
that of the uterus, and where it is not; the first we shall call
_natural_, the second _faulty_, presentations of the child. A description
of the natural presentations will form the contents of the present
chapter.

The reader will almost anticipate us when we state, that the natural
presentations consist of two classes, those where the cephalic, and those
where the pelvic end of the child presents; in the first case, it will be
a presentation of the cranium or of the face; in the second, of the nates,
knees, or feet.[77]

_Cranial presentations._ The presentation of the cranium, (or _vertex_, as
it has been improperly called,) is of by far the most frequent occurrence;
thus, for instance, of 4042 children which were born in the lying-in
hospital, at Heidelberg, 3834 presented with the head; of these the 3795
with the cranium, and 39 with the face: in either case, whether it be a
presentation of the cranium or of the face, it will be either with the
right or the left side more or less foremost; the former, from its greater
frequency, has been called the first position of the cranium or face, the
latter the second position.

_First cranial position._ It will be recollected we have stated, that the
os uteri at the end of pregnancy is turned obliquely backwards,
corresponding to the upper part of the hollow of the sacrum. If we examine
during the first stage of labour, when it is just dilated sufficiently to
allow the finger to pass, we shall feel the sagittal suture of the head
running across it, dividing it into two unequal portions, the os uteri
itself corresponding nearly to the middle of this suture. If the os uteri
be sufficiently dilated to let us trace its course, we shall find that it
corresponds more or less to the direction of the right oblique diameter,
viz. that it runs from the right and backwards, obliquely forwards, and to
the left. If we follow it with our finger in this last-mentioned
direction, we come to a spot where it divides into or meets two other
sutures; these are the right and left lambdoidal sutures, and beyond them
is the hard convex occiput, the point where they meet being the posterior
or occipital fontanelle. If we trace our finger along the suture in the
other direction, viz. backwards and to the right, we shall come to a four
cornered space, where four sutures meet at right angles to each other;
these are the sagittal, the frontal, and right and left coronal sutures;
the open space itself is the great or anterior fontanelle.

That part of the head which lies lowest or deepest in the pelvis, and
which the finger first touches upon when introduced along the vagina, is
the right parietal protuberance; and if the os uteri be sufficiently
dilated, we distinguish it by its hard and conical feel. In primiparæ,
where the head usually is deep in the pelvis at the commencement of
labour, and where the anterior and inferior segment of the uterus is
closely stretched over it, the parietal protuberance may be felt through
this part. Hence, then, the first position of the cranium, (or more
correctly speaking, parietal bone,) is marked by the following characters:
the sagittal suture crosses the os uteri, and runs parallel with the right
oblique diameter of the pelvis: the vertex is therefore turned towards the
upper part of the hollow of the sacrum, the posterior fontanelle forwards
and to the left: the right perietal protuberance, therefore, is
necessarily that part which is deepest in the pelvis; and the
perpendicular diameter of the head, instead of corresponding to the axis
of the pelvic brim, runs in an oblique direction upwards and forwards.

If the head at this early stage of labour be high up in the pelvis, viz.
has scarcely entered the brim, as is frequently the case in multiparæ, the
sagittal suture approaches in its direction to that of the transverse
diameter, or to one between the transverse and oblique diameters, the
posterior fontanelle corresponding to about the left acetabulum. The
higher the head is in the pelvis, the nearer does its greater diameter
correspond to the transverse one of the pelvis: the more oblique also is
its perpendicular diameter, from which reason the right ear at this time
can usually be felt without difficulty behind the pubic bones. Sometimes
both fontanelles can be reached with equal ease; most frequently the
posterior one is lowest, but occasionally the reverse is the case, and it
is the anterior fontanelle, without, however, at all influencing the
progress of the labour.

As the head advances through the brim and begins to enter the cavity of
the pelvis, the sagittal suture corresponds more closely with the right
oblique diameter, so that now the posterior fontanelle is turned towards
the left foramen ovale, and as it approaches the outlet of the pelvis, the
occiput advances still more forwards, although the head entirely quits its
oblique position. At this stage of the labour, the fontanelles can usually
be again reached with equal facility, and we find the anterior one
corresponding to the right sacro-iliac synchondrosis, the occiput is
completely behind the left descending ramus of the pubes, the right
lambdoidal suture running parallel with it. Owing to this slight change in
the position of the head, the occiput having advanced somewhat forwards,
we no longer feel the right parietal protuberance to be lowest and in the
centre of the pelvis, but the finger now touches upon the posterior and
superior quarter of the right parietal bone, for this is the part of the
head which first comes under the pubic arch, and first enters the external
passages.

If there be but little liquor amnii, or the membranes have been ruptured
prematurely: if the head be firmly pressed against the os uteri, and we
examine when it is not more than two-thirds dilated, we feel a puffy
oedematous swelling upon that part of the head which corresponds to the os
uteri. This will therefore be found to be situated upon the sagittal
suture, nearly equidistant from the anterior and posterior fontanelles; it
arises from the circulation in the scalp being obstructed by the pressure
of the os uteri upon the head. If the remaining portion of the labour be
rapidly completed, this will be the situation of the swelling with which
the cranium is born; if, however, it follows a more gradual course, and
the head passes slowly through the os uteri into the vagina, as it thus
advances deeper into the pelvis, and alters its position more or less, the
swelling upon the sagittal suture disappears in part, and forms on that
portion of the head which is advancing under the pubic arch, and is now
tightly encircled by the external passage: we shall, therefore, find that
this second swelling is situated upon the posterior and superior quarter
of the right parietal bone, and this is precisely the situation of the
swelling of the head, which the child is usually born with.

From these facts we may deduce the following simple law respecting the
mechanism of parturition, where the head presents: viz. that the head
enters, passes through, and emerges from, the pelvis obliquely; and this
is the case not only as to its transverse diameter, but also as to the
axis of its brim; the side of the head being always lowest or deepest in
the pelvis. This shows the beautiful mechanism of the process, for, on
account of its oblique position, there is no moment during the whole
labour at which the greatest breadth (still less length) of the head is
occupying any of the pelvic diameters; even at the last, when the head is
passing under the pubic arch, the complete obliquity of its position, in
order that it should take up the least possible room, is very remarkable;
for the ring of soft parts, by which the head is now encircled, passes
obliquely across it, running close behind the left, and before the right
parietal protuberance. The head never advances with the occiput, forwards,
under the pubic arch, as is stated in works on midwifery, still less with
the sagittal suture parallel to the antero-posterior diameter of the
pelvis; for the direction of the right lambdoidal suture, as also of the
posterior fontanelle, and the position of the cranial swelling, or _caput
succedaneum_, as it has been called, completely prove the inaccuracy of
such a theory, the sagittal suture crosses the left labium at an acute
angle, the right lambdoidal suture being parallel with the left descending
ramus of the ischium.

Not less incorrect is the theory (for we can call it nothing else) of the
head presenting with the vertex, and turning with its long diameter, from
the oblique, into the antero-posterior or conjugate diameter, and the face
into the hollow of the sacrum, for it is disproved by all the
above-mentioned facts, which careful examination during labour puts us in
possession of. When the head is born, the face looks backwards and to the
right, viz. to the back part of the mother's right thigh, for the
shoulders are by this time passing through the pelvis in its left oblique
diameter, the right shoulder being forwards and to the right, and lowest
in the pelvis: it is also that which is first expelled.

Such is the manner in which the head presents in the first or most common
position: a slight modification of it is occasionally observed during the
early stages of labour, without influencing the favourable character of
its progress: the head at first is in the left oblique diameter of the
pelvis, the occiput towards the left sacro-iliac synchondrosis, the
anterior fontanelle towards the right acetabulum; but as the labour
advances, the head turns, so that the occiput corresponds to the left
acetabulum, the anterior fontanelle being turned towards the right
sacro-iliac synchondrosis, the sagittal suture running parallel with the
right oblique diameter of the pelvis. This peculiar commencement of the
labour is probably not detected so frequently as it really occurs, owing
to its changing into the common position at so early a period.

_Second position of the cranium._ The other or second position of the
cranium is, where the _left_ side of the head presents. It is, in fact,
merely the reverse of the one just described: the sagittal suture crosses
the os uteri at the beginning of labour, as in the former case, only now
the posterior fontanelle is turned to the right instead of to the left; it
is the _left_ parietal protuberance which is deepest in the pelvis, and
which the finger first touches upon. As the labour advances, and the head
approaches the pelvic outlet, it is the posterior and superior quarter of
the _left_ parietal bone which first enters the vagina and protrudes
through the os externum, and upon which the swelling of the scalp or
_caput succedaneum_ is situated.

The chief peculiarity is, that the change, which we noticed in the first
position as an occasional occurrence at the beginning of labour, is in
this case the regular commencement of it. In the second cranial position,
the head at the beginning of labour, with very few exceptions, is always
with its long diameter parallel with the right oblique diameter of the
pelvis, the posterior fontanelle turned towards the right sacro-iliac
synchondrosis, the anterior one towards the left foramen ovale. During the
early periods of labour, when the head is passing through the brim, both
fontanelles may be reached; and, generally speaking, the posterior one
with greater ease, from its being usually somewhat the lower; but as
labour advances, and the head has fairly engaged in the pelvic cavity,
they may both be reached with equal ease, the anterior fontanelle still
corresponding to the left foramen ovale, or rather to the descending ramus
of the left pubic bone. "As soon as the head experiences the resistance
which the inferior part of the pelvic cavity opposes to it, or, in other
words, the oblique surface which is formed by the lower end of the sacrum,
the os coccygis, the ischiadic ligaments, &c. by which it is compelled to
move from its position backwards in a direction forward, it turns by
degrees with its greater diameter into the left oblique diameter of the
pelvic cavity, viz. the posterior fontanelle is directed to the right
foramen ovale, and as the head approaches nearer and nearer to the
inferior aperture, it is the posterior and superior quarter of the left
parietal bone which is felt in the cavity of the pelvis opposite to the
pubic arch, so that when the point of the finger is introduced under and
almost perpendicular to the symphysis pubis, it touches nearly the middle
of the posterior and superior quarter of the left parietal bone: and this
is precisely the part, as the head advances farther, which first distends
the labia, with which the head first enters the external passages, and the
spot upon which the swelling of the integuments forms itself." (Naegelé,
_Mechanism of Parturition_, transl.)

The manner in which this change in the position of the head takes place,
varies a good deal in different labours: in primiparæ it usually takes
place slowly, and requires several pains before it is completed; as the
pain comes on, the posterior fontanelle, which was backwards and to the
right, now advances more forward and comes more within reach; the anterior
fontanelle, which was towards the left foramen ovale, retreats, so that
when the pain has reached its maximum the head will for a moment be felt
in the transverse diameter of the pelvis, and again resumes its former
position as the pain goes off: with the recurrence of each pain there is a
repetition of this screw-like motion, but by degrees the head not only
passes from the right oblique into the transverse diameter, but from the
transverse into the left oblique, so that at length the anterior
fontanelle corresponds to the left sacro-iliac synchondrosis, and the
posterior one to the right foramen ovale.

In women who have already had children, the whole change is frequently
effected during one pain, so that the head, which but a few minutes
previously was presenting in what is called the third position of the
German schools, will now be found to be in the second.

It is to the celebrated Naegelé of Heidelberg that we are indebted for
having first pointed out the uniform occurrence of this change in the
second position. From his extensive and accurate observations, confirmed
since by ourselves, as well as by many others, the head presents with the
occiput _originally_ forwards and to the right very rarely, but passes
into this position during the course of labour. No one has ever described
the mechanism of parturition so minutely and correctly; and the value of
his investigations is the more enhanced, when we recollect what erroneous
notions have prevailed upon this important subject up to the present time.
"In the former part of my practice," says this distinguished obstetrician,
"not knowing that the head made this turn, I always concluded that my
examinations in the early part of labour were incorrect, and was very
uneasy that I did not find it all exactly as the books described, and
attributed my want of success in ascertaining the position to my own
awkwardness. At length in a private case, in which I was much interested,
I again felt what I thought was the anterior fontanelle towards the left
foramen ovale; and circumstances occurring which rendered it necessary to
apply the forceps and terminate the labour, I found that the head had been
actually in the position which I imagined I had felt. Since this time I
have, in many cases, sat by the bed-side during the whole labour, with my
finger upon the head, and thus come at the truth." (_MS. Lectures._)

The very circumstance of this change in the position of the occiput from
the sacro-iliac synchondrosis to the foramen ovale of the same side, is of
itself quite sufficient to mislead; nor is it to be wondered at that it
should have been so long unnoticed, when we recollect how difficult the
examination is at this early stage of labour, and how few give themselves
the trouble to attain that degree of dexterity and tact, which, even under
the most favourable circumstances, is required for this species of
investigation.

The diagnosis of the sutures and fontanelles may be rendered more
difficult by other circumstances: when there is a large quantity of liquor
amnii between the head and membranes, it renders the diagnosis exceedingly
obscure in the early part of labour. In some cases the cranial bones are
remarkably thin and yielding, and communicate a sensation to the finger as
if it were touching a fontanelle; in others, the sutures run an irregular
course, and form ossa triquetra, &c. which may easily mislead. We may
also notice the changes, already mentioned, which are produced by the
death of the child, and the various congenital anormalities of
hydrocephalus, acephalus, &c. &c. In some cases the sagittal suture is
continued backwards through the occipital bone, dividing it into two equal
portions, and thus making the posterior fontanelle four cornered, and not
to be distinguished from the anterior. Nor is it always easy to
distinguish the posterior from the anterior fontanelle under more normal
and favourable circumstances; for it would be hazardous to conclude that
it is the posterior fontanelle merely because we feel three sutures
meeting together, as it may possibly be the anterior one, and we are not
able to reach the sagittal suture beyond. In this case we may ascertain
which it is by the following rule: if it be the posterior fontanelle in
the first position we shall feel a suture running more or less forwards
(the right lambdoidal,) but none backwards; but if it be the anterior
fontanelle forwards and to the left, we shall also feel a suture (the
right coronal) running backwards. Lastly, in the second cranial position
the face when born turns to the posterior surface of the mother's left
thigh.

Such are the two positions in which the head presents during labour, and
such is the manner in which it passes through the pelvis and external
passages. Slight deviations do occasionally take place, the chief of which
is, that the head in the second position does not always make the quarter
of a turn as above described, but comes out with the anterior fontanelle
forwards and to the left: this is by no means of common occurrence, and,
as far as we have observed, increases the difficulty of labour very
little.

_Face presentations._ The face, like the cranium, may present in two ways,
either with its right or left side forwards. The former is the most
frequent occurrence, and bears a striking analogy to the first cranial
position; indeed, we cannot too strongly impress upon the minds of our
readers the advantages of accurately knowing the different features of the
two cranial positions just described; for by this means the positions of
the face will be rendered much more simple and easy of comprehension.
Whether the right or the left side of the face presents (first or second
facial position,) the root of the nose crosses the os uteri exactly in the
same manner as the sagittal suture does in the two cranial positions; the
chin is turned to the right acetabulum, and as the face descends through
the pelvis during the progress of the labour, the chin moves somewhat more
forwards, as the occiput does in the cranial positions.

At an early stage of labour the right eye and zygoma is that part of the
face which is lowest in the pelvis, and which the finger first touches
upon during examination, precisely as it was the right parietal
protuberance in the first cranial position; and as in this case the caput
succedaneum was situated upon the posterior and superior quarter of the
right parietal bone, so here the livid bruise-like swelling, which the
face brings with it into the world, is situated upon the right cheek, this
part being the first which presses through the os externum; the chin
passes under the right branch of the pubic arch, as the occiput in the
first cranial position does under the left, the face during the whole
process preserving a strictly oblique position, both as to the transverse
diameter and axis of the pelvis.[78]

_Second position of the face._ The second position of the face is merely
the reverse of the first: it is now the left side which is turned
forwards, the left eye and zygomatic process being those parts which are
lowest in the pelvis; the chin is turned to the left side and somewhat
forward, and advances towards the left foramen ovale during the farther
progress of the labour. As the face approaches the inferior aperture of
the pelvis, it is the left cheek which first enters the os externum, and
upon which the swelling is situated: likewise the chin passes beneath the
left branch of the pubic arch.

It has been supposed by some authors, and we think correctly that the
majority (if not all) of face presentations are originally cranial
presentations: if this be the case, we can easily understand why the right
side of the face presents more frequently than the left, for if the head
in the first cranial position moves round upon its transverse diameter,
and thus allows the face to turn downwards, we shall immediately have a
first position of the face. We are the more inclined to adopt this
opinion, not only from the greater number of cases where the right side of
the face presents, but also from our having more than once met with cases
where so long as the head of the child was moveable above the brim, the
presentation was midway between one of the cranium, and of the face. On
one side of the pelvis we could feel the anterior fontanelle; on the other
we could, with some difficulty, reach the orbital process of the frontal
bone: as the pains increased, and the head advanced lower, the side of the
face came more within reach; so that by the time it had fairly entered the
cavity of the pelvis, it had become a complete presentation of the
face.[79]

We distinguish the face by the bridge of the nose, which from its crossing
the os uteri may be detected at a very early period of labour: it is far
better than the eye, for not only is this liable to mislead us in our
examination, but it may also receive injury from the finger. Nor is the
malar bone a guide, for this might easily be mistaken for the tuberosity
of the ischium, or even for the shoulder. The nose not only tells us that
the face is presenting but also in which position, for at one end we
shall feel the soft cushiony extremity of it, at the other we shall reach
the broad hard expanse of the forehead.

It was not until nearly the end of the last century that presentations of
the face ceased to be accounted unnatural, and impossible to be terminated
by natural means. Although the fact had been pointed out by Portal so
early as 1685, that these presentations were very little removed from the
usual one, it seems to have excited but little attention until the time of
Deleurye in 1770. "I have," says Portal, "delivered several women whose
children came with the face foremost, and always without any great
difficulty, it being only observed, _that in such cases no violence must
be used, but nature be left to its own course; which done, there is no
danger either of mother or child_." (Portal's _Midwifery_, transl. obs.
66:) La Motte in 1721, although so accurate an observer, could not divest
himself of the general opinion that these were unfavourable positions,
even although the face was usually expelled by the natural efforts, after
he had fruitlessly endeavoured to rectify it, and although he himself
confesses never to have "seen any that had not done well."

Giffard has recorded two cases of face presentation (_Cases in Midwifery_,
1734, p. 59, 443.,) both of which he delivered by his extractor, which was
one of the early forms of midwifery forceps; and in both, although the
labour had lasted some time, the child was alive. He describes the
position of the face in the second case, the chin being turned towards the
right side. The only practical observation which he makes is, that turning
is very difficult where the "waters are gone off, and the uterus closely
envelopes the child." This is probably given as an explanation for his
deviating from the usual practice of turning in these cases. Deleurye in
supporting Portal's views observes, "one daily sees similar labours
terminate naturally: it is true they are somewhat longer, but they
terminate without the aid of art." (_Traité des Accouchemens_, 1770, §
736.)

Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still
more decided point of view when he asserted, that "face presentations
being merely a rare form of natural labour, should be left to be completed
by the natural efforts, since neither the mothers nor their children were
exposed to any more danger in this form of labour than they were in the
most usual forms of all." Having charge of the great lying-in hospital of
Vienna, Boer had ample means of ascertaining the most accurate results on
all points of practical midwifery, and his observations on labours where
the face presented, are, therefore, peculiarly interesting, and tend
strongly to contradict the prevailing opinion respecting the difficulty
and danger of these presentations.

"Of eighty cases of face presentations which have occurred during a period
of some years, and which I have myself observed and noted down, there
were three, or at the most four, where the children were born dead. None
of the patients suffered in the slightest degree from any of these
labours; and, except one case, all were left entirely to nature: in one
case only, on account of the weakness of the pains and doubtful character
of the symptoms, I deemed it necessary to terminate the labour by the
forceps." (Boer's _Natürliche Geburtshülfe_, erstes buch, p. 137.) In
spite of this valuable practical fact, supported by experience on so great
a scale, the opinion that face presentations were preternatural, continued
to prevail upon the Continent, being supported by the authority of
Baudelocque and Osiander. A similarly unfavourable opinion was entertained
by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures
delivered prior to the publication of his plates on the gravid uterus
(and, therefore, at an early date,) states, "in this case I do not turn
the head round in order to deliver, but nineteen times in twenty leave it
to itself to come as it will." (W. Hunter, _MS. Lectures_.)

Dr. R. W. Johnson, who dedicated his _New System of Midwifery_, &c. to Dr.
W. Hunter and others, in 1769, and probably attended his lectures,
expresses a similar opinion, and says, that in these cases "nature herself
will do the work." (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks
favourably of these presentations. "The head will, however, in most cases,
advance in that position by the force of the natural pains, though the
delivery will be more slow or painful." (_Outlines of the Theory and
Practice of Midwifery._)

Farther experience has shown that, so long as the pelvis is of the natural
size, the head can be born in this position without peculiar difficulty,
the soft parts usually require a little more dilatation than where the
cranium presents, and, therefore, this stage of the labour is generally
somewhat slower. Although presentations of the face are not so favourable
for the child as those of the cranium, they stand next to them in point of
safety. Where the cranium presents, a slight misproportion between the
head and pelvis produces little or no increase of difficulty to the
passage of the child; but under similar circumstances, where the face
presents, the difficulty may become very serious, for if the labour is
prolonged, "the brain and vessels of the neck," observes Smellie, "will be
so much compressed and obstructed as to destroy the child." (Explanation
to table 25.) A similar view has been given by Dr. Denman, and still more
recently by Professor Chaussier, of Paris, and Professor Naegelé; the two
latter authorities examined the brain in several still-born children where
the face had presented, and invariably found the cerebral vessels gorged
with blood.

The presenting side of the face when born is frightfully distorted by the
livid swelling above-mentioned; the mouth is pulled to one side and
upwards; the angle of the eye is drawn downwards, and the corresponding
ala of the nose scarcely discernible amid the purple mass of tumefaction:
the less this is meddled with the better, for in the course of a day or
two the parts will have returned to their condition; whereas, if friction
or hot poultices, &c., be used, ulceration may be the result, and produce
considerable disfigurement.[80]

_Nates presentations._ "After the presentations of the cranium those of
the nates are the most frequent in point of occurrence, and also the most
natural," says the celebrated Boer, in the work already quoted. Under the
term _nates_ presentations, we include those of the knees and feet, as
these latter presentations can only be looked upon as modifications of the
former. Professor Naegelé, jun., in his new edition of the admirable essay
upon the mechanism of labour, published by his father, in Meckel's
_Archiv. für die Physiologie_, has very properly brought these different
positions under one head, viz. "positions of the pelvic extremity of the
child:" as, however, we possess no word in English to express this, we
shall attain the same object by considering knee and footling births as
mere modifications of breech presentations.

"As regards the relative situation of the limbs to the body of the child,
the position is the same as in the two genera of head presentations above
described, viz. the knees are usually drawn up to the abdomen, the feet
close to the nates, so that not unfrequently they may both be felt
together at the beginning of labour, and afterwards descend into the
pelvis and are born together. Sometimes the feet (or perhaps only one
foot) are felt higher above the brim than the nates; in which case, as the
nates descend they rise, and are turned upon the abdomen and breast of the
child, and descend with these parts as labour advances. Frequently it is
the reverse: the feet are somewhat lower than the nates; they are felt in
the os uteri at the beginning of labour, and descend before them as labour
advances. It is rare that the knees come down before the nates during the
farther progress of labour, and it is not probable that they are ever
found alone in the os uteri at the commencement of it." (H. F. Naegelé,
_Mechanismus der Geburt_, 1838, p. 57.)

The nates may present in two ways, either with the back of the child
forwards, or with its abdomen forwards: of these the former occurs most
frequently; thus of 161 cases which were accurately ascertained at the
lying-in hospital of Heidelburg, 121 were observed with the back of the
child forwards, and 40 with it backwards: in either of these positions the
transverse diameter of the child's pelvis always corresponds to one or
other of the oblique diameters.

"Labours with the nates or feet presenting, follow certain laws quite as
much as those where the head presents, only that one more frequently sees
deviations from them, both with respect to the manner in which the child
presents at the time of labour, and its passage through the pelvis; but
where, under a proper state of the other requisites for healthy
parturition, no prejudicial result occurs." (Naegelé, _on the Mechanism of
Parturition_, transl. § 19. p. 128.) "In every case, whether the nates
have at first a completely transverse or oblique direction, they will be
always found, on pressing lower into the superior aperture of the pelvis,
to have taken an oblique position; and that ischium, which is directed
anteriorly, to stand lowest. They pass through the entrance cavity and
outlet of the pelvis in this position, which is oblique, both as to its
transverse diameter as well as to its axis."

Thus, if in the first species the left ischium were either originally
directed more or less forward, (which is usually the case,) or had taken
this direction in passing through the superior aperture, the nates descend
in this direction into the pelvic cavity, with the left ischium during the
whole time standing lowest; and this is the part, during the farther
progress of the nates, which first passes between the labia as the os
externum dilates. As they advance, and while the left ischium, which is
directed forwards and always somewhat to the right, comes completely under
the pubic arch and presses against it, the other ischium, which is
situated in the opposite direction, and which has to make a much greater
circuit, passes forwards over the strongly distended perineum, so that,
when the pelvis is born, the abdomen of the child will be directed to the
inner and posterior surface of the mother's right thigh.

"The rest of the trunk follows in this position, and as the breast
approaches the inferior aperture of the pelvis, the shoulders press
through its superior aperture in the direction of the left oblique
diameter; and during its passage (viz. the breast) through the pelvic
outlet, the arms and elbows which were pressed against it are born at the
some moment. But whilst the shoulders are descending in the
above-mentioned oblique position, the head, which during the whole
progress of the labour rests with its chin upon the breast, presses into
the superior aperture in the direction of the right oblique diameter,
(viz. with the forehead corresponding to the right sacro-iliac
synchondrosis,) and then into the cavity of the pelvis in the same
direction, or one more approaching the conjugate diameter. After this, it
presses through the external passage and the labia, in such a manner, that
whilst the occiput rests against the os pubis, the point of the chin,
followed by the rest of the face, sweeps over the perineum as the head
turns on its lateral axis from below upwards.

"But it is sometimes the right ischium, which, in this chief division, is
either originally turned forwards, or in the process of time assumes this
direction. In this case the child passes through the pelvis in the same
manner as before, only with the difference, that the surface of the body
takes of course a different position with respect to the pelvic parietes,
viz. its anterior surface, which in the former case corresponded to the
right side of the pelvis, will be directed to the left, and the head will
press through the superior aperture of the pelvis, in the direction of the
left oblique diameter (the forehead passing before the left sacro-iliac
synchondrosis.)"

"As in positions of the cranium, the swelling of the integuments is
chiefly met with on that parietal bone which during the passage of the
head, is situated lowest, and on that spot with which it enters the
external passage, so in this case the livid coloured swelling appears on
that part which, directed forwards, was situated lowest during the passage
of the nates, and with which the nates were born.

"In the second chief position, viz. with the anterior surface of the child
corresponding to the anterior abdominal parietes of the mother, it is
chiefly the left ischium which is either originally situated forwards, or
takes this direction as the nates sink through the superior aperture of
the pelvis, which latter preserve this oblique direction during the
farther progress of the labour, both whilst pressing into the pelvic
cavity, and when entering the external passages.

"If the ischia be already born, the anterior surface of the child turns
itself to the right and backwards, either immediately, or as the rest of
the trunk advances; but the manner in which the head in this case presses
through the entrance cavity and outlet of the pelvis, is the same as has
already been described." (Naegelé, _op. cit._ p. 128, 130.)

It appears to be a law in nates presentations, that whatever may be the
direction of the child (first or second position) at the beginning of
labour, it will always, if not interfered with, be found with its anterior
surface turned towards one or other of the sacro-iliac synchondroses, when
the thorax or the shoulders are beginning to pass through the outlet of
the pelvis. When the nates have once passed the os externum, the position
of the child frequently varies a good deal, the abdomen turning first to
one side and then to the other. This is especially the case in the second
position, where it is more or less forwards; nevertheless, as labour
advances, it will almost invariably turn obliquely backwards, and be born
in this position. Dr. Collins is, as far as we know, the only English
author who has distinctly noticed this fact. "It is very desirable," he
observes, "the child should be delivered in this position (viz. the back
of the child towards the mother's abdomen,) as it renders the getting away
of the head much less difficult; yet where there has been no interference
by the attendant in the previous part of the labour, he will rarely find
it necessary to alter subsequently the child's position, the breech
naturally making the turn above alluded to in its passage." (_Practical
Treatise on Midwifery_, by Robert Collins, M. D. p. 41.)

It sometimes, although rarely, happens in these presentations, that the
head does not rest with the chin upon the breast, but the occiput is
pressed against the nape of the neck, as in presentations of the face. The
passage of the trunk through the pelvis follows, as above-mentioned, as
far as the head: this enters the brim with the occiput in advance, and
vertex towards one or other ilium. As it advances through the brim into
the cavity of the pelvis, it gradually turns more and more backwards, so
that when the body is born, the vertex is turned towards the hollow of the
sacrum, and the under surface of the lower jaw behind the symphysis pubis.

The _diagnosis_ of nates presentations is not difficult. The pointed and
more or less moveable coccyx, bounded at its broader end by the hard
uneven sacrum, and in the contrary direction by the anus, will scarcely
admit of a mistake. The tuberosities of the ischia may easily be mistaken,
for the malar bone of a face presentation, or even a shoulder, can
scarcely be distinguished from them, and the external organs of generation
become too much swollen and pressed together to give any certain
diagnosis; nor indeed can they be examined in this state without
considerable risk of injury. The direction of the sacrum, like that of the
forehead in face cases, points out the exact position of the child.

Presentations of the nates, although perfectly natural as far as labour is
concerned, are far more dangerous for the child than those of the face,
for when the head enters the pelvis, if every thing be not favourable for
its passing rapidly through it, the cord is so long compressed that the
child is almost certainly lost.

The natural position of the foetus in utero is admirably adapted for its
safe passage through the pelvis under these circumstances, and is what we
ought to maintain, as far as possible, during labour. The legs are turned
upon the abdomen, the arms are crossed upon the breast, the chin rests
upon it, the head being bent forwards, so that the whole forms an oval
mass. So long as the child advances gradually, the fundus presses firmly
upon the head, and keeps the chin close upon the breast; the head
therefore enters the pelvis in the most favourable position possible, and
the uterus, not having been suddenly emptied of a part of its contents,
continues to act briskly, and presses the head so rapidly through the
pelvis, that the child is born without having suffered from any serious
pressure upon the cord. As however the body of the child diminishes from
its pelvis up to the axillæ, it is very apt to be rapidly expelled as soon
as the nates have passed the os externum; and if not, it is but too
frequently _assisted_, as it is called, at the very moment when it ought
rather to be supported and prevented from advancing too suddenly. When
this is the case, the fundus ceases to press upon the head, the chin quits
the breast, and as a space is thus left between them, the arms slip into
it, and then turn upwards, so that the head not only enters the pelvis in
a most unfavourable position, but, to make matters still worse, it has an
arm on each side of it: at this critical moment the uterus, from having
been suddenly emptied, ceases to contract, and the head remains so long in
the pelvis that the child has no chance of escaping with its life.

Where the child has descended gradually, and the arms have advanced with
the breast into the pelvis, if the cord be considerably upon the stretch,
a portion should be pulled gently down in order to relax it, and we should
endeavour as far as possible to guide that part of it which is within
reach towards one of the sacro-iliac synchondroses, being less liable
there to suffer from pressure. One or two fingers should be introduced to
bring down the arms, which are now coming into the lower part of the
hollow of the sacrum: they should be hooked down by the bend of the arm,
in order to prevent the humeri from sticking across the passage. When this
has been effected, the shoulders follow as the head descends through the
pelvis. The body of the child should now be wrapped in warm flannel, and
two fingers passed up towards the face: the lower jaw must not be trusted
to in bringing the head through the pelvic outlet and os externum, for it
may easily be broken: the fingers should be applied one on each side the
nose, and the chin depressed as much upon the breast as possible, by which
means the head will come in a much more favourable direction, and pass
readily.

In no case is so much mischief done by impatient interference as in
presentations of the lower end of the child. This is still more so in
footling cases, for here the soft parts are not so well dilated as in
nates presentations, where the child comes double: hence the fact, that
presentations of the feet are easier to the mother but more dangerous to
the child. In either case, the passage of the head through the pelvis must
ever be attended with considerable hazard, for if it be delayed beyond a
short time, the child's death is certain. "The more gradually the nates
and body of the child are expelled, the quicker will its head pass through
the pelvis, and the better will be its chance of being born alive."
(_Obstet. Memorand._ 2d ed.) Hence, therefore, if the pains are slow at
this moment, it will be desirable to rouse them with a dose of ergot; and
if the child gives a convulsive twitch, the forceps ought instantly to be
applied. The result of Professor Busch's practice in the lying-in hospital
at Berlin shows, that by the timely use of the forceps a large majority of
children may be saved. For the same purpose, the nurse should be
instructed to have a warm bath in readiness, with some spirit, &c. for
resuscitating the child the moment it is born.

The numbers which we subjoin are taken from the cases in the Dublin
Lying-in-Hospital, under the late Dr. Joseph Clark and Dr. Collins, from
the private practice quoted in Dr. Merriman's _Synopsis_, and from the
General Lying-in-Hospital.

Of 71,578 labours, the nates presented once in every 78 cases, and the
feet once in every 108-1/2. Of the nates cases the child was born dead in
the proportion of 1 to 3·8, and in the footling births 1 to 2·8.



PART IV.

MIDWIFERY OPERATIONS.



CHAPTER I.

THE FORCEPS.

    _Description of the straight and curved forceps.--Mode of action.--
    Indications.--Rules for applying the forceps.--History of the
    forceps._


Before describing the various species of dystocia, or faulty labour, it
will be necessary to consider the different means with which the
increasing experience of years has furnished us, of giving artificial
assistance in such cases. These may be brought under two heads, first,
where delivery can be effected with safety to the mother and her child;
secondly, where this can only be effected at the expense of the infant's
life. Under the first head come the forceps, turning, the Cæsarean
operation, and artificial premature labour; under the second are
craniotomy or perforation, and embryotomy.

Of these the forceps is by far the simplest and safest means of artificial
delivery, and is therefore an operation which should always be had
recourse to in preference to any of the others wherever it is possible.

The forceps is the simplest imitation of nature, for in fact it is nothing
more than a pair of artificial hands introduced one on each side the head.
It is impossible to define any precise limits of pelvic contraction,
within which the forceps can, or beyond which it cannot, be safely
applied, for the difference in the size and hardness of the child's head,
and in the condition of the soft parts, will greatly modify the degree of
resistance to the progress of the labour: hence the attempt to fix the
exact degree of contraction beyond which the forceps becomes inapplicable
is quite impracticable, as in some cases we might be led to make a trial
of it where it would be quite improper, and in others have recourse to the
perforator where a cautious application of the forceps would have been
attended with success. For the farther consideration of this subject we
must refer to the chapter on DYSTOCIA PELVICA.

The forceps consists of three parts--the blades, the lock, and the
handles.

The blades of the present forceps are not solid, but are merely elongated
bows of polished metal, by which they are not only rendered much lighter,
but allow the most prominent parts of the head to project between them,
and thereby take up no additional room when introduced into the pelvis. In
the simplest form, viz. the straight forceps, the blades have only one
curvature for adapting them to the convexity of the head. The degree of
curve varies a good deal in different instruments: the greater the curve
the more firmly will the blades hold, because they act more or less as
blunt hooks, and do not require much pressure upon the head for the
purpose, but on the other hand, they are more difficult to introduce;
whereas, blades which are slightly curved can be applied with greater
ease, but require much more pressure upon the head in order to hold fast.

It has been a general rule with almost every modification of forceps, that
the greatest distance between their blades should not be less than two
inches and a half, for as this is the breadth of the basis cranii in the
foetal head, it would be impossible to compress the head beyond this
extent. The form of the head curvature will determine the situation of the
point where the blades are most distant from each other: in some forceps
it is about one-third the length of the blades from their extremities; in
some it is nearly equidistant; whereas, in others it is nearer to the
lock; the medium between these extremes is the best. The extremities of
the blades ought to be at least half an inch apart: in this country they
are usually somewhat more; on the Continent they are much less, being
rarely more than one or two lines asunder. The fenestræ, or open spaces in
the blades, should be wide and ample, for not only are the projecting
parts of the head allowed to protrude between them, but the pressure of
the blades is diffused over a larger extent of surface: this is remarkably
seen in the forceps of the late Dr. Hopkins and that of Professor Davis,
both of which are extensively used. It is also important that the edge at
the extremities of the blades should be well rounded and not too thin; it
is thus less liable to catch against corrugations either of the vagina or
foetal scalp. The greatest breadth of the fenestræ is generally towards
the extremities of the blades; in some, their edges are parallel; whereas,
in those of Drs. Orme and Lowder the greatest breadth is near the lock:
upon the whole, an oval shaped fenestra is the best, for it can be easily
introduced, and has the advantages of a wide blade.

In 1751 and the following year another curve was given to the blades of
the forceps by the celebrated M. Levret of Paris, and by the equally
distinguished Dr. Smellie of London, by which the instrument was adapted
to the curve formed by the axes of the brim, cavity, and outlet of the
pelvis, and by which the head could be seized much higher in the pelvis
than by the straight forceps. Each have an equal claim to the merit of
having invented this "pelvic curvature," as it has been called: the
priority of the invention is perhaps due to Levret; but as he made a
secret of it for some years, it is impossible to ascertain the precise
fact. The pelvic curve, as it is called,[81] is especially adapted to the
long forceps, which thus becomes an instrument of very considerable power.
Numerous modifications of these curved forceps have since been made, but
they are merely varieties of the original ones invented by Smellie and
Levret, which have become the national instruments of their respective
countries.

Perhaps the greatest improvements in the blades of modern times is seen in
the forceps of Dr. Hopkins, above alluded to: the head curvature forms an
elongated oval, admirably adapted to the form of the foetal head when
considerably compressed during a difficult labour; and from the great
breadth of the fenestræ, the pressure of the blades is applied over a
large extent of surface; the pelvic curve is but slight, being greater on
the posterior edge of fenestræ than on the anterior; the blades themselves
are thin, their inner surface flat to ensure a firmer hold, their outer
surface slightly rounded in order to be introduced with greater ease; and
for a similar reason the edges of their extremities are somewhat thicker
and carefully rounded in a peculiar manner.

[Illustration: Naegelé's forceps.]

The lock of the modern English forceps consists of two deep grooves, into
which the shank of each blade mutually fits, so that the two blades are
fixed upon each other merely by the pressure exerted upon the handles. In
former times the blades were united together by a pivot, which could screw
and unscrew at pleasure. This was abandoned by Chapman, who published the
first work in English on operative midwifery.[82] He found that the
forceps held better without the pivot than with it; and from what we have
brought forward elsewhere (_Med. Gaz._ Jan. 8, 1831,) there can be little
doubt that he invented the lock which is now generally used in this
country. Chapman's forceps was adopted in France prior to this improvement
in its lock, especially by Gregoire, and has retained the original pivot
lock which now forms one of the most distinguishing marks between the
French and English forceps. Although the pivot forms by far the firmest
lock, for the blades can never slip from each other, still the difficulty
in locking, and also in separating, the blades at a moment's notice,
render it much inferior to the English lock. An ingenious modification was
invented by the late Professor Von Siebold of Berlin, but the most perfect
lock is that of Professor Brüninghausen of Würzburg, first introduced by
ourselves into this country, and commonly known among the
instrument-makers under the name of Professor Naegelé's forceps. The shank
of one blade has a semicircular indentation, which at the moment of
locking fits into a fixed pivot in the other: this, therefore, combines
the advantages of the French and English locks. We can safely affirm, from
extensive experience for many years, that there is even less difficulty in
locking it than with the English lock: the blades are capable of instant
separation, and yet when locked, the firmness of their union is equal to
that of a pivot joint.

The handles of the English forceps are pieces of wood or ivory fixed upon
each shank below the lock, flat upon the inside, convex externally and
furnished with a depression or groove at the lower end for fixing a
ligature round them. These handles were probably first introduced by Dr.
Smellie, who seems to have borrowed the idea from the forceps of M.
Mesnard, for the earlier English forceps, viz. of Giffard and Chapman,
terminated in blunt hooks, those of the former being curved inwards, those
of the latter outwards, a form of handle which has been retained in the
French forceps up to the present time.

There are two pieces of forceps, the _long_ and the _short_ forceps; the
former for cases where the head is still high in the pelvis, the latter
when it is at the pelvic outlet and approaching the os externum; the
former with few exceptions being curved, the latter straight.[83]

The forceps act in three ways, 1. by mere pulling; 2. as a species of
double lever, by moving the handles from side to side; and 3. by
compressing the head, thus still farther disposing it to elongate and
adapt itself to the passage through which it has to be expelled.

The blades should always, if possible, be applied one on each side of the
head, the position of which must be determined by the direction of the
fontanelles and sutures, not by feeling for the ear, as is usually
recommended in this country. The ear can seldom be reached without causing
a good deal of pain, even under the most favourable circumstances; in
cases, therefore, where the head is so impacted as to be incapable of
advancing by the natural powers, it cannot surely be justifiable to force
up the finger between the head and the pelvis to ascertain this point, the
more so, as the soft parts soon become swollen and more or less inflamed,
and, therefore, little able to bear such rude treatment. No operation
requires such an intimate acquaintance with the mechanism of parturition
as that for applying the forceps: it is simple and generally perfectly
easy when the precise position of the head and its relations to the pelvis
are accurately known; on the other hand, it is not less injurious and
painful to the patient than difficult and unsatisfactory to the
practitioner.

The most usual circumstances under which the forceps is applied, are where
the head is already deep in the pelvis and approaching the os externum; in
such cases it is generally required not so much for the purpose of
overcoming an unusual degree of resistance, as for assisting the natural
powers, which are becoming exhausted: the head is near the os externum,
and therefore easily reached; and from there being little or no impaction
present, the blades are applied without difficulty.

The application of the forceps when the head is at the upper part of the
pelvis, and where the greater portion of it has not yet passed the brim,
is rarely practised in this country, because as the necessity for
performing the operation at this stage arises in most instances from
contraction of the brim, the perforator has usually been preferred,
wherever the expelling powers have proved incapable of overcoming the
resistance to the passage of the head. The circumstance also of this
condition requiring the long forceps has been another source of objection,
from the much greater power which this instrument is capable of exerting,
and from its being therefore more liable than the short forceps to prove
mischievous in the hands of the inexperienced.

Cases however do occur where there is but a very slight want of proportion
between the head and pelvis, where the obstacle is easily overcome, and
where, but for the application of the forceps, the labour would either
have been protracted to a dangerous degree, or have required the use of
the perforator.[84] "On the whole," says Dr. Burns, "I would give it as my
opinion that a well instructed practitioner, who has already had some
experience in the use of the short forceps, is warranted to make a
cautious, steady, but gentle attempt to apply and act with the long
forceps in a case where he is not quite decided that the perforator is
indispensable, and where the head is higher than admits the application of
the short forceps." (_Principles of Midwifery_, 9th ed. p. 493.)

In applying the forceps, whether short or long, there are two conditions
which, _cæteris paribus_, are requisite in every case; first, that the os
uteri shall be fully dilated; secondly, that the pains are within the
bounds of what are commonly known as moderate pains. In the first case it
will be very difficult and frequently quite impossible to pass the blades
between the head and os uteri when only partly dilated; it will be
difficult to avoid injuring its edge more or less, and if we do succeed in
applying and locking the forceps, on making an extractive effort we shall
find that the uterus descends with the head as we draw it down.

In the second place we ought never to apply the forceps whilst the pains
are violent, for not only do they render its application difficult and
even dangerous, but we are adding still farther to the force (already too
great) with which the head is pressed against the pelvis. Where the head
remains immoveable under violent exertions of the uterus, it is not a case
for the forceps but for the perforator; nor does it admit of much delay,
for it endangers much injury of the soft parts or even rupture of the
uterus.

It is exceedingly difficult to assign any precise limits of pelvic
contraction, within which the forceps can, and beyond which they cannot be
applied, for the size and hardness of the foetal head, the nature of the
pains, and the condition of the patient must also be taken into account in
every instance; hence, we frequently meet with cases where the pelvis is
scarcely if at all contracted, and yet where the labour has been
terminated with the greatest difficulty by means of the forceps; whereas,
in others where we know the pelvis to be more or less deformed, the child
has been delivered by the natural powers. This subject will be still
farther considered under DYSTOCIA PELVICA.

The _general indications_ for the use of the forceps are two: 1. They are
indicated in all labours which are difficult or impossible to complete,
either from deficiency in the expelling powers, or from misproportion
between the head and pelvis, or from the arm coming down with the head. 2.
They are indicated by circumstances or accidental causes, which render
labour dangerous for the mother or child, and where the danger can only be
removed by hastening labour, as in cases of hæmorrhage, convulsions,
syncope, alarming debility, faulty condition of the organs of respiration,
danger of suffocation, obstinate vomiting, unusually severe pains in
nervous irritable habits, hemorrhoids which have burst, hernia, retention
of urine, determination of blood to the head, prolapsus of the cord, (in
certain cases,) inflammation of the uterus, &c. (Naegelé, _MS. Lectures_.)

We have already stated that an intimate acquaintance with the mechanism of
parturition is of the greatest importance in applying the forceps. Knowing
that the head always presents in one of the two oblique diameters of the
pelvis, and that the blades are applied on each side of the head, it
follows that the forceps must always be applied in the contrary oblique
diameter of the pelvis to that in which the head is. Before speaking of
the operation itself, we must first consider what position of the patient
will be the most convenient. In this country no alteration is made in her
position, beyond bringing her close to the side of the bed, with the nates
projecting as much as possible over the edge, for the greater convenience
of the operator; unless this be attended to, it will be difficult to
depress the handle of the upper blade sufficiently when introducing it.
Upon the continent, and also in America, where the long forceps is more
generally used, the patient is usually delivered on her back; she is
placed in a half-sitting posture upon the edge of the bed, her back
supported by pillows, &c., her feet resting on two chairs, between which
the operator stands or sits, and applies the forceps in this position.
This, in many respects, is the most convenient posture for him, but the
very preparation which it requires cannot but be alarming to the patient,
who is obliged to be a witness of all his manipulations; whereas, when she
lies upon her left side, she is aware of little or no preparation being
made, and if any slight exposure happens to be necessary, viz. at the
moment of locking, it can be done without her knowledge.[85]

The simplest case for applying the forceps is, where the head has already
descended nearly to the os externum, and has begun to press upon the
perineum: it is for this that the straight forceps is chiefly intended;
and as this is the instrument which is generally used, we shall describe
its application first.

_Mode of applying the forceps._ Having ascertained that the rectum and
bladder are empty, examined the position of the head, and warmed and
greased the blades, we proceed to introduce the upper or lower blade
first, according as its lock is directed forwards: this precaution is for
the purpose of preventing the locks being turned away from each other when
brought together after the introduction of the second blade. The
trochanter major will guide us as to the precise position of the
patient's pelvis, and is especially useful in pointing out the direction
of the left oblique diameter, in which the forceps (on account of the
first position of the head being in the right oblique diameter) should be
most frequently applied: in this case, we pass the upper blade, as it
were, beneath the trochanter, and the lower one in the opposite
direction.[86]

Let us suppose that the head is in the first position, with its sagittal
suture parallel with the right oblique diameter of the pelvis, and that in
accordance with the above rule, the upper blade is to be introduced first.
Having passed one or two fingers up to the head, we guide the blade along
them, depressing the handle so as to make the extremity of the blade lie
closely upon the head, neither allowing the point alone to impinge upon
the head, nor _vice versâ_, to protrude against the vagina. The extremity
of the blade, therefore, must be our guide for the direction in which we
hold the handle: we must carefully insinuate this by a gentle vibratory
motion between the head and passage which surrounds it: the convexity of
the head will show the course which it has to take, nor is there any need
of passing the finger farther; for when once the extremity of the blade is
fairly engaged between the head and passage, it will almost guide itself,
and needs little more than to be pushed on gently, the handle gradually
rising according to the curve of the blade. The shank or handle should,
therefore, be held lightly like a pen, by which means the operator will
possess much more feeling with his instrument, than if he grasped it with
his whole hand. As the blade advances, he should keep his eye on the
general form of the pelvis, the curve of the loins, the situation of the
trochanter and symphysis pubis, and thus gain a more accurate idea of the
course which the instrument must take. This will, in great measure, depend
upon the situation of the head: if it be quite down upon the perineum, the
blade should be pointed towards the promontory of the sacrum, and the
handle turned downwards and forwards; if it be still in the cavity of the
pelvis, and only beginning to engage in the outlet, the blade must be
directed upwards towards the centre of the brim, and the handle turned
directly downwards. Having passed the blade to its full extent, we must
press the handle backwards against the perineum, to allow sufficient room
for the introduction of the second blade, and give it to an assistant or
the nurse, with the caution to hold it steadily and firmly, especially
during the pains, when it is apt to slip into the hollow of the sacrum if
held carelessly.

As we have passed the upper blade behind the right acetabulum or foramen
ovale, so now we must introduce the other in the opposite direction, viz.
before the left sacro-iliac synchondrosis: and, as the blades being
exactly opposite to each other is essential to the easy locking of the
instrument, it will be necessary to guide the course of the second blade,
not so much by the form of the pelvis, as by the direction of the first
blade. It must, therefore, pass up, so that when introduced to its full
extent, the inner surface of its handle shall correspond precisely to that
of the first blade. The easy or difficult locking of the blades is a proof
of their having been correctly or incorrectly introduced. If, therefore,
on bringing the locks together we find that they do not correspond, that
the inner surfaces of the handles are not parallel, but form an angle with
each other, we must endeavour to rectify this, by withdrawing, to a short
extent, that blade which deviates most from the proper direction, and pass
it up again more correctly. All attempts to twist the handles so as to
correspond with each other, are bad and cannot fail to put the patient to
much suffering.

When we are about to lock the blades, we cannot be too careful in
preventing the soft parts from being pinched between them, for it causes
most intolerable pain, and frequently makes the patient give such an
involuntary start, as to run the risk of altering the position of the
instrument.

The whole process of introducing and fixing the forceps should be
conducted in as gentle and gradual a manner as possible: no attempt should
be made to proceed with the operation during a pain; and in no case is
force either necessary or justifiable.

Every thing being now prepared for the extraction, we must endeavour to
make this resemble as far as possible the natural expulsion. When a pain,
therefore, comes on, we should grasp the handle firmly, and pull gently,
at the same time giving them a rotatory motion. The direction of the
handles, as before said, will depend upon the situation of the head in the
pelvis: if it be at the outlet, it will point downwards and forwards; if
in the cavity, nearly directly downwards. If the head makes but little or
no advance with one or two efforts, it will be advisable to tie the
handles firmly together, and thus keep up a continued pressure upon it,
and dispose it the more to elongate and adapt itself to the passages. As
it advances and begins to press upon the perineum, we must be more than
ever cautious not to hurry the expulsion, and give the soft parts time to
dilate sufficiently. At this period it is desirable to make the extractive
effort not so much forwards as the direction of the handles would seem to
indicate: we thus avoid pressing too severely upon the urethra and neck of
the bladder, which might otherwise suffer, and assist the dilatation of
the perineum. When the head is on the point of passing the os externum,
all farther extractive efforts should cease; the perineum must be
supported in the usual manner, and the head should be expelled if possible
by the patient herself.[87]

In applying the curved forceps we must bear in mind another rule in
addition to the one above-mentioned for selecting the first blade, viz.
the pelvic curvature must correspond with that of the sacrum. As with the
straight, so also with the curved forceps, the extremity of the blade will
be our best guide as to the direction in which we should hold the handle
at the moment of introduction; it must be directed more or less forwards
in proportion to the degree of the pelvic curvature of the blade. If, for
instance, it be the upper blade which is to be introduced first, we pass
it obliquely over the lower thigh or nates of the mother, making it glide
closely round the convexity of the head, between it and the pelvis,
without impinging either on the one or the other. As the position of the
head is still more distinctly oblique at this earlier period of its
progress through the pelvis, so will the blades require a more oblique
direction, and also (as in the former case) they must be introduced in the
contrary oblique diameter to that in which the head is.

As the blade passes up between the head and pelvis, so does the handle
gradually make a sweep backwards, until at length it approaches to the
edge of the perineum. During the process of introduction, one or two
fingers should press against the posterior edge of the blade to guide it
up to the brim of the pelvis, and prevent its slipping too far backwards
towards the hollow of the sacrum.

The second blade will be guided in its direction by that of the first: it
must be introduced so that the inner surface of its handle corresponds
exactly with that of the first. The locking must be performed under the
same precautions as with the straight forceps: the more so, as in some
cases it has to take place just within the os externum, and therefore
requires the most careful attention to prevent the soft parts from being
caught and pinched between the blades when they are brought together. In
extracting the head we must bear in mind the part of the pelvis in which
it is impacted, and make our effort in the direction of its axis; we must
also recollect the curved form of the instrument, and that we must not
pull in the direction in which the handles point, but rather hold them
firmly with one hand, and, by pressing against the middle of the forceps
with the other, guide the head downwards and backwards into the cavity of
the pelvis. We shall thus make our extractive effort in the direction of
the upper portion of the blades, or that part which has the chief hold
upon the head: hence, therefore, as it descends, the handles are directed
more and more forwards, so that when it has reached the perineum, the
handles will not only point forwards, but considerably upwards. Whilst
extracting we should, as with the straight forceps, slowly move the
handles from side to side, and even make them describe a circle: we thus
not only use the forceps as a simple extracting instrument, but make it
act as a lever in every direction, and greatly facilitate the advance of
the head, even under circumstances of considerable impaction. It is in
these cases where keeping up a continued pressure upon the head by tying
the handles tightly together, and tightening it after every successive
effort, has such excellent effects in diminishing the degree with which it
is wedged against the pelvis and soft parts, and in disposing it by
gradual elongation to assume a form which is better adapted for advancing
through the passages.

The slow and gradual pressure of the forceps thus exerted upon the head of
a living foetus will have a very different result to that of the
experiments by Baudelocque and others, in attempting to compress the head
of a dead foetus by the application of a sudden and powerful force. Even
if we were capable of effecting no greater diminution of its lateral
diameter than a quarter, or at the most, three-eighths of an inch, as
stated by Dr. Burns, we should, in most cases of impacted head, where the
forceps is justifiable, find it quite sufficient to remove the obstructing
causes.

The forceps is also occasionally required in presentations of the face and
nates. In the first case we must pass up the blades on each side of the
face, and along the side of the head, having previously ascertained to
which side of the pelvis the chin is turned. In nates cases, the blades
should also be passed up along the sides of the child's pelvis, and here
the advantages of a broad fenestra will be very evident, for otherwise our
hold will not be firm enough without exerting an improper degree of
pressure.

Cases every now and then occur, where from convulsions, &c., it is
desirable to apply the forceps whilst the patient is lying upon her back,
as is practised upon the continent. "The patient is placed across the bed,
propped up in a half-sitting posture, by pillows, &c., her pelvis resting
upon the edge, her feet on two chairs, the knees supported by assistants.
Two, and generally three fingers are passed, if possible, up to the os
uteri, on the side where the blade is to be introduced: the index finger,
is held a little behind the middle finger, so that this last, by
projecting somewhat, forms a species of ledge upon which the blade slides,
and which acts as a fulcrum to it. The handle is held at first nearly
perpendicular; but as the blade advances, it gradually approaches the
horizontal direction, being guided by the pelvic curve of the instrument.
The middle finger, along the ulnar surface of which the convex edge of the
blade slides, prevents its extremity from passing too far backwards, and
directs it in the axis of the pelvis. When introduced to the full extent,
the handle is inclined obliquely downwards, and is now grasped by an
assistant passing his hand below the patient's thigh. The other blade is
introduced in the same way on the opposite side of the pelvis; and the
locking, extraction, &c., conducted much in the same manner as in
England." (_British and Foreign Med. Rev._ vol. iii. April 1837, p. 419.)

_History of the forceps._ We have already mentioned some historical points
connected with the improvements of the present French and English forceps;
it will now be unnecessary to enter more fully into the history of this
instrument. The earliest trace of the midwifery forceps which we possess
is under the form of a secret in the hands of an English family, named
Chamberlen. As to when and by whom it was first invented, this must
probably remain for ever unknown; and at any rate there is no more reason
to suppose that Dr. Hugh Chamberlen was the inventor than his father or
brothers were. He was compelled to quit England on account of being
involved in the political troubles of the time, and went to Paris in the
beginning of the year 1770, and evidently had then been some time in
possession of the secret. He returned to London, in August of the same
year, having in vain attempted to sell it to the French government, after
having entirely failed in a case of difficult labour which he had asserted
he could deliver in a few minutes, although Mauriceau had stated that the
Cæsarean operation would be required. Dr. H. Chamberlen published in 1772,
a translation of Mauriceau's work, which had appeared four years
previously, and in his preface he publicly alludes to this secret, and
says, "My father, brothers, and myself (though none else in Europe, as I
know) have, by God's blessing and our industry, attained to, and long
practised a way to deliver women in this case without any prejudice to
them or their infants: though all others (being obliged, for want of such
an expedient, to use the common way) do or must endanger, if not destroy,
one or both, with hooks." He thus apologizes for not having divulged this
secret: "there being my father and two brothers living, that practice this
art, I cannot esteem it my own to dispose of, nor publish it without
injury to them."

Whether a work, entitled _Midwife's Practice_, by Hugh Chamberlen, 1665,
was by the translator of Mauriceau's work, or by his father, must now
remain a matter of doubt: it was, however, in all probability by the
latter, from what the translator says in his preface, viz. "I designed a
small manual to that purpose, but meeting some time after in France, with
this treatise of Mauriceau, I changed my resolution into that of
translating him." On account of his being attached to the party of James
II. he was again obliged to quit England, in 1688, and crossed over to
Amsterdam, where he settled, and in five years after succeeded in selling
his secret to three Dutch practitioners, viz. Roger Roonhuysen, Cornelius
Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands,
and in those of their successors, it remained a profound secret until
1753, when it was purchased by two Dutch physicians, Jacob de Visscher and
Hugo van de Poll, for the purpose of making it generally known. It turned
out to be a flat bar of iron, somewhat curved at each end: this lever was
stated to have been received from Roonhuysen, one of the original
purchasers of the Chamberlen secret; but there is no reason to suppose
that any such instrument had been communicated by Chamberlen either to him
or the others, as we have distinct evidence that both Ruysch and Bökelman
possessed _forceps_, the blades of which united at their lower end by
means of a hinge and pin. It is known also that Roonhuysen used a double
instrument consisting of two blades. The above-mentioned flat bar of iron,
commonly called Roonhuysen's lever, was, without doubt, invented after his
time, by Plaatman, who received the Chamberlen secret from him. (_Edin.
Med. and Surg. Journal_, Oct., 1833.)

[Illustration: Chamberlen's Forceps.]

Not many years ago a collection of obstetric instruments were found at
Woodham, Mortimer Hall, near Mildon, in Essex, which formerly belonged to
Dr. Peter Chamberlen, who, having purchased this estate "some time
previous to 1683," was, in all probability, one of the brothers alluded to
by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's
work. This collection, (now in the possession of the Medico-Chirurgical
Society, of London,) contains several forceps, two of which appear to have
been used in actual practice: these differ from each other only in size,
and present a great improvement upon the instrument possessed by Hugh
Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well
formed: the locks are the same as of a common pair of scissors, except
that in one case the pivot is riveted into one lock, which passes through
a hole in the other when the blades are brought together. In the smaller
forceps there is merely a hole in each lock through which a cord is
passed, and then wound round the shanks of the blades to fasten them
together, an improvement in which Dr. Peter Chamberlen had evidently
anticipated Chapman, in making the first approach to the present English
lock.

The earliest professors of the forceps, besides the Chamberlens, were
Drinkwater, who commenced practice at Brentford, in 1668, and died in
1728; Giffard, who has given cases where he used his extractor as early as
1726; and Chapman, who possessed a similar instrument about the same
time. These forceps correspond very nearly with the above-mentioned ones
of Dr. Peter Chamberlen; and as it is well known that from those of
Giffard and Chapman, the forceps of the present day are descended, we
cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for
these instruments, to which his bear so distant a resemblance, as to his
relations, who, from living together in England, had doubtless assisted
each other by their mutual inventions, and thus brought the instrument to
that state of improvement in which it was found as above-mentioned.

For more detailed information respecting the history of the forceps we may
refer our readers to Mulder's _Historia Forcipum_, &c., particularly, the
German translation by Schlegel, to a similar work brought down to the
present time, by Professor Edward von Siebold, to our own lectures on this
subject, published in the _London Med. and Surg. Journal_, for March 28,
1835, vol. vii., and to the two papers already alluded to in the _London
Med. Gazette_, Jan. 8, 1831, and _Edinburgh Med. and Surg. Journal_,
October, 1833. [Also, _Researches on Operative Midwifery_, &c. By
FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. _Dublin_,
1841.--ED.]



CHAPTER II.

TURNING.

    _Turning.--Indications.--Circumstances most favourable for this
    operation.--Rules for finding the feet.--Extraction with the feet
    foremost.--Turning with the nates foremost.--Turning with the head
    foremost.--History of turning._


Turning is that operation in midwifery where the feet, which had not
presented at the time of labour, are artificially brought down into the os
uteri and vagina, and in this manner the child delivered. (Naegelé, _MS.
Lectures_.)

Besides turning with the feet foremost as now described it has also been
proposed, as being safer for the child, to bring down the nates or the
head, but these operations, especially the former, have scarcely ever been
practised, and in most cases are impracticable.

Turning, in the strict sense of the word, is that operation, by which,
without danger to the mother or her child, the position of the latter is
changed, either for the purpose of rendering the labour more favourable,
or for adapting the position of the child for delivering it artificially.

The delivery of the child with the feet foremost, by means of the hand
alone, may be looked upon as a second stage of the operation; where,
however, the turning has been undertaken on account of malposition of the
child, it has been very properly recommended by Deleurye, (_Traité des
Accouchemens_, 1770,) Boer, (_Naturliche Geburtshülfe_, 1810,) Wigand,
(_Geburt des Menschen_, 1820,) and other high authorities in midwifery,
that as the position is now converted into a natural one, (viz. of the
feet,) it should be left as much as possible to the natural expelling
powers; hence, therefore, under these circumstances, artificial extraction
of the child with the feet foremost can scarcely be said to exist, the
operation itself being confined to changing the position of the child.

Where, however, the circumstances of the case require that labour should
be hastened in order to avert the impending danger, the extraction of the
child with the feet foremost, by means of the hand alone, becomes a
distinct operation.

The artificially changing the child's position into a presentation of the
feet is indicated in cases where, on account of malposition of the child,
the labour cannot be completed, or at least without great difficulty.

_Indications._ The artificially delivering the child with the hand alone,
or the extraction of it with the feet foremost (which of course presumes
that it has presented with the feet, either originally or has been brought
into that position by interference of art,) is indicated in all cases
where the labour requires to be artificially terminated either on account
of insufficiency of the expelling powers, or from the occurrence of
dangerous symptoms. Under this head, on the part of the mother, are
violent floodings, especially under certain circumstances, convulsions
with total loss of consciousness, great debility, faintings, danger of
suffocation from difficulty of breathing, violent and irrepressible
vomiting, rupture of the uterus, death of the patient, &c.;--on the part
of the child, prolapsus of the cord under certain circumstances. (Naegelé,
_Lehrbuch der Geburtshülfe_, §§ 394, 395. 3d edit.) Hence, therefore, the
general indications of turning are the same as those of the forceps, it
being indicated in all those cases where nature is unable to expel the
foetus, or which demand a hasty delivery of the child, but which cannot be
attained by the application of the forceps.

Turning is an operation which is far inferior to that of the forceps, both
as regards the safety of the mother and her child, and also the ease with
which it is performed. Whenever the circumstances under which it is
undertaken are unfavourable, it not only becomes a very difficult
operation, but also one of considerable danger: for the child especially
is this the case, as the very circumstance of its being born with the feet
foremost shows that it is necessarily exposed to the same dangers as those
already mentioned in nates presentations, in addition to those of the
first part of the operation, viz. the changing its position.

The most favourable moment for undertaking the operation of turning is
when the os uteri is fully dilated and the membranes are still unruptured.
In this state, the vagina and os uteri are most capable of admitting the
hand, and the uterus, from being filled with liquor amnii, is prevented
contracting upon the child, the position of which is changed with great
ease and safety; but when the os uteri is only partially dilated, its edge
thin and rigid, the membranes ruptured, and the liquor amnii drained off
for some hours, it becomes a matter of great difficulty and danger either
to introduce the hand into the uterus under such circumstances, or to
attempt changing the child's position: the os uteri tightly encircles the
presenting part, and the uterus contracts upon the child itself so as to
render it nearly, if not altogether immoveable.

The os uteri ought always if possible to be fully dilated: this however is
not so essential as with the forceps, for when once it has reached the
size of a crown piece, it mostly yields easily to the introduction of the
hand. Where turning is indicated in malposition of the child we may safely
await its full dilatation so long as the membranes remain unruptured.
Where the membranes have been ruptured some hours and the os uteri hard,
thin, and rigid, it will be impossible to turn until, either spontaneously
or by proper treatment, it becomes soft, cushiony, and dilatable.

In cases which require turning as a means of hastening labour, as for
instance in flooding from placenta prævia and other causes, the hæmorrhage
is seldom so severe as to demand it without at the same time rendering the
os uteri so relaxed as to present little or no obstruction to the hand.
Where convulsions indicate turning, the bleeding and other depleting
measures, which are necessary to control them, will have a similar effect
in preparing the os uteri for this purpose.

In ordinary cases of turning there will be no need to change the patient's
position, as it will be just as easy to perform it as she lies upon her
left side, merely bringing her pelvis nearer to the side of the bed in
order to reach her with greater facility. Where, however, from the
position of the child or from the state of the uterus, the introduction of
the hand and searching for the feet will probably be attended with
considerable difficulty, it may be advisable to place her across the bed,
sitting upon its edge, her back supported by pillows, her feet resting on
two chairs, in the same way as it is used by the Continental practitioners
for applying the forceps; or if it be really a case of very unusual
difficulty, it will be better to put her upon her knees and elbows, for in
this position we gain the upper and anterior parts of the uterus with
greater ease.

In choosing which is the best hand for performing the operation, the
practitioner must not only be guided by the position of the child, but
also by the hand with which he possesses most strength and dexterity: many
always use the left hand for turning when the patient lies upon her left
side; for our own part we have always used the right, and have never
failed except in one or two cases of great difficulty, where we judged it
more prudent to put the patient on her knees and elbows than risk any
injury by using too much force. In introducing the hand into the vagina as
the patient lies on her left side, the right is moreover preferable, as we
can pass it more completely in the axis of the vagina, than we can the
left.[88]

The directions which are usually given to introduce one hand or the other
according to the child's position, are not practical, because cases occur
where it is impossible to ascertain this point without passing the hand
into the uterus, as in placenta prævia, and occasionally in shoulder
presentations; and it would be by no means justifiable to make the patient
undergo the suffering from a repetition of this operation, merely because
the position of the child is such as is stated in books to require the
left hand instead of the right.

Having evacuated the bladder and rectum, and greased the fore-arm and back
of the hand, we should gently insinuate the four fingers, one after the
other, into the os externum: the whole hand must be contracted into the
form of a cone; the thumb will pass up easily along the palm; the passage
of the knuckles is the most difficult, for as the os externum is the
narrowest part of the vagina, and the hand is widest across the knuckles,
it follows that this is the point of the greatest resistance and
suffering, and that, when once this is overcome, our hand will advance
with greater ease both to ourselves and to our patient. This part of the
operation can scarcely be conducted too gradually or gently, for if we
give the soft parts sufficient time to yield, it is scarcely credible what
an extent of dilatation may be effected by a comparatively moderate degree
of pain; the os externum is also the most sensitive part of the vagina,
and serious nervous affections may even be provoked by the intolerable
agony arising from a rude and hasty attempt to force the hand through it.
We must not advance the hand merely by pushing it onwards, but endeavour
to insinuate it by a writhing movement, alternately straightening and
gently bending the knuckles, so as to make the vagina gradually ride over
this projecting part as the hand advances.

In passing the os uteri the same precautions must be observed,
particularly when the os uteri is not fully dilated; at the same time we
must fix the uterus itself with the other hand, and rather press the
fundus downwards against the hand which is now advancing through the os
uteri. In every case of turning we should bear in mind the necessity of
duly supporting the uterus with the other hand; for we thus not only
enable the hand to pass the os uteri with greater ease, but we prevent in
great measure the liability there must be to laceration of the vagina from
the uterus, in all cases where the turning is at all difficult. "In those
cases (says Professor Naegelé) where artificial dilatation of the os uteri
is required to let the hand pass, it should be done in the following
manner:--during an interval of the pains, we introduce, according to the
degree of dilatation, first two, then three, and lastly four fingers; and
by gently turning them and gradually expanding them we endeavour to dilate
it sufficiently to let the hand pass. This must only be done under
circumstances of absolute necessity and always with the greatest
caution--in fact, only in those cases where the danger consequent upon
artificial dilatation of the os uteri is evidently less than that, to
avert, which we are compelled to turn before it is sufficiently yielding
or dilated." (_Lehrbuch der Geburtshülfe_, p. 212. 3tte ausgabe.) This
observation from so high an authority evidently applies to those cases
where the os uteri is not only soft and yielding, but also nearly dilated;
the _forcible_ dilatation of the os uteri is justly deprecated by Madame
la Chapelle: "I never attempt to produce this forced dilatation, _not even
in cases of hæmorrhage_. But we may frequently promote the dilatation of
the passages in a remarkable manner by moistening and relaxing them and
diminishing their state of excitement, viz. by the steams of hot water,
tepid injections, and more particularly by warm baths and bleeding." (p.
49.) Her diagnosis of the condition in which the os uteri will yield to
the introduction of the hand is well worthy of attention. "If the inactive
uterus be unable to expel the child, or to make the head clear its orifice
although considerably dilated, if, in this state of affairs, the membranes
give way, we can feel the os uteri retract, from being no longer pressed
upon. How different is this state of passive contraction to the rigidity
of an orifice which has not yet been dilated: in this case, although the
os uteri is contracted and even thick, it is soft, supple, and easily
dilatable; there is no feeling of tightness or resistance; it is little
else than a membranous sac, and the head has not descended sufficiently to
press upon it; or if the head does not present, it is some part of the
child, as for instance the shoulder, which is unable to advance and act
upon the os uteri: in this case operate without fear--in the other wait."
(_Pratique des Accouchemens_, p. 86.)

If the membranes be not yet ruptured we should use the greatest caution to
preserve them uninjured: the hand must be gently insinuated between them
and the uterus, and should be passed either until the feet are felt, or at
least, until it has gained the upper half of the uterus. Now, and not till
now, ought they to be ruptured. As this is done at the side of the uterus
little or no liquor amnii escapes, for the torn membranes are pressed
closely against the uterine parietes, and the vagina is completely closed
by the presence of the arm in it acting as a plug; the uterus is unable to
contract upon the child on account of the fluid which surrounds it, and
the hand, therefore, passes up with great facility. The uterus is not
diminished by the loss of its liquor amnii; its contractile power is,
therefore, not increased. When the hand has broken the membranes it can
move about in perfect freedom: if the feet have not as yet been reached
they will now be easily found, and the position of the child will be
changed without difficulty.

The importance of passing in the hand without rupturing the membranes was
first shown by Peu in 1694.[89] But it excited little or no notice at the
time, not even by La Motte, who paid so much attention to improving the
operation of turning. Dr. Smellie appears to have been the first after Peu
who recommended this mode of practice, although he makes no mention of his
name. "Then introducing one hand into the vagina we insinuate it in a
flattened form within the os internum, and push up between the membranes
and the uterus as far as the middle of the womb: having thus obtained
admission, we break the membranes by grasping and squeezing them with our
fingers, slide our hand within them without moving the arm lower down,
then turn and deliver as formerly directed." (_Treatise on the Theory and
Practice of Midwifery_, vol. i. p. 327. 4th edit.) In 1770, Deleurye again
pointed out the value of this mode of introducing the hand, and expressly
directs us "introduire la main dans la matrice _sans_ percer la poche des
eaux, détacher les membranes des parois de ce viscère, et les percer à
l'endroit où l'on juge que les pieds peuvent le plus naturellement se
trouver."[90] Dr. Hamilton, of Edinburgh, five years afterwards
recommended the same method, and in nearly the same terms. Little notice,
however, has been taken of it since, either in this country or upon the
Continent, and the old objectionable mode of rupturing the membranes at
the os uteri is still taught even by the most modern authors. The
celebrated Boer also added his testimony in favour of Deleurye's mode of
practice,[91] and it has still farther been confirmed by Professor
Naegelé.

Turning under these circumstances is an easy operation, and a very
different affair compared with its performance in cases in which the
membranes have been some time previously ruptured, and the uterus drained
of liquor amnii: the hand is passed up with difficulty, the feet are
quickly found, and the child moved round with a degree of facility which
is scarcely credible. Where, however, the uterus is irritable and closely
contracted upon the child, the liquor amnii having long since escaped,
where the os uteri is not more than two-thirds dilated, its edge thin,
hard, and tight, as is especially seen in a neglected case of arm or
shoulder presentation, every step of the operation is attended with the
greatest difficulty, and in fact is neither possible nor justifiable,
until by bleeding to fainting, by the warm bath and opiates, we have
succeeded in producing such a degree of relaxation as to enable us to
introduce the hand. "Blood-letting is the only remedy with which we are
acquainted that has any decided control over the contracted uterus. It is
one almost certain of rendering turning practicable under such
circumstances, if carried to the extent it should be. A small bleeding in
such cases is of no possible advantage, for unless the practitioner means
to carry the bleeding to its proper limits, which is a disposition to, or
the actual state of syncope, he had better not employ it." (Dewees'
_Compendious System of Midwifery_, § 629.) "The vagina is never so soft,
so dilatable, and capable of admitting the hand as during the presence of
an active hæmorrhage, and this is equally the case in primiparæ as in
those who have had several children: and it is a mistaken kindness in the
medical attendant, who in order to spare his patient's sufferings, under
these circumstances delays to introduce his hand until the hæmorrhage
shall have ceased. The moment this is the case, the vagina regains more
vitality, sensibility and power of contraction, the hand now experiences
much more opposition, and excites far greater pain than during the state
of syncope." (Wigand, _Geburt des Menschen_, vol. ii. p. 428.)

When once a powerful impression has been made upon the system by an active
bleeding, opiates, which before it, would have only tended to render the
patient feverish, are now of great value: they relax the spasmodic action
of the uterus, allay the general excitement and irritability, and induce
sleep and perspiration. As with bleeding in these cases, they must be
given in decided doses: a grain of hydrochlorate of morphia given at once,
or in two doses quickly repeated, and at the same time from half a drachm
to a drachm of Liquor Opii Sedativus thrown into the rectum with a little
thin starch or gruel, will rarely or never fail to produce the desired
effect. The opiate by the mouth may be advantageously combined with
James's powder, and thus assist its diaphoretic action. The warm bath will
also prove a valuable remedy.

"If the arm or funis of the child presents and is prolapsed into the
vagina, we must not try to push back these parts into the uterus again,
but we must endeavour to pass our hand along the inner surface of the
presenting arm; or if it be the cord, we must guide it so as to press the
cord as little as possible: if however a coil of it has passed out of the
vagina and is still beating, we had better carry it upon the hand with
which we are about to turn the child." (Boer, _op. cit._ vol. iii. p. 5.
1817.) For farther information on this head we must refer to the
observations on _Malposition of the Child_.

If the head or nates be occupying the brim of the pelvis it will be
necessary to raise them gently and press them to one side: this however is
usually effected by the very act of passing up the hand, and seldom
produces any difficulty, unless these parts have already advanced deeper
into the pelvis; in which case, as turning under these circumstances can
only be undertaken with a view to hasten labour, it will become a matter
of consideration whether we shall not be able to attain this object better
by the aid of the forceps.

Although it ought ever to be considered as a rule that turning must not be
attempted whilst the pains are violent, the introduction of the hand into
the uterus always excites it more or less to contraction: the degree of
pressure and impediment which it will produce to the progress of the hand
will in a great measure depend upon the quantity of liquor amnii which it
contains. Where the uterus has been drained of the fluid, every
contraction will be felt in its full force by the operator: his hand is
firmly jammed against the child, and if it happens to be caught in a
constrained posture at the moment, is liable to be attacked with a severe
fit of cramp, which benumbs and renders it powerless. Wherever we find
that the hand is tightly squeezed during a pain, we should lay it flat
with the palm upon the child, and hold it perfectly still: in this posture
it will bear a powerful contraction without inconveniencing ourselves or
injuring the uterus; and by letting it be quite flaccid and motionless we
shall not provoke the uterus to farther exertions. Attempting to turn
during the pain would not only be useless, but we should exhaust the
strength of our hand which cannot be spared too much; we should torture
the patient unnecessarily, and run no small risk of rupturing the uterus.

In letting the pressure of our hand be upon the child during a pain,
instead of against the uterus, we must select any part rather than its
abdomen, for pressure here seems to act as injuriously as pressure upon
the umbilical cord.

_Rules for finding the feet._ In searching for the feet we must endeavour
to gain the anterior surface of the child, for (unless its position be
greatly distorted) they are usually turned upon the abdomen: in arm
presentations the position of the hand will also guide us, the palm of it
being mostly turned in the same direction as the abdomen, and therefore
points to the situation of the feet; the rule also, as above given by
Boer, of passing the hand along the inside of the presenting arm, is well
worthy of recollection, for this can scarcely fail to guide us to the
anterior part of the child. Where, either from the pressure of the uterus
or other circumstances, it is difficult to distinguish the precise
position of the child, it will be better to follow Dr. Denman's simple
rule, that the hand "must be conducted into the uterus, on that side of
the pelvis where it can be done with most convenience, because that will
lead most easily to the feet of the child." The soft abdomen, the curved
position of the child, and its extremities crossed in front are so many
reasons why there should be more room in this direction.

During all this time the other hand placed externally will be of great
service, not only in supporting the uterus, but in fixing the child and
rendering the different parts of it more attainable. Where the feet are at
some distance, we frequently come first to an arm or thigh, which soon
leads us to the elbow or knee; if the introduction of the hand has been
attended with some difficulty, it will not be very easy to distinguish
these joints from each other, without bearing in mind the following
diagnostic points:--the knee present two rounded prominences (condyles of
the femur) with a depression between them, whereas, the elbow presents
also two rounded prominences, but with a sharp projection (olecranon)
between.

If the foot is not easily reached, there will be no need of forcing up the
hand farther to gain it: it will be much better and safer to hook the
finger into the bend of the knee and hold by it for a pain or two: this
will generally be sufficient to bring it within reach; or during an
interval of the pains, the leg may be gently disengaged and brought down.
Not unfrequently we can only feel the toes with the extremities of our
fingers, and therefore cannot maintain a sufficient hold upon the foot so
as to bring it down: here again the same rule will be applicable, for by
keeping but a slight hold upon it during a pain, it will be found to have
approached nearer when the pain has gone off; in fact our first attempt to
move the child must be done in this cautious manner, and we shall effect
our object with greater certainty by merely holding the feet still during
the pain, not allowing them to recede from that position in which we had
placed them during the intervals, than by using considerable efforts to
bring them to the os uteri. By the time we have got one foot fairly within
grasp, the other is seldom very distant and should always be brought down
if possible: by bringing down both feet we cause the hips of the child to
enter the brim of the pelvis more equally; whereas, if one leg only is
brought down, the pelvis of the child comes more or less awry, and the
ischium of the other side is apt to lodge against the brim of its mother's
pelvis.[92] This practice has been recommended on the grounds that, by
bring down only one leg, we make the presentation rather resemble a breech
case, which is known to be more favourable for reasons already mentioned,
and that by having the other leg turned upon the abdomen it will protect
the cord from undue pressure. As far as the abdomen is concerned this may
possibly be the case, but the pressure of the head upon the cord, which is
the real source of danger to the child in turning, can in no wise be
influenced by this position.

In bringing down the feet it must be done with the articulation, that is,
the child must be turned forwards; at the same time the hand upon the
abdomen, externally, will be of great service in assisting us to move the
child, and in preventing the change of its position from taking place in
too sudden and violent a manner, a circumstance which is apt to paralyze
the uterus considerably, and even produce alarming symptoms from the shock
it occasions.

_Extraction._ When once we have brought the feet into the vagina, the
first part of the operation, viz. the changing the position of the child,
is completed: it has now become a presentation of the feet, and as such
ought to be treated, unless some source of danger be present which
requires that the delivery should be hastened. The value of this practice
in footling cases was first pointed out by Deleurye,[93] and particularly
applied to the second act of turning by Wigand. "I have made it," says he,
"a strict rule in turning, from the moment that I have brought a foot of
the child as far into the vagina as I can without force, to do nothing
beyond patiently waiting for the return of the pains, even if this did not
take place for many hours, and leaving the rest of the labour entirely to
nature. I have found by doing so that when the pains at length began to
expel the child, they did it with so much force and activity as was not
even seen in the most natural case of head presentation." (_Geburt des
Menschen_, vol. ii. p. 130.)

As the feet descend towards the os uteri, the presenting part,
particularly if the arm has been prolapsed into the vagina, begins to
recede, the hand externally will assist in moving the child round, and we
should perform this step of the operation so gradually as to be assured
that the presenting part has quitted the pelvis before the feet have
entered. Without attention to this point, the child may easily be fixed
across the upper part of the pelvis, or even the body brought down, while
the head is wedged into the cavitas iliaca of the ilium, and produce a
serious obstacle to its farther advance. This is a sort of mishap which
can rarely happen except to young practitioners. If the process be slowly
and carefully conducted, we doubt much if it be ever necessary to
disengage the presenting part as has been so frequently recommended: the
uterus in fact will move the child round with very little assistance on
our part, and we shall find that after every pain the advance of the feet
and recession of the part has increased considerably. From our own
observations we would say that in all difficult cases, of turning
especially, it is desirable for the patient to have several pains between
the moment of gaining the feet and bringing them fairly into the vagina:
very little force is required to bring them down, and the uterus does not
appear to suffer; but where the position of the child has been rapidly
changed, its contractile power seems to be injured, and it is ill able to
make those exertions during the last stage, which will be required of it
in order to save the child's life.

Not less necessary is it that we should proceed with the second stage as
cautiously as possible: the grand principle is the same, viz. to conduct
the expulsion as gradually as possible: there is no use whatever in
hurrying this part of the operation, for if the child be alive, we place
it in imminent danger of its life; and if it be dead, as will easily be
known by the cord not pulsating, we are putting the mother to a great deal
of suffering for no reason. Now that it has become a footling case, it
must be managed according to rules already given for this species of
presentation: the uterus must be emptied as slowly as possible, the
anterior part of the child must be directed more or less backward, and the
funis guided into the vicinity of one or other sacro-iliac synchondroses.
By retarding the advance of the child, we resist the action of the uterus
somewhat, and thus excite it to contract more actively, the head enters
the pelvis in the most favourable position, and as the pains are still
brisk, it passes through so quickly as to subject the child to little or
no danger by pressing upon the cord. Where however the passage of the head
through the pelvis threatens to be delayed, we would strongly recommend
the application of the forceps in order to terminate the delivery before
the child has begun to suffer: it is to this mode of practice that
Professor Busch, of Berlin, attributes the extraordinary success of
turning in his hands; of forty-four cases where turning was deemed
necessary only three children are stated to have lost their lives from the
effects of the operation, a result which is by far the most favourable
known.

_Turning with the nates foremost._ It has been proposed by several authors
of the last century to turn the child with the breech foremost, as being a
less dangerous operation for it than the common one of bringing down the
feet. Levret has distinctly proposed this mode (_L'Art des Accouchemens_,
§ 767,) and Smellie on more than one occasion has alluded to bringing down
the nates. Dr. W. Hunter has also recommended turning with the breech
foremost: still more recently has this mode of practice been confirmed by
W. J. Schmitt, of Vienna,[94] also by some other continental authors; but
the difficulty in bringing down a part of the child's body, upon which we
can exert so little hold, will always be very considerable, wherever the
circumstances under which the operation is undertaken is at all
unfavourable. Schmitt recommends that as soon as we reach the nates we
should apply the hand flat upon them; while in order to turn the child,
active pressure is kept up from without by the other hand: when once we
have succeeded in moving the breech somewhat downwards, its farther
descent is very easy.

A still more recent modification of turning the child in arm and shoulder
presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists
in raising the presenting part, and at the same time turning the child
upon its long axis, as the hand placed in the axilla carries the shoulder
to the upper parts of the uterus, after which, as the hand descends, it
brings the feet along with it into the vagina.

_Turning with the head foremost._ In former times, as the head was
considered the only natural presentation of the child, every deviation of
its position from this was looked upon as unnatural, and, therefore, the
operation of turning only applied to bringing down the head, which had not
presented: as, however, the difficulties already mentioned, in turning
with the nates, would apply still more forcibly to bringing down the head,
it is plain that this mode of turning would rarely be practicable. "Were
it practicable at all times," says Dr. Smellie, vol. i. book iii. chap.
iv. sect. iv. number v., "to bring the head into the right position, a
great deal of fatigue would be saved to the operator, much pain to the
woman, and imminent danger to the child: he, therefore, ought to attempt
this method, and may succeed when he is called before the membranes are
broke, and feels by the touch that the face, ear, or any of the upper
parts present." Still, however, he confesses that the usual method of
turning by the feet is the safest. In his first volume of cases,
(collection 16, number 6, case 5,) he has given a description of this mode
of turning. Dr. Spence also turned with the head foremost, as is shown by
his thirty-second case, where the hand and cord were prolapsed into the
vagina. "I introduced my hand into the vagina, and in the intervals
between the pains reduced both the arm and the cord: but as I found they
were like to return again upon my withdrawing my hand, I therefore
continued to support them till such time as, by the strength of the pains,
the child's head was so far forced down as to prevent any danger of their
returning, the happy consequence of which, was, that she was delivered of
a live child in about half an hour after: both mother and child did well."
(Spence's _System of Midwifery_, p. 465.) Dr. Merriman has recorded a
similar case in his own practice: "The arm was returned at two o'clock;
there was afterwards no occurrence of pain till six, after which, they
became very strong, and between eight and nine the child was born. This
was the only infant that Mrs. R. has seen alive out of six." (_Synopsis of
Difficult Parturition_, 1838, p. 250.) Still more recently turning with
the head foremost has been tried by Dr. Michaelis, of Kiel, (_Neue
Zeitschrift für Geburtskunde_, vol. iv. 1836.) When once the faulty
position has been altered, the liquor amnii is allowed to drain off, the
uterus contracts and presses the head down into the pelvis, and the child
is born without farther difficulty.

_History of turning._ Turning, as it is generally practised at the present
day, viz. changing the position of a living child so that the feet are
brought down foremost into the vagina, was unknown to the ancients. There
is little doubt, however, that if they could have been induced to have
looked upon presentations of the nates and feet as natural labours, they
would have been in possession of this valuable means of effecting
artificial delivery; as it is, we meet with detached allusions to it in
their writings, although applying only to cases where the child is dead.
In the writings of Aspasia and Philumenus, which, but for the quotations
of Oetius, would have been entirely lost to us, we find directions for
turning the child. Thus, Philumenus states, "Si caput foetûs locum
obstruxerit ita ut prodire nequeat infans in pedes vertatur atque
educatur." At a still later period, Celsus gave similar directions, but to
all appearance they also merely apply to a dead child. "Medici vero
propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes
si forte aliter compositus est;" and again he says, "Sed in pedes quoque
conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas
manus commode educitur." (Celsus, _de Medicinâ_, lib. vii. cap. 29.)

From this time the whole subject seemed to sink into oblivion, until
Pierre Franco, in his work on surgery[95] proposed the extraction of the
child with the feet foremost: this was put into practice by the celebrated
French surgeon, Ambrose Paré, (Ambr. Paræus, _Opera Chirurgia_, 1594,)
who, nevertheless, recommended turning with the head foremost, where it
was possible. His work was afterwards translated into Latin by Guillemeau,
who, although he still adhered to the old plan of bringing down the head,
showed the value of Paré's mode of turning in hæmorrhages and convulsions.
To Francis Mauriceau, a man of great learning and experience, we are
indebted for this operation being greatly improved, by means of his
valuable work, in 1668; but it is Philip Peu, in 1694, and William
Manquest de la Motte, in 1721, to whom the merit is due of having pointed
out the value of two great laws in turning--the one of not rupturing the
membranes as already mentioned, the other of not attempting to push back
the arm which presents.[96]



CHAPTER III.

CÆSAREAN OPERATION.

    _Indications.--Different modes of performing the operation.--History
    of the Cæsarean operation._


The next operation in Midwifery for delivering the full-grown foetus alive
is that of _Hysterotomy_, commonly called the Cæsarean operation, viz.
where the foetus is extracted through an artificial opening made through
the parietes of the abdomen and uterus.

The _indications_ for performing the operation are so different in this
country to what they are elsewhere that they require especial mention: in
England the operation is never performed upon the living subject except
where the child cannot be delivered by the natural passage; under these
circumstances it is scarcely undertaken in this country for the purpose of
saving the child's life, but merely that of the mother, it being
considered preferable to deliver the child by perforation or embryotomy,
even when known to be alive, than to expose the mother to so much
suffering and danger.

On the Continent and also in America, it has not been considered in so
dangerous a light as in this country, still less as an operation almost
certainly fatal to the mother: therefore, besides being indicated as a
means for preserving the mother's life, it is performed for the purpose of
saving the child's life in cases where, by using the perforator, the child
might be brought through the natural passages. The results of the Cæsarean
operation have been so unfavourable, and the character of the process so
frightful, as to have rendered it a measure of peculiar dread to
practitioners, and in different times and countries the strongest feelings
have been excited against it. By many of the celebrated authors of former
times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as
altogether unjustifiable, and a similar opinion was entertained by many of
our own countrymen at a much more recent period, (Dr. W. Hunter, Dr.
Osborn, &c.)

There is no doubt that in England it has been peculiarly unsuccessful. Dr.
Merriman has collected the results of 26 cases of Cæsarean operation: of
these only 2 mothers and 11 children survived; thus out of 52 lives only
13 were saved. On the Continent it has been far more successful. Klein has
collected with the greatest care 116 well authenticated cases, of which 90
terminated favourably; and Dr. Hull, in his _Defence of the Cæsarean
Operation_, has recorded 112 cases, of which 69 were successful. M. Simon
has not only collected a number of cases which were favourable, to the
number of 70 or 72, but which were performed on a few women, "some of them
having submitted to it three or four times, others five or six, and even
as far as seven times, which if they were all true, would superabundantly
prove that it is not essentially mortal." (_Baudelocque_, transl. by
Heath, § 2095.)

During the last fifteen or twenty years the operation has become
remarkably successful in the hands of the German practitioners, so that
there has been scarcely a journal of late from that part of the Continent
which has not contained favourable cases of it. One of the most
interesting instances of later years is that recorded by Dr. Michaelis, of
Kiel, where the patient, a diminutive and very deformed woman, was
operated upon four times:[97] the second operation was performed by the
celebrated Wiedemann, and is stated to have been completed in less than
five minutes, and without any extraordinary suffering on the part of the
patient, who complained most when sutures were made for bringing the lips
of the wound together. The uterus became adherent to the anterior wall of
the abdomen, so that in the fourth operation the abdominal cavity was not
even opened, the incision being made through the common cicatrix into the
uterus.

There is every reason to suppose that the chief cause of its want of
success in this country has been the delay in performing it. "In France
and some other nations upon the European Continent," says Dr. Hull, "the
Cæsarean Operation has been and continues to be performed where British
practitioners do not think it indicated; it is also had recourse to early,
before the strength of the mother has been exhausted by the long
continuance and frequent repetition of tormenting, though unavailing
pains, and before her life is endangered by the accession of inflammation
of the abdominal cavity. From this view of the matter we may reasonably
expect that recoveries will be more frequent in France than in England and
Scotland, where the reverse practice obtains. And it is from such cases as
these, in which it is employed in France, that the value of the operation
ought to be appreciated. Who could be sanguine in his expectation of a
recovery under such circumstances as it has generally been resorted to in
this country, namely, where the female has laboured for years under
_malacosteon_ (_mollities ossium_,) a disease hitherto in itself
incurable; where she has been brought into imminent danger by previous
inflammation of the intestines or other contents of the abdominal cavity,
or been exhausted by labour of a week's continuance or even longer."
(Hull's _Defence of the Cæsarean Operation_.)[98]

The difficulty of deciding upon the operation according to the indications
of the Continental practitioners, is much more perplexing than according
to that which is followed in this country: the question here is, can the
child under any circumstances be made to pass _per vias naturales_ with
safety to the mother? The impossibility of effecting this object is the
sole guide for our decision. In using the operation as a means for
preserving also the life of the child, we must not only feel certain that
the child _is_ alive, but that it is also capable of supporting life,
before we can conscientiously undertake the operation upon such
indications. This uncertainty as to the life or death of the child greatly
increases the difficulty of deciding. Under circumstances where there is
reason to believe that, although the child may be alive, it is
nevertheless unable to prolong its existence for any time, and the pelvis
so narrow that it can only be brought through the natural passage
piecemeal, we are certainly not authorized in putting an adult and
otherwise healthy mother into such imminent danger of her life for the
sake of a child which is too weak to support existence. Circumstances may
nevertheless occur where the pelvis is so narrow that the child cannot be
brought even piecemeal through the natural passage: in this case, even if
the child be dead, the operation becomes unavoidable.

Under the above-mentioned circumstances, it is the duty of the surgeon to
perform the operation; and he can do it with the more confidence from the
knowledge of many cases upon record where it has succeeded even under very
unfavourable circumstances, and where it has been performed very
awkwardly: moreover, it seems highly probable that the unfavourable
results of this operation cannot often be attributed to the operation
itself, but to other circumstances. Not unfrequently the uterus has been
so bruised, irritated, and injured by the violent and repeated attempts to
deliver by turning or the forceps, and the patient so exhausted, and
brought into such a spasmodic and feverish state by the fruitless pains
and vehement efforts, together with the anxiety and restlessness which
must occur under such circumstances, that it is impossible for the
operation to prove successful. Here it is an important rule that we
should decide as soon as possible, whether she can be delivered by the
natural passages or not: we should allow of no useless or forcible
attempts to deliver her; and if these have been made, we should carefully
examine whether the passages, &c. have been injured, and proceed to the
operation without delay. Moreover, the patient can the more easily make up
her mind to the operation, as she will suffer far less than from the
fruitless efforts and attempts to deliver her by the natural passages.
(Richter, _Anfangsgründe der Wundarztneikunst_, band vii. chap. 5.)

Although it is so important that we should lose no time, still
nevertheless it does not appear desirable to operate before labour has
commenced to any extent; for unless the os uteri has undergone a certain
degree of dilatation, it will not afford a sufficiently free exit for
liquor amnii, blood, lochia, which, by stagnating in the uterus after the
operation, would soon become irritating and putrid, in which case they
would be apt to drain through the wound into the abdominal cavity and
create much mischief.[99]

_Different modes of operating._ The incision has been recommended to be
made in different ways by different authors; but the highest authorities,
as also later experience, combine in favour of that in the linea alba.
Richter states, that one great advantage from making it in this direction
is, that when the uterus contracts and sinks down into the pelvis, the
incision in it still corresponds with that through the abdominal parietes,
and therefore admits of a free discharge of pus, &c. through the external
wound; whereas, if it have been made to one side, viz. at the outer edge
of the rectus abdominis muscle, as recommended by Levret for the purpose
of avoiding the placenta, the wound in the uterus when contracted ceases
to correspond with it, and the discharge escapes into the abdominal
cavity. Besides this the abdomen is usually more distended at the linea
alba; the uterus here lies immediately beneath the integuments; the
intestines are usually pressed towards each side; and therefore when the
incision is made on one side they frequently protrude, a circumstance
which rarely happens when it is made in the linea alba, except perhaps
towards the end of the operation. In the linea alba we have only to cut
through the external integuments in order to reach the uterus, while at
the side, we have to cut through considerable layers of muscle.

Previous to operating, the rectum and the bladder should be emptied,
particularly the latter, because it is desirable to carry the incision of
the abdominal integuments, for reasons just given, as near as possible to
the symphysis pubis (viz. an inch and a half,) which otherwise would
endanger the safety of the bladder. The experience of later years proves
decidedly that three intelligent assistants are necessary, "two to prevent
the protrusion of the intestines, and a third to remove the placenta and
foetus." (_Neue Zeitschrift für Geburtskunde_, band iii. heft 1. 1835.) We
are convinced, that the success of the operation depends more upon
carefully preventing the slightest protrusion of any portion of the
intestines, and excluding all access of the external air than upon any
other cause, for by this means alone can we save the patient from the
dangerous peritonitis which is so apt to follow. The two assistants, whose
duty it is to support the abdominal parietes and keep the edges of the
wound closely pressed against the uterus, should be furnished with napkins
or sponges soaked in oil in order instantly to cover any coil of intestine
which may protrude, and press it back as quickly as possible; it is to
this that the great success of the Cæsarean operation in later years is
chiefly owing.

The incision in point of length varies from five to six, seven, or more
inches, beginning at about two to four inches below the navel, and
terminating at rather less than that distance above the symphysis pubis.
The peritoneum is usually divided with a bistoury and director, and the
wound through the uterus made an inch or two shorter than that of the
abdominal integuments. If, on dividing the uterine parietes, the placenta
presents, it must be separated, and removed as quickly as possible to one
side, the membranes ruptured, and the child extracted; after which the
uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for
this reason the sooner the child is removed the better, as otherwise the
uterus is apt to contract upon a portion of it when passing through the
wound, and thus retain it. It is desirable to remove the membranes as far
as possible, especially from the os uteri, to allow of a free discharge
from the uterus per vaginam. No sutures are needed for the uterine
incision: the contractions of the organ not only diminish its length, but
generally bring its edges into sufficiently close contact.

Some discrepancy of opinion has existed respecting the treatment of the
external wound: sutures are of course the most secure means of retaining
the edges in apposition, but they produce great suffering, and, from
taking up a good deal of time, delay the closing of the abdominal wound
more or less; whereas, straps of sticking plaster are applied much quicker
and without any suffering to the patient. To do this most effectually it
will be advisable to arrange them under the loins previous to the
operation: they should be from five to six feet long, and the ends may be
rolled up until wanted; the wound can thus be instantly closed and in the
most secure manner. Where the operator finds it necessary to use sutures,
he must avoid puncturing the peritoneum as far as possible: the lower inch
of the wound should be left open to allow any matter to drain out, and the
whole dressed according to the common rules of surgery. The patient should
be placed upon her side with the knees bent to relax the abdominal
parietes. A grain of the hydrochlorate of morphia has been given in these
cases with the best effects, having procured sleep and allayed the
disposition to spasmodic coughing and vomiting, which so frequently exists
after the operation.

One of the greatest triumphs of modern surgery is the performance of this
dangerous operation four times successively on the same patient. The first
operation was performed in June 1826, the woman being then in her
twenty-ninth year, the second in January 1830, the third in March 1832,
and the fourth on the 27th June, 1836. The second operation was performed
by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it
appear that the patient's sufferings were very great, for the application
of sutures on this occasion elicited more complaint than all the
operations put together.[100]

_History._ Although the early records of the Cæsarean operation are not
very distinct, still we possess sufficient data to pronounce it of very
considerable antiquity. The earliest mention of it shows that it was at
first used merely for the purpose of saving the child by extracting it
from the womb of its dead mother, a law having been made by Numa
Pompilius, the second king of Rome, forbidding the body of any female far
advanced in pregnancy to be buried until the operation had been performed.

The mythology of the ancients refers to two cases of an exceedingly remote
period where a living child was taken from the dead body of its mother:
these were the birth of Bacchus and Æsculapius; but as these traditions
are so enveloped in allegory and mystery, it is difficult to come to any
other conclusion than a mere inference of the fact: one circumstance,
however, connected with the birth of Bacchus is curious, viz. that his
mother Semele died in the seventh month of her pregnancy.

The oldest authentic record is the case of Georgius, a celebrated orator
born at Leontium in Sicily, B. C. 508. Scipio Africanus, who lived about
200 years later, is said to have been born in a similar manner. There is
no reason to suppose that Julius Cæsar was born by this operation, or
still less that it derived its name from him, for at the age of thirty,
he speaks of his mother Aurelia as being still alive, which is very
improbable if she had undergone such a mode of delivery. We would rather
prefer the explanation of Professor Naegelé, viz. that one of the Julian
family at Rome had been delivered _ex cæso matris utero_, and had been
named Cæsar from this circumstance, so that the name was derived from the
operation, not the operation from the name.

"The earliest account of it in any medical work is that in the _Chirurgia
Guidonis de Cauliaco_, published about the middle of the fourteenth
century. Here, however, the practise is only spoken of as proper after the
death of the mother." (Cooper's _Surg. Dict._) Among the Jews, however, it
appears to have been performed on the _living_ mother at a very early
period; a description of it is given in the _Mischnejoth_, "which is the
oldest book of this people, and supposed to have been published 140 years
before the birth of our Saviour, or, according to some, even antecedently
to this period. In the _Talmud_ of the Jews, also, their next book in
point of antiquity, the Cæsarean operation is mentioned in such terms as
to render it extremely probable that it was resorted to before the
commencement of the Christian era. In the _Mischnejoth_ there is the
following passage, 'In the case of twins, neither the first child which
shall be brought into the world by the cut in the abdomen, nor the second,
can receive the rights of primogeniture, either as regards the office of
priest or succession to property.' In a publication called the _Nidda_, an
appendix to the _Talmud_, there is the following remarkable direction: 'It
is not necessary for women to observe the days of purification after the
removal of the child through the parietes of the abdomen.'" (_Introduction
to the Study and Practice of Midwifery_, by W. Campbell, M. D. p. 260.)

The first authentic operation upon a living woman in later times was the
celebrated one by Jacob Nufer, upon his own wife, in 1500, after which,
owing to its fatal character and the strong feeling against it, it was
performed but rarely: still, however, sufficient evidence existed to mark
its occasional success and urge its repetition in similar cases; and from
what we have already stated, the history of the last twenty years shows
that its results have rapidly become more and more favourable, so that in
the present day it can be no longer looked upon as an operation of such
extreme danger and almost certain fatality, as it was in former
times.[101]



CHAPTER IV.

ARTIFICIAL PREMATURE LABOUR.

    _History of the operation.--Period of pregnancy most favourable for
    performing it.--Description of the operation._


Perhaps the greatest improvement in operative midwifery since the
invention and gradual improvement of the forceps is the induction of
artificial premature labour for the purpose of delivering a woman of a
living child, under circumstances of pelvic contraction, where either the
one must have been exposed to the dangers and sufferings of the Cæsarean
operation, or the other to the certainty of death by perforation, or at
least where the labour must have been so severe and protracted as to have
more or less endangered the lives of both. It consists in inducing labour
artificially, at such a period of pregnancy that the child has attained a
sufficient degree of development to support its existence after birth, and
yet is still so small, and the bones of its head so soft, as to be capable
of passing through the contracted pelvis of its mother.

_History._ Few improvements have met with more violent opposition, or have
been more unjustly stigmatized or misrepresented, than artificial
premature labour, and it redounds, not a little, to the credit of the
English practitioners that they have not only had the merit of its first
invention, but with very trifling exceptions, have been the great means of
bringing it into general practice and repute.

To the late Dr. Denman we are under especial obligations in this respect;
for, although himself not the inventor of this operation, he,
nevertheless, was one of the first who widely recommended it to the
profession, and actively promoted it by the powerful support of his name
and writings. "A great number of instances," says he, "have occurred to my
own observation of women so formed that it was not possible for them to
bring forth a living child at the termination of nine months, who have
been blessed with living children, by the accidental coming on of labour
when they were only seven months advanced in their pregnancy. But the
first account of any artificial method of bringing on premature labour was
given me by Dr. C. Kelly. He informed me that about the year 1756 there
was a consultation of the most eminent men in London, at that time, to
consider of the moral rectitude and advantages which might be expected
from this practice, which met with their general approbation. The first
case in which it was deemed necessary and proper, fell under the care of
the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly
informed me he himself had practised it, and among other instances
mentioned that the operation had been performed three times on the same
woman, and twice the children had been born living." (Denman's
_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 174.)
Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall,
Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of
evidence in its favour, and have, we trust, tended not a little to
diminish the frequency of perforation. On the Continent it experienced a
very different reception, being regarded as immoral, barbarous, and
unjustifiably endangering the life of the mother and her child. In France,
although at first successfully adopted by a few practitioners, (_Sue_,)
its farther progress was completely stopped by the powerful opposition of
Baudelocque, and by the plausible though erroneous objections which he
made against it. A similar course was pursued by Gardien and Capuron, and
even by the celebrated Madame la Chapelle, all of whom have taken a
singularly incorrect view of it and assign it a totally different object
to that which is intended: the very name which they have given to it of
_Avortement artificiel_, plainly shows how little they have understood of
its real character.

Among his objections, Baudelocque states, that "the neck of the uterus at
seven months has seldom begun to open; it is still very thick and firm.
The pains, or the contractions of that viscus, cannot then be procured but
by a mechanical irritation pretty strong and long continued; but those
pains, being contrary to the intentions of nature, often cease the instant
we leave off exciting them in that manner. If we break the membranes
before the orifice of the uterus be sufficiently open for the passage of
the child, and the action of that viscus strong enough to expel it, the
pains will go off in the same manner for a time, and the labour afterwards
will be very long and fatiguing; the child deprived of the waters which
protected it from the action of the uterus, being then immediately pressed
upon by that organ, will be a victim to its action before things be
favourably disposed for its exit, and the fruit of so much labour and
anxiety will be lost. Premature delivery obtained in this manner is always
so unfavourable to the child, that I think it ought never to be permitted
except in those cases of violent hæmorrhage which leave no chance for the
woman's life without delivery; the nature of the accident also disposes
the parts properly for it." (_Baudelocque_, transl. by Heath, § 1986,
1987.) All this plainly shows that Baudelocque did not rightly understand
the real objects and nature of artificial premature labour, to which, in
fact, his objections do not apply, but to the _accouchement forcé_ of the
French practitioners, where, on account of the sudden accession of
dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri
was rapidly and violently dilated by the hand, which was then passed into
the uterus, the feet seized, and the child forcibly delivered, an
operation which is now rarely performed in Germany and never in this
country.

The celebrated Carl Wenzel, of Frankfort, was the first in Germany who
declared himself in favour of the operation. Kraus and Weidemann followed,
the former two having performed it with complete success. The favourable
results also in the hands of English practitioners and its increasing
reputation quickly silenced the virulent abuse which was levelled at it by
Stein, jun., and some other German authorities; the celebrated Elias von
Siebold, of Berlin, who had first opposed it, candidly confessed his error
and became one of its earliest supporters. Increasing experience showed
that it could scarcely be looked upon as a dangerous operation for the
mother, and that in by far the majority of instances it was also
successful as regarded the child. Professor Kilian, in his work on
operative midwifery, has collected the results of no less than 161 cases
of artificial premature labour. (_Operative Geburtshülfe_, erster band, p.
298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3
in Holland: of these cases, 115 children were born alive and 46 dead; of
the 115 living children, 73 continued alive and healthy; 8 of the mothers
died after the operation, but of these, 5 were evidently from diseases
which had nothing to do with the operation.

The most unfavourable circumstances under which the operation can be
undertaken are, where the child presents with the arm or shoulder: here it
will require turning, which, in many cases, owing to the faulty form and
inclination of the pelvis, cannot be effected without considerable
difficulty, and greatly diminishing the chances of the child being born
alive. With this exception we cannot see why it should not be as
favourable as labour at the full term of pregnancy; it is far less
dangerous than other species of premature labour, for the hæmorrhages,
which are so apt to attend them, are never known to occur here.

This mode of delivery has not only been proposed in cases of contracted
pelvis: "There is another situation," says Dr. Denman, "in which I have
proposed and tried with success the method of bringing on premature
labour. Some women who readily conceive, proceed regularly in their
pregnancy till they approach the full period, when, without any apparently
adequate cause, they have been repeatedly seized with rigour and the
child has instantly died, though it may not have been expelled for some
weeks afterwards. In two cases of this kind, I have proposed to bring on
premature labour, when I was certain the child was living, and have
succeeded in preserving the children without hazard to the mothers."
(_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 180.)

_Period for performing the operation._ Although under the head of
PREMATURE EXPULSION we have stated that a foetus is capable of maintaining
its existence if born after the twenty-eighth week of pregnancy, we must
not be supposed to recommend the artificial induction of premature labour
at so early a period as this. "Experience has shown that it was not
necessary to induce labour at so early a period as was first imagined, on
account of the very great difference which even one or two weeks are found
to make in the hardness of the foetal skull. Thus, for instance, in cases
where the antero-posterior diameter was only three inches, six weeks
before the full term of utero-gestation were found sufficient, and where
it was three inches and a half, fourteen days made sufficient difference."
(Naegelé, _MS. Lectures_.) Still, however, as it is so difficult to be
quite sure of the data upon which we have made our reckoning, it will be
safer to fix the operation a week or two earlier; and if we lose a little
time by failing in our first endeavours to induce uterine action, it will
be of so much the less consequence: hence, therefore, as a general rule,
the most eligible time will be between the thirty-fourth and thirty-sixth
week; and if the deformity be very considerable, we may commence
operations as early as the thirty-second week or two months before the
full term, short of which it will seldom either be justifiable or
necessary. On the other hand, where the state of the cervix and the
history of her pregnancy combine to make our reckoning nearly a matter of
certainty, the later we can safely delay the operation the better, for by
so doing the process resembles more a natural labour, and the chances in
favour of the child are much increased.

_Operation._ The original mode of artificially inducing premature labour
was merely by puncturing the membranes and allowing the liquor amnii to
escape; the more gradually this is done the better, for by this means the
uterus is not entirely drained of its fluid contents, and is, therefore,
prevented contracting immediately upon the child; the value of this
precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A
considerable interval may elapse between puncturing the membranes and the
first contractions of the uterus, generally varying from forty to eighty
hours: it should be performed while the patient is in the horizontal
posture, in order to prevent the escape of too much liquor amnii. A
moderately curved male catheter, open at its point and carrying a strong
stilet sharpened at the end, is the best and simplest instrument for the
purpose: on passing it up to the membranes, the stilet should be
protruded, but to a short extent, to avoid injuring the child; and as soon
as the liquor amnii runs from the other end, the instrument should be
withdrawn, and the patient desired to remain quiet. A dose of opium has
been usually given after the operation by the English practitioners, but
its utility appears rather questionable: a brisk purge of calomel and
jalap, some hours previously, is much more important; uterine action comes
on much more regularly and effectively, and there will be much less chance
of those rigours occurring which some practitioners, although erroneously,
have supposed, were connected with the death of the child.

The practice of dilating the os uteri first, as recommended by
Brüninghausen, Kluge, and others, has, as far as we know, never been
attempted in this country, and resembles much too closely the
_accouchement forcé_ of the French authors ever to be permitted.

The simplicity of the operation of tapping the membranes has rather led
practitioners to overlook a still greater improvement, viz. the inducing
uterine action first: this was proposed by Dr. Hamilton to be effected by
passing up a catheter, and separating the membranes from the uterus to a
considerable distance above the os uteri. The operation certainly succeeds
in some cases; but our own experience goes to prove, that in the majority
it is not sufficient by itself to provoke uterine contraction, and in
order to ensure success we must combine with it other means.

The plan of treatment which we have found most certain is first to clear
out the bowels by a full dose of calomel and colocynth, then to give the
patient a warm bath, in which she may remain twenty or more minutes, after
which the abdomen should be well rubbed with stimulating liniment as she
lies in bed, and the secale cornutum given in doses of a scruple of the
powder in cold water, repeated every half hour for five or six times.
Contractions of the uterus rarely fail to follow, and although they
generally require the secale to be renewed after a few hours, they will be
found to have effected several very important changes preparatory to
actual labour;--the abdomen has sunk, the fundus is lower, the cervix is
shorter or has disappeared, and not unfrequently we feel the head has
already passed the brim and is now in the cavity of the pelvis; the vagina
and os uteri are lubricated with a copious secretion of remarkably pure
and albuminous mucus; and in these cases especially, we frequently meet
with those little lumps of inspissated mucus which were formerly called
the _ovula Nabothi_. All these precursory changes are so many preparations
of nature for a natural labour, and contribute not a little to the
successful termination of the case, advantages which cannot be enjoyed
where the membranes have been previously ruptured. If, however, we do not
succeed in producing more than a slight dilatation of the os uteri, if the
repeated exhibition of the ergot only produce vomiting, or constant pains
which have no other effect beyond preventing rest and inducing exhaustion,
the separation of the membranes from the uterus, as proposed by Dr.
Hamilton, will now have the best effects: even if this fail and we are
compelled to puncture the membranes, it will now be performed under so
much more favourable circumstances, from labour having already commenced
to a certain extent.

A warm bath and the other usual means for recovering the child should be
in readiness. In most cases the secretion of milk follows as after labour
at the full term, which is a great advantage; for the thin watery
secretion of this early period is much better adapted to the weak
digestive organs of the premature child. It is frequently a matter of some
difficulty under these circumstances to make a child take the breast at
first, and this is the chief reason why their digestive organs so soon
become deranged. "In case no milk be present, a good substitute may be
made by beating up fresh eggs and milk, boiling them over a gentle fire
and straining off the thin fluid." (Reisinger, _die künstliche
Frühgeburt_.)

One great encouragement in cases requiring this operation is the fact that
in every successive pregnancy the uterus is more easily excited to
premature action; and in some cases where it has been induced several
times, it has at length, as it were, got so completely into the habit of
retaining its contents only up to a certain period, that labour has come
on spontaneously exactly at the time at which in the former pregnancies it
had been artificially induced.[103] We have already alluded to this
circumstance in the chapter on PREMATURE EXPULSION OF THE FOETUS.[104]



CHAPTER V.

PERFORATION.

    _Variety of perforators.--Indications.--Mode of operating.--
    Extraction.--Crotchet.--Embryulcia._


The perforation is that operation "where we make an opening into the
cranial cavity, and, by allowing the brain to escape, thus diminish the
bulk of the head." (_Obstetric Memoranda._)

Perforation is one of the most ancient operations in midwifery, for in
former times it was the only means of artificially delivering the child
when the head presented: hence we find that from the age of Hippocrates
down to the last century, midwifery instruments almost entirely consisted
of knives or lancets for piercing the foetal head, and blunt or sharp
hooks for extracting or dismembering the child.

Thus Hippocrates, Celsus, and Albucasis, and others, have described a
variety of such instruments and given full directions for their use.

_Variety of perforators._ No instrument has been so greatly modified or
has appeared under such different forms as the perforator; but it is not
our object to enter into any detailed account of its history, for it would
not, like that of the forceps, lead to any useful information; we shall,
therefore, content ourselves with mentioning those few which have been in
general use during the last century. They are chiefly of the scissor kind;
the two most commonly known are the perforators of Dr. Smellie and M.
Levret: the former are merely strong long-handled scissors, the backs of
the blade being neither exactly sharp nor blunt,[105] and furnished each
with a projecting shoulder or rest to prevent them from entering too far.
Levret's perforator, which is extensively used in this country under the
name of Dr. Denman's perforator, and which was originally invented by
Bing, of Copenhagen, is also formed like scissors, but has its cutting
edges outside; the blades are also furnished with rests or shoulders like
the Smellie perforator.

[Illustration: Naegelé's perforator.]

A useful modification has been invented by Professor Naegelé, which
supplies a considerable defect in the two above-mentioned instruments,
viz. the necessity of using both hands to open the blades, thereby
requiring that the hand which guides the instrument in the vagina should
be removed at this moment: for this purpose the blades do not cross at the
lock as the others do, by which means the grasp of one hand is sufficient
to squeeze the handles together, and thus make the blades diverge in order
to dilate the opening. A similar one has been invented by the surgical
instrument maker, Mr. Weiss, but it does not appear to be quite so safe.

The object of these instruments is not merely to bore through the skull,
but to break down the parietal bone to a certain extent, in order to
enlarge the opening: a slight curve of the blades is advantageous, because
their points thus impinge more directly upon the skull, and enter it at
once without running the risk of slipping along the surface.

_Indications._ "The perforation is indicated, first, in all cases where
the labour is dangerous for the mother, and where the antero-posterior
diameter, although more than two inches and a half, is so small that the
head which presents, cannot be delivered by the forceps. Secondly, it is
indicated where the head is much larger than natural, as in
hydrocephalus." (Naegelé, _MS. Lectures_.) For a more detailed and special
account of the precise circumstances under which it will be required, we
must refer to those different forms of DYSTOCIA, where it is occasionally
required, particularly our fourth species, viz. DYSTOCIA PELVICA.

Much discrepancy of opinion has existed as to how far the operation itself
was justifiable, and has, therefore, given rise to very different results
in the practice of different schools. The most obstinately prejudiced
against perforation was the late celebrated Benjamin Osiander, of
Göttingen, who asserted, that it was never necessary, for, where others
were obliged to open the head, he would deliver the patient by means of
his forceps, an instrument which, from its great length and the various
hooks &c. for applying additional hands, was capable of exerting a degree
of force which nothing could justify. In France, the predilection for
using exceedingly powerful forceps to a degree, which in this country and
the greater part of Germany would be looked upon as very injurious, if
not dangerous, has tended to render the perforation a comparatively rare
operation: thus out of somewhat more than twenty thousand labours at the
Maternité, of Paris, only sixteen were delivered by this means. Of the
ninety-six cases in whom the forceps was applied, no mention is made as to
the result with respect to the mothers; but, from the description of a
forceps case at the Hôtel Dieu which we have received from an eye-witness,
the force used must have been carried to a most unwarrantable extent.

The English practitioners have frequently been accused by their
Continental brethren with being too ready in the use of the perforator;
but, with one or two exceptions, the charge is not just, for, as already
stated, we are not justified in subjecting an adult and otherwise healthy
woman to so much suffering and danger for the sake of a child which, after
all, will be probably sacrificed by the severity of the labour.[106]

_Operation._ In performing the operation we introduce two or three fingers
along the vagina to the presenting part of the foetal head, and carefully
guide up the perforator against it: these fingers will not only protect
the soft parts from injury, but steady the point so firmly upon the skull,
as to enable the other hand to bore through it without difficulty. Having
passed the blades up to the shoulders or rests, we dilate the opening,
first one way and then the other, to form a crucial incision: we now
insert the instrument up to the basis cranii, breaking down the
attachments and structure of the brain, and thus enabling it to come away
with greater facility. To favour this object still farther, and make the
cranial bones collapse more readily, we must pass a long elastic tube
through the opening, and by means of a syringe, throw up a powerful stream
of water into the cavity of the skull: if this be introduced to the base
of it, the water will necessarily drive out the brain before it, so that
with every stroke of the piston, a quantity of brain will be expelled
nearly equal to that of the water injected.

When the perforation has been made, it will be desirable to wait a few
hours before making any attempt to extract: we thus give the mother an
opportunity of getting a little rest; the attachments of the cranial bones
after a short time become more yielding, the head collapses more readily,
and adapts itself better to the form of the passages. "In all
circumstances," says Dr. Osborn, "which admit and require precision, I
would recommend the delaying all attempts to extract the child till the
head has been opened at least thirty hours: a period sufficient to
complete the putrefaction of the child's body, and yet not sufficient to
produce any danger to the mother. From such conduct, the beneficial
effects of facilitating the extraction of the child, I am firmly
convinced, by frequent experience, will much overbalance any possible
injury which may reasonably be expected from the putrid state of the child
and secundines in so short a time. The propriety, however, of this delay
entirely depends upon the head being opened in the beginning of labour:
for if we do not perform the first part of this operation till the labour
has been protracted so long as that the woman's strength begins to fail,
we must expedite the delivery as speedily as possible, otherwise, the
danger which we wish to avoid, will infallibly be incurred: no woman can
suffer continued labour beyond a certain period without fever,
inflammation, and the most imminent danger, if not death ensuing."
(Osborn's _Essays on the Practice of Midwifery_.)

It has been recommended to perforate the head at the sutures, on account
of the greater facility in passing the instrument through them: but that
part of the head which is lowest in the pelvis, or which, in other words,
_presents_, must necessarily be the most convenient, not only for the
introduction of an instrument, but also for the evacuation of the brain.
When the perforation is made at a suture, the edges of the bones gradually
overlap as the head diminishes in size, and thus close the opening, a
circumstance which cannot occur when it is made through a bone.
Splintering the bone in making a crucial opening has been objected to on
the ground that the sharp edges and spiculæ are apt to wound the soft
parts of the mother: of this, however, there will be but little danger so
long as they are covered by the scalp, which we should be somewhat
cautious of, and not tear or otherwise destroy the cranial integuments
unnecessarily, for it has long since been remarked by the celebrated Peter
Frank, that inflammation of the uterus produced by wounds from spiculæ of
bone or sharp instruments becoming blunt, &c., usually prove fatal: it is
also desirable to disfigure the head as little as possible. Still,
however, we are far from recommending the trepan-shaped perforators which
have been used by Professors Assalini, Joerg, &c. as they cannot make a
sufficiently free opening, nor break down the skull to the necessary
extent.

_Extraction._ Where sufficient time has been allowed for the cranial bones
to collapse, the finger inserted into the opening and acting as a blunt
hook will, if assisted by the pains, be enabled to exert a sufficient
degree of force to bring the head down to the pelvic outlet; by which time
the action of the vagina and abdominal muscles in aid of the uterine
efforts will soon succeed in pressing it through the os externum. By
using the finger in this way we pull by that part of the head which is
already lowest in the pelvis, and, therefore, run no risk of altering the
position of the head and bringing it down in an unfavourable direction;
this objection (among others) applies to the hook, whether it be fixed
internally or externally, and thus frequently renders the passage of the
head through the outlet and os externum more tedious, difficult, and
painful, than it otherwise would have been. The craniotomy forceps are
still more objectionable in all ordinary cases of perforation, for they
not only alter the position of the head, but by tearing away portions of
bone from time to time are very liable to wound the soft parts.

From our own experience, we would recommend the application of the common
curved forceps in all cases where the pelvic deformity is not of a very
unusual degree, for by this means the hand is equally grasped and
compressed, the soft parts to a considerable extent are protected by the
blades, and the whole mass brought down exactly in the position in which
it presented. On several occasions where the craniotomy forceps and
crotchet have failed to move the head, the midwifery forceps has been
applied, and the delivery easily and quickly accomplished. Dr. Smellie
recommends the crotchet to be applied on the outside of the head, and was
evidently aware that its position was liable to be altered by this means.
He directs the practitioner to "introduce it along his right hand with the
point towards the child's head, and fix it above the chin, in the mouth,
back part of the neck, or above the ears, or in any place where it will
take firm hold. Having fixed the instrument, let him withdraw his right
hand, and with it take hold on the end or handle of the crotchet, then
introduce his left to seize the bones at the opening of the skull (as
above directed) _that the head may be kept steady_, and pull along with
both hands." (vol. i. chap. 3. sect. 7. numb. 4.) Where there was
considerable difficulty in bringing down the head, Dr. Smellie used to
introduce a second crotchet opposite to the first, like the second blade
of the forceps, and having locked them together was thus enabled to apply
a greater degree of force.

_Crotchet._ The usual mode of applying the crotchet at the present day is
to pass it into the cranial cavity, and endeavour to fix it upon some
portion of the skull, which will afford a sufficiently firm hold for the
purpose; the best spot is the petrous portion of one or other of the
temporal bones. The plan of passing up the hook on the outside of the head
is objectionable, for in most cases where there is much impaction of the
head, it will be exceedingly difficult, if not impossible, to push the
hook past it without much suffering and probable injury. Not wishing to
differ from so great an authority as Dr. Smellie without reason, we have
repeatedly tried this mode of using the crotchet, but invariably found
that its introduction on the outside of the head was attended with so much
difficulty and pain as to make us relinquish the attempt. His objections
to passing the hook into the cranial cavity are not valid, for we should
never try to fix it upon the "thin bones," nor should we hold it in such a
manner that, if it did slip or tear through, it would wound either our
hand or the soft parts of the mother.

The common form of the crotchet in general use is but ill adapted for
taking hold of any part within the skull: it is, in fact, the very
instrument left us by Dr. Smellie for applying on the outside of the
skull: and, therefore, that which was intended to take hold of a convex
surface cannot possibly be also suited for one of the contrary form, viz.
a concavity; for this reason, the shank of the hook requires to be
straight, so that the point may project at a considerable angle, by which
means it will take hold with much greater ease.

The point of the hook guarded by the finger should be cautiously
introduced up the vagina, and passed into the cranial cavity; having fixed
it, as above directed, the finger should be applied externally, so as to
correspond with the hook inside: by so doing, if the point slips or tears
through the bone, the finger is ready to protect the soft parts from it;
the operator is equally safe from injury, for, by grasping the shank of
the hook with his thumb and other fingers, his whole hand moves with it
and gives him instant warning of its going to slip. Where the deformity of
the pelvis is very great, it may be necessary to break down the bones of
the head still farther, in order to produce greater comminution; but even
here, so long as the bones collapse well together, it will be better not
to displace them from their attachments, the whole mass will come down
better and with less chance of injuring the soft parts. Where, however,
this is admissible, we must give the head sufficient time to undergo that
process of softening which is one of the early stages of putrefaction; the
cranial parietes may be gradually removed, one after the other, until we
have nothing remaining but the base of the skull and the face. Dr. Burns
recommends us now to convert it into a face presentation with the root of
the nose directed to the pubes: "I have carefully measured, (says he,)
these parts placed in different ways, and entirely agree with Dr. Hull, a
practitioner of great judgment and ability, that the smallest diameter
offered, is that which extends from the root of the nose to the chin."

_Embryulcia._ This is merely a degree farther than the perforation: it
consists in evacuating the chest and abdomen of their contents, and thus
enabling their parietes to collapse. It is chiefly had recourse to in
cases of deformed pelvis, where the arm or shoulder has presented, or
where the distortion is so great as to prevent the trunk from passing
without its bulk being lessened. Dr. Smellie's perforator with its
scissor edges is best suited for this object. Having made an opening into
the most presenting part of the thorax, we enlarge it by cutting away
portions of the ribs and thoracic parietes, and removing the contents of
the chest. The abdominal viscera are brought away in a similar way through
a perforation in the diaphragm; and if this be not sufficient to let the
trunk pass, the crotchet must be inserted into the brim of the child's
pelvis, which must be brought down doubled upon the spine, somewhat like
the process of spontaneous expulsion.

The success of this operation, will, in a great measure, depend not only
upon its being undertaken sufficiently early before the patient's strength
is exhausted, but upon a sufficient length of time intervening between the
removal of the thoracic and abdominal viscera and the extraction of the
child. The excellent rule of Dr. Osborn, above quoted, is peculiarly
applicable here; for when softened by the effects of incipient
decomposition, the body will sometimes even be expelled by the unassisted
efforts of the uterus.

In a case of this sort, the perforation of the head is the last part of
the process to be performed. It will be by all means, desirable not to
separate it from the body, but to pass up the curved perforator along the
neck, and make an opening behind the ears: this is effected without much
difficulty, and the head can be brought away whole, or in portions,
according to the nature of the case.



PART V.

DYSTOCIA, OR ABNORMAL PARTURITION.


_Divisions and species._ By the term Dystocia, we understand those labours
which either cannot be completed by the natural powers destined for that
purpose, or at least, not without injury to the mother or her child.[107]
These will, therefore, consist of the two following classes:--

1. Labours that are difficult or impossible to be completed by the natural
powers.

2. Labours which are rendered faulty without obstruction to their
progress.

The first division of dystocia may either arise from a faulty condition of
the expelling powers, or, without any anormality in this respect, it may
depend upon the faulty condition either of the child, or of the parts
through which it has to pass.

As respects the child it may arise from,

1. Malposition.

2. Faulty form and size of the child.

3. Faulty condition of the parts which belong to the child.

On the part of the mother this division of dystocia may arise from a
faulty condition.

4. Of the pelvis.

5. Of the soft passages.

6. Of the expelling powers.

The second condition where labour is rendered dangerous for the mother or
her child, without any obstruction to its progress, may arise from,

1. Following too rapid a course.

2. Prolapsus, &c. of the umbilical cord.

3. From accidental circumstances, which render the labour dangerous, viz.
convulsion, syncope, dyspnoea, severe and continued vomiting, hæmorrhage,
&c.

We propose to consider the different species of dystocia in the order
above enumerated.



CHAPTER I.

FIRST SPECIES OF DYSTOCIA.

    _Malposition of the child.--Arm or shoulder the only faulty position
    of a full-grown living foetus.--Causes of malposition.--Diagnosis
    before and during labour.--Results where no assistance is rendered.--
    Spontaneous expulsion.--Malposition complicated with deformed pelvis
    or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm
    not to be put back or amputated.--Presentation of the arm and head.--
    Presentation of the hand and feet.--Presentation of the head and
    feet.--Rupture of the uterus.--Usual seat of laceration.--Causes.--
    Premonitory symptoms.--Symptoms.--Treatment.--Gastrotomy.--Rupture in
    the early months of pregnancy._


We have already stated that the presentations of the full-grown living
foetus may be brought under three classes, viz. those of the head, of the
nates or lower extremities, and of the arm or shoulder: the former two
have already been considered under the head of eutocia or healthy
parturition, and may be distinguished from the latter, by the great
peculiarity that in them the long axis of the child's body is parallel
with that of the uterus, whereas, in arm or shoulder presentations this
cannot be the case, its body lying across the uterus.

Although malposition of the child, strictly speaking, refers to one
species of presentation only, viz. to that of the arm or shoulder, yet it
has been rendered a matter of great perplexity by the speculations and
theoretical notions of authors. No one has propagated more serious errors
upon this subject than the celebrated Baudelocque, the more so as the
great authority of his name has tended to silence all doubts as to the
accuracy of his views upon this subject. Almost every author since his
time has contented himself with copying more or less from him, without
ascertaining by personal observation how far they corresponded with the
actual course of nature. By forcing a stuffed figure into a pelvis in
every possible direction, he succeeded in making actually ninety-four
presentations of the child, all of which he described as if they had
really occurred in nature.

Few have taken so simple a view of this subject as the late Dr. Denman.
"The presentations of children at the time of birth," says this
distinguished accoucheur, "may be of three kinds, viz. the head, the
breech or inferior extremities, the shoulder or superior extremities; the
back, belly, breast or sides, properly speaking, never constitute the
presenting part."

The two greatest Continental authorities of modern times, viz. Madame La
Chapelle and Professor Naegelé, confirm this opinion: the former points
out one of the sources of error which has induced practitioners to suppose
that they had met with other species of faulty presentation besides those
of the arm or shoulder. "In the greater number of shoulder presentations,"
says this experienced authoress, "I have very distinctly touched the
chest, in some positions of the nates I have been able to reach the loins,
the hips, or lower part of the abdomen; but it would require no slight
bias from prejudice and theoretical systems to find presentations of the
chest, the back, the abdomen, or the loins, the neck or the ear."[108]

We would, therefore, limit the term malposition of the child merely to
presentations of the arm or shoulder: other presentations, it is true,
occur, but not of the full-grown living foetus; they are only where the
child is premature, or has been dead in utero some time. Under such
circumstances it will follow no rule whatever; for in the first case it is
too small, and therefore the passages can have no effect in directing its
course through them; and, in the second, a child which has been dead some
time becomes so softened by gradual decomposition, that it may be squeezed
by the pressure of the uterus into almost any shape: it is by this cause
that we occasionally see in still-born children parts in close contact,
which in a living child could not have been brought together.

We do not deny that such presentations may be made by ignorant and awkward
attempts to deliver, but it is to be hoped that such cases are daily
becoming of rarer occurrence.

Malposition of the child is fortunately not of very frequent occurrence:
as a general average we would say that it occurs once in 230 cases, as the
following results will show:--At the Westminster General Dispensary (1781)
it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in
Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr.
Merriman, once in 155: "calculated from a great number of cases," to
Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr.
Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle,
once in 230.

In arm and shoulder presentations the back of the child is turned towards
the anterior part of the uterus more than twice as frequently as it is in
the contrary direction, from which circumstance Professor Naegelé has
called this the first position of the shoulder to distinguish it from the
other, which, as being rarer, he calls the second.

In investigating the nature of the causes which produce malposition of the
child, which, from the above observations, is evidently a circumstance of
rare occurrence, the question naturally suggests itself, by what means is
the long diameter of the child in so large a majority of cases kept
parallel with that of the uterus? This depends in great measure on the
form and size of the uterus. Where the uterus is not unduly distended with
the liquor amnii, and where it preserves its natural oval figure, it is
scarcely possible that the child should present in any other way than with
its cephalic or pelvic extremity foremost. There can be no doubt that the
first early contractions of the uterus in the commencement of labour have
a great effect in regulating the position of the child; for, by the gentle
and equable pressure which they exert upon it, they not only maintain it
in the proper direction, but tend materially to correct any slight
deviations from the right position. Hence, therefore, we find that where
any cause has existed to impair or derange the action of these precursory
contractions of the uterus, the child is apt to lie across, or, in other
words, to present with the arm or shoulder. Thus, for instance, if the
uterus be much distended with liquor amnii, the contractions of its
parietes can have little influence upon the child's position; this will be
particularly the case where the accumulation is very considerable, for
here the uterus becomes more or less globular, and presents but little
variation as to the length of its diameter in any direction.

The form of the uterus is no less worthy of attention as a cause of
malposition, and is also in a great measure influenced by the character of
its early contractions. Thus in a uterus for the first time pregnant, they
generally act equally on all sides: hence it is why in primiparæ the
uterus is so exactly oval, and why we so rarely meet with faulty
presentations. Sir Fielding Ould, of Dublin, was the first and almost the
only practitioner in this country who noticed the influence which the
early contractions of the uterus have in determining the position of the
child. "The first labour pains, which are very short, continue their
repetition for two or three hours, or perhaps for more, before there is
the least effect produced upon the os tincæ, which time must certainly be
employed in turning the head towards the orifice." (_Treatise of
Midwifery_, p. 14.)

Wigand, in reasoning upon the physical impossibility of a child presenting
wrong, where the uterus is of the natural configuration, says that "the
chief cause of faulty position of the child does not depend so much upon
the child itself, as upon the deviation of the uterus from its natural
elliptical or pyriform shape." (Wigand, vol. ii. p. 107.)

The theory at one time so universally entertained, that the obliquity of
the uterus was the chief cause of malposition of the child, has long since
been disproved, although it continues to find a few adherents to the
present day: the uterus, in fact, towards the end of pregnancy, is
scarcely ever quite straight; the upright posture of the human female
rendering it almost necessary that the fundus should incline somewhat to
one side or to the other, or forwards, and yet we find that it has no
influence upon the position of the child when labour comes on. The moment
a pain commences, the fundus moves towards the median line of the body, so
that its axis corresponds nearly with that of the pelvic brim: as the pain
goes off, so does it return towards its former oblique position. Even in
those cases where it is strongly inclined forwards, and where the abdomen
is quite pendulous, the position of the child is unaffected by it.

Where, however, the uterus has been altered in point of form, where from
irregular contractions of its fibres it has been pulled down unequally to
one side, while it is quite relaxed in the opposite direction, the
position of the child may be seriously affected, for it will now present
obliquely as regards its long axis, and become a case of malposition.

We may, therefore, state that the causes of arm or shoulder presentations
are of two kinds, viz. where the uterus has been distended by an unusual
quantity of liquor amnii; or where, from a faulty condition of the early
pains of labour, its form has been altered, and with it the position of
the child.

It is a well-known fact that cross births, as they have been called, are
frequently preceded by severe spasmodic pains in the abdomen, from which
the patient suffers for some days or even weeks before labour has
commenced: the uterus is more or less the seat of these attacks, which
usually come on towards night-time; and, in some instances, it is felt for
the time hard and uneven from irregular contraction. It was the
circumstance of this symptom having preceded five successive labours of a
patient, in all of which the child had presented with the arm or shoulder,
which induced Professor Naegelé, when attending her in her sixth
pregnancy, to endeavour to allay these cramp-like pains, which had begun
to show themselves as severely as on former occasions. Having tried opium
by itself, and also in combination with ipecacuanha or valerian without
effect, he ordered her a starch injection with twelve drops of Tinct. Opii
every night as long as she continued to suffer from these attacks: the
spasms soon ceased, nor did they appear again during the remainder of her
pregnancy, and he had the satisfaction of delivering her at the proper
time of a living child, which presented in the natural manner.

Many other causes of malposition have been enumerated by authors, which
evidently exist only in theory and not in reality: thus, shortness of the
umbilical cord, or its being twisted round the child, insertion of the
placenta to one side of the uterus, faulty form or inclination of the
pelvis, obliquity of the uterus, as above-mentioned, violent exertions or
concussions of the body, plurality of children; of all these, we do not
believe that there is one which can exert the slightest influence in
determining the position of the child. There is no doubt that several of
them will render labour difficult or even dangerous, more especially
deformed pelvis; but we constantly meet with it under every degree and
variety without at all altering the child's position. Indeed, if
malformation of the pelvis were to be a cause of malposition of the child
during labour, what difficulties would it not add to the process of
delivery under such circumstances? And yet we find, with very rare
exceptions, that in every case requiring artificial assistance on account
of contracted pelvis, the head is resting upon the brim which is too
narrow to allow it to pass.

We may also mention another circumstance which has occasionally seemed to
produce a faulty position of the child. It sometimes happens that the
hand, which is frequently felt lying by the side of the face at the
beginning of labour, instead of slipping up out of reach as the head
descends, which is usually the case, advances more and more, until it not
only prevents the head from engaging farther into the pelvis, but pushes
it out, so that the head slips up to one side, and lodges in the cavitas
iliaca, allowing the shoulder with the rest of the arm to descend.

Where, however, the pelvis is large or the head small, the arm will not
always force it to one side, but the two will come down together and be
born in this position. (See case in our _Midwifery Reports, Med. Gaz._
April 19, 1834.)

Sometimes the two hands present (_La Motte_, book iii. ch. 26.,) or a hand
and foot: this, however, does not long continue so, for when the membranes
have ruptured, the liquor amnii flowed away, and the uterus contracted
upon the child, one shoulder and arm descend before the rest, and remain
in this position.

The complication of two arms presenting with the head we disbelieve
entirely, except where it has been made during some awkward and ignorant
attempts at delivery.

Although the symptoms of malposition of the child during the last few days
before, or at the commencement of labour, are far from being distinct,
still, however, when taken collectively, they will be sufficient to excite
our suspicion. The abdomen is irregularly distended, and marked with
unequal prominences; anteriorly, it is more or less pointed. It is usually
much increased in breadth, and this is generally in an oblique direction,
forming a globular protuberance at the upper part on one side, and at the
lower part on the other: the former is the pelvic extremity of the child;
the other, from its size, form, and hardness, may easily be recognised as
the head.

"The movements of the child feel differently to what they did before;
they are no longer exclusively confined either to one side or the other.
Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen,
during which it is more or less distorted with violent movements,
apparently of the child, as if it were trying to force its way through the
abdominal parietes at this spot." (Naegelé, _Lehrbuch_, p. 223.)

Upon examination _per vaginam_, either no presentation is to be reached at
all, or only small parts can be indistinctly felt, such as the hand, the
arm, or the shoulder. The not being able to feel a presenting part in a
primipara shortly before or at the commencement of labour, is an
unfavourable symptom; for the head at this time ought to be deep in the
cavity of the pelvis; still, however, it does not necessarily prove that
the child is presenting wrong, for it may be a presentation of the nates,
which, as we have before shown, do not descend so low into the pelvis just
before labour, as the head does; or it may arise from the unusual size of
the child's head, especially in cases of congenital hydrocephalus. It may
arise from a large quantity of liquor amnii, and where the head is
nevertheless presenting; it may be a case of twins, or lastly of dystocia
pelvica, where the head is presenting, but unable to pass through the
contracted brim.

In women who have had several children, it is frequently impossible to
reach the presentation during the early part of the labour: this arises
either from the abdomen in these cases being generally more or less
pendulous, or from the circumstance of the uterus having been distended in
so many previous pregnancies: its lower part does not become so fully
developed as before, but continues more or less funnel-shaped, a
considerable portion of the cervix still remaining. Where this is the
case, the head will not descend so low as usual at first, but remains out
of reach, or nearly so, until the os uteri is fully dilated and the
membranes have given way.

"If, upon such an examination, it should be ascertained that the os uteri
is considerably dilated, and the child cannot be felt, this affords reason
to suspect that the presentation is preternatural. Should the liquor amnii
be discharged and the child be out of reach of the finger, the probability
of a preternatural position is greater. Should the membranes be found
hanging down in the vagina not of the usual globular form, but rather
conical and small in diameter, this likewise is a presumptive proof of a
cross-birth; especially if there be any part presenting through the
membranes which is smaller, feels lighter, or gives less resistance when
touched than the bulky heavy head."[109]

The diagnosis of the shoulder is by no means easy: it offers no
distinctive marks, and may readily be mistaken for the nates, or even for
the head. It feels round, but is smaller and softer than the head. The
scapula and clavicle, the neck, the armpit, the arm itself, and the ribs,
assist us in our diagnosis. From the direction of these parts, we shall be
able to ascertain the position of the rest of the body, and which shoulder
presents. If the hand has prolapsed, the direction of the palm and of the
thumb will soon show the position of the child.

Labours with malposition are always dangerous; when left without
assistance, they are almost always fatal to the child, and generally so to
the mother.

When a full-grown child has presented with the arm or shoulder, and
nothing has been done to assist the delivery of it, the results are
usually as follow:--After the membranes have burst, and discharged more
liquor amnii than in general where the head or nates presents, the uterus
contracts tighter around the child, and the shoulder is gradually pressed
deeper into the pelvis, while the pains increased considerably in
violence, from the child being unable, from its faulty position, to yield
to the expulsive efforts of nature. Drained of its liquor amnii, the
uterus remains in a state of contraction even during the intervals of the
pains; the consequence of this general and continued pressure is, that the
child is destroyed from the circulation in the placenta being interrupted,
the mother becomes exhausted, and inflammation or rupture of the uterus or
vagina are almost the unavoidable results.

Another although much rarer consequence of malposition of the child, is
that peculiar mode of expulsion which was first noticed by Dr. Denman in
1772. From the supposition that the shoulder receded and the nates came
down into the pelvis, in which position the child was born, he called it
"_the spontaneous evolution of the foetus_;" but the term _spontaneous
expulsion_, as proposed by Dr. Douglas in 1811, is much better adapted, it
having been shown by that gentleman that the explanation of this process
as given by Dr. Denman was not correct. (_An Explanation of the real
Process of the spontaneous Evolution of the Foetus_, by J. C. Douglas, M.
D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the
pubes, the side of the thorax and abdomen, followed by the nates, passed
in one enormous sweep over the perineum, leaving the head and other arm
still to be extricated.

The shoulder and thorax thus low and impacted, instead of receding into
the uterus, are at each successive pain forced still lower, until the ribs
of that side, corresponding with the protruded arm, press on the perineum,
and cause it to assume the same form as it would by the pressure of the
forehead in a natural labour. At this period, not only the entire of the
arm but the shoulder can be perceived externally, with the clavicle lying
under the arch of the pubes. By farther uterine contractions the ribs are
forced more forwards, appearing at the os externum, as the vertex would in
a natural labour, the clavicle having been by degrees forced round on the
anterior part of the pubes with the acromion looking towards the mons
Veneris. "The arm and shoulder are entirely protruded with one side of the
thorax, not only appearing at the os externum, but partly without it: the
lower part of the same side of the trunk presses on the perineum, with the
breech either in the hollow of the sacrum or at the brim of the pelvis,
ready to descend into it, and, by a few farther uterine efforts, the
remainder of the trunk, with the lower extremities, is expelled."
(Douglas, _op. cit._ p. 28. 2nd ed.)

Farther experience has confirmed the correctness of Dr. Douglas's views
(_Med. Trans. of the Royal Coll. of Physicians_, vol. vi. 1820;) and,
indeed, the original case as related by Dr. Denman himself tends to prove
that nothing like an "evolution" of the foetus takes place. I found the
arm much swelled, and pushed through the external parts in such a manner
that the shoulder nearly reached the perineum. The woman struggled
vehemently with her pains, and during their continuance _I perceived the
shoulder of the child to descend_.

Some years afterwards, the late Dr. Gooch had the opportunity of observing
a case of spontaneous expulsion with great accuracy, and came to the same
conclusion as Dr. Douglas had done. "Resolved to know what became of the
arm, if this (the spontaneous expulsion) should happen, and thus fit
myself for a witness on this disputed point, I laid hold of it with a
napkin and watched its movements: so far from going up into the uterus
when a pain came on, it advanced, as well as the shoulder, still forwarder
under the arch of the pubes, the side of the thorax pressing more on the
perineum and appearing still more externally; it advanced so rapidly that
in two pains, with a good deal of muscular exertion on the part of the
patient, but apparently with less suffering than attends the birth of the
head in a common first labour, did the side of the chest, of the abdomen,
and of the breech, pass one after the other in an enormous sweep over the
perineum till the nates and legs were completely expelled." (_Ibid._)

The celebrated Boer, has, however, detailed a case where the arm had
prolapsed into the vagina, the hand appearing externally; and on
introducing his hand for the purpose of turning, he felt the hand
distinctly receding, and the breech beginning to occupy the cavity of the
pelvis. This is very different to a case of spontaneous expulsion: "the
child lay completely across, with its abdomen towards the back of the
mother;"[110] it had, in fact, not yet begun to press against the brim,
or to assume any definite position, there having been as yet but little
uterine contraction, and both rectum and bladder being considerably
distended. When these were evacuated the pains increased: the breech being
nearest to the brim, descended, and the arm in consequence receded. Dr.
Gooch considers it most probable that "it was only a breech presentation,
the hand having accidentally slipt down into the vagina."

Although in cases of malposition where turning has become excessively
difficult and dangerous, the spontaneous expulsion must be looked upon as
a most fortunate process by which nature effects delivery, still, however,
we must never venture to wait for it without making such attempts to turn
the child as the state of the patient may justify. It is always more or
less dangerous to the mother, and almost certainly fatal to the child.
Indeed, it is our opinion, that the spontaneous expulsion can rarely, if
ever take place, except where the child has been already dead some time,
or where it is premature. "Nor can any event," says Dr. Douglas, "ever be
calculated upon than that of a still-born infant. If the arm of the foetus
should be almost entirely protruded with the shoulder pressing on the
perineum, if a considerable portion of its thorax be in the hollow of the
sacrum with the axilla low in the pelvis, if with this disposition the
uterine efforts be still powerful, and if the thorax be forced sensibly
lower, during the presence of each successive pain, the evolution may with
great confidence be expected." (_Op. cit._ p. 42.)

On the other hand, if either from the rigidity, &c. of the child or of the
passages, but little material advance is made in the manner
above-mentioned, if the soft parts are become swollen and inflamed, and
the powers of the patient are beginning to flag, and exhaustion coming on,
if turning has been attempted as far as could be done with safety, and
still without success, we have no choice left but that of embryotomy; the
chest and abdomen must be evacuated of their contents as already directed
under the head of PERFORATION, and in this manner the child delivered.

_Malposition with deformed pelvis, or rigidity of the uterus._--Where the
pelvis is deformed, or the uterus (from the early escape of the liquor
amnii) spasmodically contracted upon the child, and the os uteri in a
state of rigidity, the difficulties and danger of the case are greatly
multiplied: in the former complication the embryotomy must be carried much
farther, in the latter we must have recourse to bleeding, opium,
warm-bath, &c. as recommended under the head of TURNING.

_The prolapsed arm is not to be put back or amputated._--Where the arm has
been some time prolapsed, and, from the pressure of the soft parts, much
swollen, it fills up the vagina so completely that it would seem almost
impossible to introduce the hand, unless we push up the arm first:
experience however confirms the valuable rule of La Motte, viz. that we
must slide our hand along the arm into the uterus; we shall rarely find,
where the passages are in a proper state for undertaking the operation,
that the prolapsed arm presents any serious obstruction to the passage of
the hand. "An arm presenting," says Chapman, "and advanced as far as the
armpit, is not to be returned, but the hand is to be introduced (which, as
Deventer justly observes, is often found to penetrate with much more ease
when the arm hangs down than when it is thrust back again) and the feet to
be sought for, which, when found, the arm will prove no great hindrance in
turning the child." (Chapman's _Midwifery_, p. 46. 2nd. ed., 1735.)

In no case is it necessary to separate the arm at the shoulder, "for I
have found it," says Dr. Denman, "a great inconvenience, there being much
difficulty in distinguishing between the lacerated skin of the child and
the parts appertaining to the mother." (_Essay on Preternat. Labours_, p.
32.)

Dr. Meigs, of Philadelphia, has added another powerful argument against
this practice, viz. that cases have occurred where the arm had been cut
off and where the child was nevertheless born alive.

As to how far it is possible or advisable so to alter the position of the
child as to make it present with the nates or head, this has already been
considered in the chapter upon TURNING.

The _presentation of the arm with the head_ is of very rare occurrence, so
much so that some have doubted if it really existed: two cases of this
kind have come under our own notice, in both of which the child was born
in this position, although with some difficulty.

"Independent of the awkwardness of position which the head may assume,
from the circumstance of the hand or arm descending with it into the
pelvis, there will be so much increase in the bulk of the part as to
render its passage slow and difficult; yet if the case be not interrupted
by mismanagement, it will terminate favourably, for this complication of
presentation seldom happens but in a wide pelvis." (Merriman's _Synopsis_,
p. 48, last ed.)

It is by no means uncommon to feel the hand lying upon the side of the
head or on the cheek; but this produces no impediment to the labour, for
as the head descends through the brim of the pelvis the hand usually slips
up: in the other case we have felt the arm bent over the head, and
pressing the ear on the opposite side.

_Presentation of the hand and feet._ We sometimes also meet with cases
where the hand presents with one or two feet; but these complications
merely exist at the commencement of labour, where the uterus has been
greatly distended with liquor amnii, and where its contractions have not
yet begun to press the child into the brim. Cases of this nature sooner
or later are sure to terminate in presentations of the nates or shoulder,
unless the process of labour has been interfered with.

_Presentation of the head and feet._ Presentations of the head and one or
both feet have also been described: these, however, have only occurred
during the operation of turning, when the feet have been brought down into
the pelvis before the head had left it, and, therefore, must be considered
as having been _made_ by unskilfulness on the part of the practitioner.
Where this is the case it may be necessary to premise blood-letting, &c.,
on account of the inflamed condition of the parts from the previous
unsuccessful attempts to turn: after this, a fillet should be passed round
the feet in order to secure them, and then the head may be safely pushed
out of the pelvis.

_Rupture of the uterus._ Of the injurious results arising from protracted
or neglected cases of arm or shoulder presentation none can compare in
point of danger with those where the uterus has given way or burst. This
state may also be produced by deformity of the pelvis, tumours, and other
causes of obstruction to the passage of the child, by which the uterus is
excited to unusually violent efforts in order to overcome the impediment
during which the laceration is effected. It may also arise from injuries
to the uterine tissue without undue exertions, as from exostosis of the
pelvis, sharp projecting edges of the promontory or brim, and also from
organic disease: thus, "when the rent speedily follows the accession of
labour, before the pains have become severe, or the uterus has scarcely
begun to dilate, its structures will probably be found diseased." (_Facts
and Cases in Obstetric Medicine_, by I. T. Ingleby, p. 176.)

_Usual seat of the laceration._ The part of the uterus in which laceration
is most frequently observed to occur is near to or at the junction of the
uterus with the vagina: this happens rather more frequently behind than
before, but the difference in this respect is very trifling. Thus in 36
cases which were collected by Mr. Roberton, of Manchester, "in 1 the
cervix was separated from the vagina except by a thread: in 11 the
laceration was posterior, in 8 it was anterior, in 5 lateral, in 3
anterior-lateral, and in 3 posterior-lateral." (_Edin. Med. and Surg.
Journal_, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the
Dublin Lying-in Hospital, "in 13 the injury was at the posterior part; in
12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in
6 the particular seat of the laceration was not described." (_A Practical
Treatise on Midwifery_, &c., by Robert Collins, M. D., 1835, p. 244.)

The nature and extent of the laceration varies a good deal: in the worst
cases the uterus is torn completely through, and the child escapes either
partly or wholly into the abdominal cavity; whereas, in many, the
peritoneum has not given way, the laceration being confined entirely to
the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by
Dr. Collins, "the peritoneal coat of the uterus was uninjured, although
the muscular substance of the cervix was extensively ruptured." In other
instances the peritoneum has been cracked or torn in numerous places
without any injury to the subjacent tissue.

From the greater degree of resistance to the passage of the child, in
cases of first labour, we might naturally suppose that rupture of the
uterus would be more frequently seen among primiparæ: this, however, is
not the case, for of 29 cases mentioned by Mr. Roberton, only one of them
was a primipara; a larger (and as an average probably more correct)
proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ,
5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their
eleventh pregnancy.

Experience also shows that in a large proportion of these cases, the
duration of the labour has been very far from being longer than usual;
indeed, in a considerable majority, the mischief has taken place very few
hours after the commencement of active labour. Thus, the average duration
of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of
those by Dr. Collins, it was 17 hours: but if we take merely the
_majority_ of them we shall have a much smaller average: thus, in 20 of
Mr. Roberton's cases it was 9 hours, and in 15 of Dr. Collins's it was
only 6 hours.

_Causes._ A large proportion of cases where the uterus gives way during
labour, are connected with more or less deformity of the pelvis, and
where, from previous severe and difficult labours, its structure has been
injured, and rendered incapable of bearing that degree of tension, which
even the ordinary exertions of the uterine fibres would require. In many
others, the impediment produced by the contracted pelvis, or malposition
of the child, has roused the uterus to those violent efforts which have
produced the laceration. Organic diseases of the uterus, or cicatrisations
of the soft passages from extensive injuries in former labours, either
render its powers of resistance defective, or, by increasing the
resistance, excite it to unusual violence. "The operation of turning is
not unfrequently a cause of laceration of the vagina or mouth of the
uterus, _particularly_, where it is performed previous to the soft parts
being sufficiently dilated to admit the easy passage of the hand, or where
great haste is employed. The same consequences may ensue from rash or
violent attempts to remove a retained placenta. I have also known the
mouth of the womb to be torn by the imprudent use of the forceps when not
sufficiently dilated." (Dr. Collins, _op. cit._ p. 242.) "The sex of the
infant, it would appear, may also have some share in occasioning this very
distressing occurrence." (_Practical Remarks on Lacerations of the Uterus
and Vagina_, by Thomas M'Keever, M. D., p. 4.) Thus, of 20 cases reported
by Dr. M'Keever, 15 were delivered of boys and 5 of girls; of the 34 cases
described by Dr. Collins, "23 of the children were males. This is
satisfactorily accounted for by the greater size of the male head, as
proved by accurate measurement made by Dr. Joseph Clarke."

Another circumstance which influences to a certain extent the frequency of
rupture of the uterus, is the rank of the patient: in private practice,
especially among the better classes of society, it is an extremely rare
occurrence; but in the lower grades of life several causes concur to
render it more frequent. They are "much more exposed to falls, bruises,
and other accidental injuries during pregnancy, in consequence of which
the uterus may be either ruptured at the time they have sustained the
violence, or may be so weakened in structure at some particular point, as
readily to give way during its efforts to accomplish delivery. Lastly,
they are more liable to fall into the hands of ignorant inexperienced
midwives, who not unfrequently, with a view of expediting the process of
delivery, rupture the membranes at an early period of the labour; in
consequence of which, the firm unyielding head of the child is prematurely
brought in contact with the passages, exciting by its pressure, swelling,
inflammation, and an interrupted state of the circulation in the uterus
and adjacent parts. In such a case should there unfortunately exist any
disproportion between the parts of the mother and the head of the infant,
or should proper measures not be employed to obviate distressing symptoms,
and that the labour pains continue to recur with extreme violence, there
is great risk of the uterus giving way, the laceration being of course
most likely to occur at that part where the greatest pressure has been
sustained." (M'Keever, _op. cit._ p. 3.)

The _premonitory symptoms_ of rupture of the uterus are not always
sufficient to warn us of the impending danger, for in many cases nothing
unusual has occurred until the actual injury has been produced, and it has
then been inferred by the alarming change observed in the patient's
appearance. In many cases, especially where the muscular substance only of
the uterus was torn, the pains have continued with a sufficient degree of
power to expel the child; in others the mischief has been attended with so
little suffering at the moment, and for the time with so little
constitutional derangement, as to excite no suspicion, either on the part
of the patient, or her attendant. "Farther, as on some occasions, the
uterus has been known to give way during the very pain which effected the
delivery of the child, instances of which may be found in the works of
Crantz and Guillimeau." (_Ibid._ p. 15.)

_Symptoms._ "When a rupture of the uterus has really happened, it is
generally marked by symptoms which are decisive; but it being a case which
occurs so very rarely, they do not immediately create suspicions. When
labour has continued violent a considerable time, if a pain expressive of
peculiar agony is followed by a discharge of blood, and an immediate
cessation of the throes, there is reason to apprehend this mischief. If
nausea and languor succeed, with a feeble and irregular pulse, cold sweat,
retching, a difficulty of breathing, an inability to lie in a horizontal
posture, faintness or convulsions, there is still more reason to suspect
the nature of the case. But if the presenting part of the child, which was
before plainly to be distinguished, has receded and can be no longer felt,
and its form and members can be traced through the parietes of the
abdomen, there is evidence sufficient, I believe, to determine that the
uterus is ruptured. The labour pain, in consequence of which the rupture
is supposed to have happened, is often described by the patient, as being
similar to cramp, and as if something was tearing and giving way within
them. It has been said likewise, to have produced a noise which could be
heard by the people present." (_Observations on an extraordinary Case of
ruptured Uterus_, by Andr. Douglas, M. D., 1785, p. 48.)

Where the peritoneal coat only has been torn, we may have many of the
above-mentioned symptoms resulting from laceration of the uterus, without
any impediment to the progress of labour. This peculiar species of partial
rupture was first noticed by the late Dr. John Clarke, (_Trans. for the
Improvement of Med. and Surg. Knowledge_, vol. iii.,) since which cases
have been recorded by Mr. Partridge (_Med. Chir. Trans._ vol. xix. p.
72.,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke's case the uterus and
vagina "were found to have sustained no injury whatever; but on turning
down the fundus uteri over the pubes, between forty and fifty transverse
lacerations were discovered in the peritoneal covering of its posterior
surface, none of which were in depth above the twentieth of an inch, and
many were merely fissures in the membrane itself. The edges of the
lacerations were thinly covered with flakes of coagulated blood; and about
an ounce of this fluid was found in the fold of the peritoneum, which dips
down between the uterus and the rectum."

Where the uterus has been torn quite through, a frequent result is, that
the child passes either wholly, or in part, through the rent into the
abdominal cavity: this occurrence will, in great measure, be influenced by
the situation and extent of the laceration, and also by the degree of the
uterine contractions. It is easily recognised by the presenting part
having receded, and in all probability by the members of the child being
felt with unusual distinctness through the abdominal parietes.

_Treatment._ Under such an unfortunate complication nothing remains but to
effect the delivery in as speedy and gentle a manner as possible. Where
the os uteri is fully dilated, the head presenting and but little
receded, and the pelvis only slightly contracted, the application of the
forceps will be justifiable; but in many instances the circumstances of
the case will not warrant it, and the attempt must be made to bring down
the feet, which has been most usually had recourse to with success
although it occasionally happens that even this is attended with no slight
difficulties: the rigid and partially dilated os uteri may be a serious
bar to the introduction of the hand; this has been successfully overcome
by incisions into its edge;[111] but it is a remedy which no practitioner
would use if by any means to be avoided.

_Gastrotomy._ Where the whole child has passed into the abdominal cavity,
and the uterus has evidently contracted, so as to produce a serious, if
not insurmountable obstacle to delivering it through the vagina, or at any
rate without the risk of increasing the extent of the laceration, the
question then remains as to whether we should perform gastrotomy, or leave
the foetus in the abdominal cavity to be gradually discharged, like an
extra-uterine pregnancy, by abscess and sloughing. There can be no doubt
that the former plan is preferable, nor are there wanting upon record
successful cases of gastrotomy after rupture of the uterus; one of which
is doubly interesting from the operation having been twice performed with
a favourable result in consequence of a repetition of the injury in the
patient's succeeding pregnancy.[112] Mr. Ingleby, of Birmingham, gives a
similar opinion in favour of the operation: "The result of two cases of
Cæsarean operation in which I have been engaged, leads me to view the mere
abdominal incision with very different feelings. The operation is not half
so dangerous as the Cæsarean, whilst the celerity with which it is done,
the absence of hæmorrhage, and the facility with which the intestines are
confined within the abdomen, tend to divest it of much of its terror."
(_Op. cit._ p. 201.)

_Rupture during the early months of pregnancy._ Cases of rupture of the
uterus have occasionally been observed at an early period of pregnancy; in
many of these the foetus has passed into the abdominal cavity, where it
has been enclosed in a species of cyst, and afterwards expelled through
the rectum or abdominal parietes by an abscess. It may be doubted whether
some of these have not been cases of extra-uterine pregnancy. On the other
hand, there is reason to believe that those extraordinary cases of ventral
pregnancy, to which we have alluded, where the foetus has been found in a
sac in the abdomen, which communicated with the uterus, and to which the
placenta was attached, were the results of rupture at an early period of
pregnancy, in all probability the result of ulceration or organic
degeneration of the uterine parietes. In some instances it has been
produced by violence: and it is by no means impossible that it might take
place during a miscarriage, when the uterine contractions are occasionally
very violent. Mr. Ingleby remarks that in a case of premature expulsion at
the fifth month, the violence of the pains seemed quite equal to produce a
breech of surface.

Dr. Collins has recorded a case of ruptured uterus in about the fifth
month. The laceration appears to have taken place imperceptibly: the child
was very putrid; and as the os uteri was sufficiently dilated, the head
was perforated, and "was brought away almost without any assistance. It
was nothing more than a soft mass, being so completely broken down by
putrefaction."[113] There was no previous history to explain it; the
muscular structure of the uterus at the anterior part of its cervix was
torn, leaving the peritoneum entire.

Lastly, we may mention a very singular species of laceration of the
uterus, of which we know of but two cases, the one recorded by Mr. P. N.
Scott, of Norwich, (_Med. Chir. Trans._ vol. xi.) the other which occurred
under our own notice, where the whole os uteri separated from the uterus
during labour.[114] In both cases, the os uteri presented a degree of
unnatural rigidity, which was quite peculiar, and which in one case,
defied repeated and active bleeding, as well as opiates. In Mr. Scott's
case, the laceration took place during a violent pain, when the patient
"felt something snap, the noise of which one of the attendants declared
she heard." In the other case, the patient was not aware of any thing
peculiar having happened: it was a first labour in the eighth month of
pregnancy; the os uteri had dilated to nearly the size of half a crown,
but would dilate no farther; the child had evidently been some time dead;
the cranial integuments gave way from putrefaction, the brain escaped, the
bones of the skull collapsed, and the bag of scalp protruded so far that
we could lay hold of it, although the basis cranii had not passed. We were
thus enabled to use more extractive force than we could have ventured upon
with the crotchet: after a little effort, but without even a complaint
from the patient, the head descended and passed through the os externum.
"On the bed lay a disc of fibrous matter with a circular hole in the
middle; in fact, the os uteri separated from the uterus to the extent of
near half an inch, the edge of the laceration being as clean and smooth as
if it had been carefully cut off by a knife." In both instances the
patient recovered. Whether incisions into the os uteri for the purpose of
effecting the necessary degree of dilatation would have been justifiable
under circumstances of such unusual rigidity, does not belong to the
present subject; for the consideration of this, we must refer to the FIFTH
SPECIES OF DYSTOCIA.



CHAPTER II.

SECOND SPECIES OF DYSTOCIA.

    _Size and form of the child.--Hydrocephalus.--Cerebral tumours.--
    Accumulation of fluid and tumours in the chest or abdomen.--
    Monsters.--Anchylosis of the joints of the foetus._


In this case the labour is rendered difficult or impossible to be
completed by the natural powers on account of the faulty size, form, or
condition of the child. In the first instance, it is merely a case of
disproportion between the child and the passages, owing to the unusual
size of the former. Where the child is well formed throughout, but larger
than usual, it rarely happens that the head experiences any serious degree
of difficulty in passing through a well-formed pelvis, the greatest
resistance being observed during the dilatation of the external passages.
Even when the head is born, the shoulders may produce a considerable
obstruction to its farther passage, requiring a good deal of careful
manipulation, in order to disengage the foremost shoulder from under the
pubic arch, and thus diminish the pressure of the child against the
parietes of the pelvic cavity. Where the shoulders have been severely
impacted in this position, it has been in great measure owing to the
practitioner having endeavoured to bring down the wrong shoulder first,
viz. that which is directed more or less backwards.

_Size of the child._ We have already stated that the average weight of the
full grown foetus is between six and seven pounds, and its length about
eighteen inches; but it is frequently found to exceed these proportions
very considerably. Children are not uncommonly observed to weigh 10lbs. at
birth. Dr. Merriman once delivered a still-born child, which weighed
14lbs., and the late Sir Richard Crofts is said to have delivered one
alive which actually weighed 15lbs.; but by far the largest child which we
have yet heard of is recorded by Mr. J. D. Owens, surgeon, at Haymoor near
Ludlow; it was born dead, and the weight and admeasurements ten hours
after birth were as follow:--

  The long diameter from the occiput to the root of the nose 7-1/4 inches.
  The occipito-mental                                        8-1/2
  From one parietal protuberance to the other                5
  Circumference of the skull                                15-1/4
  Circumference of the thorax over the xiphoid cartilage    14-1/2
  Breadth of the shoulders                                   7-1/4
  Extreme length of the child                               24
  Weight of the child                                       17 lbs. 12 oz.

  (_Lancet_, Dec. 22. 1838.)

We have already pointed out the difficulty of determining the presence of
twins merely from the appearance of the mother's abdomen; the same will
necessarily hold good with regard to one large child. The size of the
patient must rarely have any influence in forming our prognosis: in most
cases she will have many symptoms, which arise either from pressure or
weight in the pelvis, such as difficulty in passing water, oedema of the
feet and legs, varicose veins of the thighs and labia, or from cramps, the
result of pressure upon the absorbents, veins, or nerves; considerable
expansion of the inferior segment of the uterus: all these will give us
reason to suspect the presence of a large child even although the abdomen
may not be remarkably distended.

Where the head is very large, the bones are seldom much ossified; they
therefore yield easily, and the head accommodates itself to the shape of
the passage: sometimes, however, it is unusually hard, the bones are well
ossified and very unyielding, so that even if it be not larger than
common, still, from its hardness, it meets with considerable difficulty in
passing through the pelvis. Cases have been described where the cranial
bones were completely ossified, and the sutures perfect; but this latter
is very doubtful. Perfect mentions an instance where the head was "almost
one entire ossification, and where it passed through the pelvis with great
difficulty." (Perfect's _Cases in Midwifery_, vol. ii. p. 370.) We have
also met with cases requiring perforation on account of deformed pelvis,
and where the cranial bones had almost the feel of a hard nut or shell;
still, however, as already observed, we seldom see any serious impediment
to the passage of a large head, so long as it is naturally formed; and
this applies also to the other parts of the child.

_Form of the child._ On the other hand, where there is an unnatural form
of the child, either from a disproportionate size or anormal configuration
of certain parts, labour may be rendered not only very difficult but
dangerous: thus one of the three great cavities may be distended with an
accumulation of fluid, the most common form of which, is the congenital
hydrocephalus.

_Hydrocephalus._ In many cases it produces much less resistance than might
be expected from the size of the head; this is, in great measure, owing to
the unusual width of the sutures and fontanelles, but chiefly to the
almost entire want of ossification in the cranial parietes, which are
little else than membranous, and so flexible as to allow the head to be
squeezed into almost any shape. In some very rare cases the head has
burst, a large quantity of fluid has come away suddenly, and this has been
followed almost immediately by the birth of the child:[115] but in the
majority the labour has been tedious and severe, and in some instances
attended with dangerous results to the patient; thus, Dr. Merriman has
"known one hydrocephalic foetus pass entire, the circumference of whose
head was 17 inches; another passed alive and lived nearly an hour, whose
head measured in circumference nearly 22 inches; both the above labours
were long and painful." Perfect relates a case of hydrocephalic head, of
which he has given engraved delineations; the labour was attended with
extreme difficulty, and the woman expired in less than two hours after
delivery; the circumference of this head was 24 inches. (_Cases in
Midwifery_, vol. ii. p. 525.) An interesting case of hydrocephalus,
attended with convulsions and laceration of the vagina, has been recorded
by Dr. Collins: "the perforator was used, upon the introduction of which
into the head fully three half pints of water gushed out; the bones then
collapsed, and the delivery was easily completed." (_Practical
Observations_, p. 205.)

_Cerebral tumours._ The bulk of the head is sometimes increased by tumours
or sacs of fluid, which arise from a suture or fontanelle: they are of the
same nature as the spina bifida, being formed by a protrusion of the
integuments and cerebral membranes from an accumulation of fluid beneath:
these are of very rare occurrence, and appear to have retarded labour but
little, even although of considerable size. The largest cases on record
are those which have been described by Ruysch, where one was as big as the
head itself, and another where it was nearly as large as the child's
body.[116] A case of fluctuating tumour upon a child's head has been
described by Mauriceau, (Case 544,) but the precise nature of it is not
very apparent.

_Accumulations of fluid, and tumours in the chest or abdomen._ It is very
rare that the chest is distended by any accumulation of fluid or morbid
growth, although this is not unfrequently met with in the abdomen. La
Motte has given three cases of ascites which, by the distention of the
abdomen, produced considerable obstruction to the delivery of the child.
(Cases 331, 332, and 333.) In other cases the liver or the kidneys have
been enormously enlarged. A case is described by Dr. Hemmer, where the
child was born as far as the shoulders, and there stuck; finding it
impossible to extract the child, he perforated the abdomen in two places,
but could not extract it; in a few minutes after it came away of itself.
The abdomen had been distended with small hydatids; these gradually
escaped, and thus diminished the size of the abdomen. (_Neue Zeitschrift
für Geburtshülfe_, band iv. heft 1, 1836.) Where the child has been dead
some time in the uterus, the abdomen is frequently tympanic, and thus
retards its expulsion.

_Monsters._ Certain cases of monstrous formation may produce very serious
obstacles to the progress of labour: the most considerable is of twins
united by the breast. It is difficult to conceive how so large a mass can
be forced through the pelvis: we can only suppose it possible where the
children have been dead some time before birth, or where they were
premature: to this latter circumstance only we can attribute the fact of
their having been born alive, as in the celebrated case of the Siamese
twins. Where the children have been united by one pelvis, &c., the chances
here of the foetus being dead before birth would be even still greater. M.
Rath, of Zetterfeld, has lately described a case of extremely difficult
labour, in consequence of twins united by the breast. "The children (two
girls) weighed 15lbs.; they were 17 inches long. The part by which they
were united was 9 inches broad and 3 long, and extended from the upper
extremity of the sternum to the navel, into which one umbilical cord,
which was common to both, entered. The diameter of the two children when
laid together was between 7 and 8 inches from one back to the other. One
child had two thumbs on the right hand. The cord was 19 inches long, and
unusually thick. After suffering some time from peritonitis, &c., the
patient recovered." (Siebold's _Journal_, band xvii. heft 2. 1833.)

_Anchylosis of the joints of the foetus._ Lastly, we may mention a very
rare cause of this species of dystocia, which has been observed by
Professor Busch, where the obstruction to the passage of the child arose
from anchylosis of its joints. "The head had been delivered by the
forceps, but the body would not follow. As no cause of obstruction could
be discovered, a gentle and then more powerful traction was used: this
was followed by a cracking sound, and the upper part of the trunk passed
through the os externum: here again it stopped, but still, as no cause of
obstruction could be discovered, and as the child was dead, another
traction was made, with a repetition of the cracking sound, and the child
was delivered. On examination it was found that all the joints of the
extremities were anchylosed in the usual position of the foetus in utero,
so that the ossa humeri and then the ossa femoris had given way. The child
had been dead some time." (_Neue Zeitschrift für Geburtskunde_, vol. xv.
1837; and _British and Foreign Med. Rev._ April 1838, p. 579.)

No precise rules can be given for the treatment of these cases of
malformation of the child; it must be modified according to the
peculiarities of each individual case. Whenever a part has undergone
considerable increase of size from accumulation of fluid, this can be in
most cases removed without much difficulty by perforation, whether it be
of the head or abdomen. With monstrous growths the accoucheur must depend
upon his own resources, ingenuity and knowledge of the mechanism of
parturition. The more careful and correct his diagnosis is, the more
efficient will be the means he adopts for delivering the child. In such
cases the examination can scarcely be made effectually by the finger
alone, but the hand will be required for this purpose.



CHAPTER III.

THIRD SPECIES OF DYSTOCIA.

    _Difficult labour from faulty condition of the parts which belong to
    the child.--The membranes.--Premature rupture of the membranes.--
    Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta._


In describing this species of dystocia, according to the arrangement of
Professor Naegelé, which we have adopted, it will be necessary to observe
that serious obstructions to the passage of the child is seldom produced
by it, although, at the same time, many slight derangements in the
progress of labour are liable to result, which demand the care of the
practitioner.

The membranes when too thick or tough (Merriman's _Synopsis_, p. 217,) may
retard the labour occasionally, especially during the second stage, when
instead of bursting and allowing the uterus to contract more powerfully
upon the child by the evacuation of the liquor amnii, they are pushed down
into the vagina, forming a large conical sac, which may even protrude
externally. We doubt much, however, if the non-rupture of the membranes at
the proper time during labour is of itself sufficient to retard its
progress, for it is frequently observed that the head will, nevertheless,
advance rapidly and even be born covered by the protruded membranes. Where
labour is rendered tedious by the unusual strength of the membranes, it is
generally connected with considerable distention of the uterus from liquor
amnii; in which case the bag of waters is so spherical that it will not
descend readily into the vagina, even although the os uteri is fully
dilated, and, therefore, prevents the advance of the head: to this we
shall recur immediately. So long as there is no undue accumulation of
liquor amnii, we may safely allow the membranes to descend to the os
externum before we rupture them. In former times a variety of instruments
were employed for this purpose, many of which were dangerous, and all
unnecessary, the finger being in most cases sufficient. The most effectual
way of doing this is to press the thumb and middle finger upon the
membranes during a pain and thus increase their tension, whilst the point
of the fore-finger is pushed against them: scratching them with the nail
during a pain will be sufficient when they are higher up the vagina.

_Premature rupture of the membranes._ More frequently the membranes
rupture too soon, that is, before the os uteri is fully dilated: this may
arise from their being too thin, a condition, however, which it is not
very easy to prove: in most instances, it is observed where the uterus is
but moderately distended, and where it has that oval or pyriform shape
which we have already pointed out as being best adapted for acting
efficiently upon the os uteri. This, perhaps, is one reason, why too early
rupture of the membranes so frequently occurs in primiparæ; and this may
be one cause, among many others, why first labours are generally so much
more tedious and severe. The membranes may also be prematurely ruptured by
violent exertions, coughing, sneezing, vomiting, &c. by straining
immoderately and too soon, by rough and awkward examination, &c. Where
this is the case, the patient should preserve the horizontal posture, and
keep as quiet as she can until the os uteri has dilated sufficiently and
allowed the head to advance.

_Liquor amnii._ Where the uterus is distended by an unusual quantity of
liquor amnii, its contractile power is necessarily much impaired; and
until the quantity of its contents be somewhat diminished, the progress of
the labour will be more or less retarded. The average quantity of liquor
amnii at the full period of pregnancy is about eight ounces; but it
frequently exceeds this very considerably, occasionally amounting to
several pints or even quarts. The causes of this extraordinary
accumulation are still but little known. "M. Mercier has, in some cases,
attributed it to an inflammatory condition of the amnion, the foetal
surface of this membrane being stated to have been partially coated with
false membrane, and the amnion itself crowded with blood-vessels of a rose
colour:" in another case "about a quarter of the foetal surface of the
amnion was inflamed, being of a deep red colour and double the natural
thickness."[117] The results of Dr. R. Lee's observations, after having
paid a good deal of attention to the subject, do not tend to confirm this
view: he has described six cases of unusual accumulation of the liquor
amnii, in one amounting actually to sixteen pints. In five of them "there
existed with dropsy of the amnion some malformed or diseased condition of
the foetus or its involucra, which rendered it incapable of supporting
life subsequent to birth." In two only of the preceding cases was "the
formation of an excessive quantity of liquor amnii accompanied with
inflammatory and dropsical symptoms in the mother; and in none did the
amnion, where an opportunity occurred for making an examination, exhibit
those morbid appearances produced by inflammation, which M. Mercier has
described, and which led him to infer that inflammation of the amnion is
the essential cause of the disease." (Lee, _op. cit._) Dr. Merriman has
given a similar opinion, and states, that "when the embryo or foetus is
diseased, the liquor amnii is sometimes immense in quantity. I once saw at
least two gallons evacuated from the uterus: the child was monstrously
formed and much diseased."[118]

In these cases the size and globular form of the uterus, the tenseness of
its parietes, the more or less distinct feel of fluctuation, the absence
of the child's movements and of any prominences arising from the
projecting portions of its body, the rapid increase which has been
observed in the size of the abdomen, the pain in different parts of the
uterus, especially in the groins and pelvis, the oedema or anasarca of the
lower extremities, serve to mark this condition. On examination per
vaginam we also feel the inferior segment of the uterus much expanded, the
cervix probably shorter than might be expected for the period of
pregnancy; the ballottement is unusually free and distinct. In some
instances the patient has suffered so much, either from the effects of the
retarded circulation in the lower extremities, or from the impeded
respiration as to require the membranes to be punctured in order to reduce
the size of the uterus. The child is usually born dead where the
accumulation has gone to so great an extent: in the three cases recorded
by La Motte, it was dead before birth in the first two, and died
immediately after birth in the third. Many of these cases, which have been
complicated with disease or malformation of the foetus, have appeared to
arise from a syphilitic taint; but in others, of more common occurrence,
where there was merely an unusually large quantity of liquor amnii without
any disease either of the mother or her child, the cause must still remain
a matter of uncertainty. This latter condition is mostly seen in women who
have been frequently pregnant; the os uteri in them is generally yielding,
and when once it has attained its full degree of dilatation, we may safely
rupture the membranes and thus expedite labour considerably.

There being an unusually small quantity of liquor amnii can scarcely
operate as an obstruction to labour, except where the membranes have been
prematurely ruptured.

The _umbilical cord_ may obstruct labour, by either being too short, or
rendered so from being twisted round some part of the child. Its length
varies very considerably. Although we have stated it to average about
eighteen or twenty inches,[119] we have met with extreme deviations both
within as well as beyond this medium length. The shortest cord which we
know of occurred some years ago at the General Lying-in Hospital, "where,
after two or three violent pains, the child was suddenly and forcibly
expelled the cord was found ruptured at about two inches from the navel of
the child, which cried stoutly. After removing the child the matron sought
for the other end of the funis, but could not find it; she examined per
vaginam but could not feel it; and on introducing her hand into the
uterus, found the placenta with the remains of the cord ruptured at its
very insertion; so that in this case the cord could not have been much
more than two inches long." (Printed Lectures in Renshaw's _Lond. Med. and
Surg. Journ._ May 1835, p. 426.)

We quite agree with Professor Naegelé, that unusual shortness of the cord
can rarely if ever retard labour; and that where the cord really produces
an impediment to its progress, it is from being twisted round the neck, or
some other part of the child. (_Lehrbuch_, 2d ed. p. 289.) This generally
arises from its unusual length, and from its having formed several coils
around the child: we have met with it forty-eight inches long, and twisted
four times round the child's neck; but Baudelocque mentions a case where
it actually measured fifty-seven inches, "forming seven turns round the
child's neck." (Heath's _Transl._ vol. i. § 516.) Mauriceau has given an
instance (_Obs._ 401.,) where the cord had "longueur d'une aune et un
tiers de notre mesure de Paris:" which, converted into English measure,
amounts to somewhat more than sixty-one inches.

Although nothing is of more common occurrence than the cord being twisted
once or twice round the child, it nevertheless, happens, but very rarely,
that its advance is thereby obstructed. In a case of this sort, the labour
usually commences quite favourably; the os uteri dilates, and the head
advances to a certain extent, beyond which it makes no other farther
progress; the uterine contractions are attended with much pain in the
fundus, during which the head advances somewhat, but retires again during
the intervals. Where the head is already near the os externum, this may be
easily attributed to the elasticity of the soft parts, until the delay
which takes place to the farther progress of the labour warns the
practitioner that something more than ordinary is the cause. But where
this takes place, and the head is still in the pelvic cavity; where at the
same time, although it refuses to advance, it is quite moveable, and
allows the finger to be passed freely round it; where any attempt to
extract it with the forceps has not only met with great opposition, but
has greatly aggravated the sense of painful dragging in the upper parts of
the uterus there will be pretty certain evidence of the cord being either
too short, or, what is most probable, of its being twisted round the
child. In each of the three cases recorded by La Motte, the head had
descended to the os externum; whereas, in two others described by Burton,
it was evidently much higher up: he ruptured the cord in both instances;
La Motte succeeded in cutting the cord with a pair of scissors in one
case, in another he appears to have separated the placenta, and in the
other to have delivered by little else than force. Where upon introducing
the hand we find it impossible to undo the coil of the funis, we should
endeavour to slip it first over one and then the other shoulder, as we
have recommended under the more ordinary circumstances: should this fail,
we must try to cut it through either by a finger nail slightly notched for
the purpose, or by the introduction of a Smellie perforator well guarded.

The cord being twisted round the child's neck may not only retard labour,
it may destroy the child itself by preventing the free return of blood
from the head: this may take place some little time before birth, or
during the actual process of labour. That suffocation cannot possibly be
the cause of death under these circumstances is sufficiently evident.

_Knots upon the cord_ have been mentioned by some authors as a cause of
danger to the child shortly before and especially during labour; for the
circulation in the umbilical vessels being more or less compressed, the
child would either be born dead or in a very weakly state. Experience has,
however, shown that these effects have been much over-rated, and that
these knots are seldom injurious to the child.[120] Baudelocque has not
only met with single, but even triple and very complicated knots tied
tightly upon the cord, and yet the child was not only born alive, but
remarkably robust and healthy. Circumstances, however, may occur by which
the knot is gradually drawn so tight as to destroy the child. Smellie has
given a case of this kind; but it is to the late Matthew Saxtorph, of
Copenhagen, that we are indebted for an admirable essay on this subject.
The result of his observations coincides with those of Baudelocque, viz.
that it rarely proves fatal to the child.[121] The manner in which these
knots are formed may be easily imagined; when by chance the cord lies in
the form of a ring, and the foetus happens to float through it, a noose is
made, which, when drawn tight by accident, forms a knot.

The most favourable time for the formation of such knots is in the earlier
months of pregnancy, when the quantity of liquor amnii, in proportion to
the bulk of the foetus, is so much greater than at an after period, and
when its movements are consequently less impeded. The circulation in the
knot will be obstructed in proportion as the knot is drawn closer: if it
be merely somewhat impeded, the vessels on each side of the knot will be
distended and varicose, and the cord itself, where it forms the knot, from
the constant gradual pressure of one fold against the other, will become
more or less flattened.[122] We believe that in every case the cord has
been of unusual length.

The _placenta_ cannot easily obstruct the birth of the child, although it
may render the labour exceedingly dangerous in a great variety of ways:
these circumstances will be considered under their respective heads.



CHAPTER IV.

FOURTH SPECIES OF DYSTOCIA.

    _Abnormal state of the pelvis.--Equally contracted pelvis.--Unequally
    contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.--
    Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely
    distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.--
    Effects of difficult labour from deformed pelvis.--Fracture of the
    parietal bone.--Treatment.--Prognosis._


This may arise from there being either too much or too little resistance
to the passage of the child; where, in the one case, labour is rendered
difficult or impossible to be completed by the natural powers; in the
other, it is unnaturally rapid. The latter condition belongs to the second
great division of dystocia, where the faulty character of the labour does
not depend upon its progress being deranged, but upon other circumstances:
we shall, therefore, delay speaking of precipitate or too rapid labour
from unusually large pelvis, until then, and devote the present chapter to
the consideration of those cases where the labour is more or less
obstructed by the faulty condition of the mother's pelvis.

The pelvis may obstruct the passage of the child in a variety of ways.

1. It may be merely a diminutive or dwarfish pelvis, viz. well formed but
smaller than usual in every direction--the pelvis simpliciter justo minor
of Continental authors.

2. It may be distorted and deformed.

3. It may be of the natural form and size, but the passage through it more
or less obstructed by exostosis.

_Equally contracted pelvis._ The first species of faulty pelvis (_pelvis
simpliciter justo minor_,) is not of common occurrence, and has received
but little notice in this country. It has been said to resemble the pelvis
of a girl in its general appearance; but this only holds good in point of
size; for, in the relative proportions of its diameter, it presents all
the characters of a well formed adult pelvis. From this circumstance, it
can scarcely be said to be an arrest of development, the necessary changes
in the form of the pelvis having taken place at the time of puberty, as
completely as if it had been of the ordinary size. A pelvis of this sort
may be not more than a quarter of an inch too small in every direction, or
it may be as much as a whole inch: we do not know of any case where the
diminution has exceeded this last degree.

The pelvis equaliter justo minor is not accompanied with a corresponding
diminutiveness in the rest of the skeleton, most of the patients in whom
it has been observed being well formed and of the usual stature.
Fortunately, as before stated, it is of rare occurrence, for even a small
diminution in the size of the bony passages, which is uniform in _every
direction_, presents a most serious obstacle to the passage of the child.
Thus, in three cases of the sort, which have been described by Professor
Busch in his report of the Berlin Lying-in Hospital, the labour terminated
fatally in two. "The first case was a presentation of the breech; the head
was delivered by the forceps; the child was dead; the pelvis measured half
an inch too small in every direction. In the second case, which was a head
presentation, the delivery was effected by the forceps, but not without
the greatest efforts; the child was still-born, and the mother died in a
day or two after from peritoneal inflammation. The third case required
perforation; this also terminated fatally, the forceps having been
previously applied, and considerable efforts made without success. On
examination after death, every diameter of the pelvis was three quarters
of an inch smaller than usual: in appearance it resembled that of a
child." (_Neue Zeitschrift für Geburtskunde_, vol. xv. 1837.)

_Unequally contracted pelvis._ The unequally contracted pelvis (_pelvis
inæqualiter justo minor_) may exist under a variety of forms; the most
common is where the antero-posterior diameter is defective, or, in other
words, where the distance between its anterior and posterior parietes is
less than usual. In a slight degree, it is frequently met with among the
poorer classes, and arises from the patient having been compelled to carry
heavy burdens in early childhood, or otherwise subjected to severe labour.
The practice of entrusting a girl of eight or ten years of age with the
care of a heavy infant, which she carries about in her arms for many hours
every day, is a fruitful source of this species of pelvic deformity; the
young and plastic pelvis is unable to bear the additional pressure which
is thrown upon the sacrum by the overloaded trunk, without having the just
proportions of its growth materially influenced and perverted, especially
at a period of life when the whole form of the pelvis is undergoing
considerable changes. The constant pressure and counter-pressure to which
the pelvis is subjected by the undue weight which is applied to the sacrum
above, and supported by the resistance of the femora against the acetabula
below, must necessarily tend at this age, even in an ordinary state of
health, to impair its symmetry, more or less, and gradually to diminish
the distance between its anterior and posterior parietes. Under no
circumstances has this cause of pelvic deformity acted to such an extent
as in the English manufactories, where young children are compelled to
remain standing for twelve or more hours at the machines: the physical
powers are unequal to the endurance of so much unceasing labour, the
skeleton of the child soon suffers in its growth, and the pelvis almost
certainly becomes contracted.

Similar effects may also be produced by undue pressure on the other parts
of the pelvis. Thus the outlet may become much contracted by sitting many
hours a day on a hard seat, as is frequently the case in schools. The
tubera ischii are pressed together, the pubic arch is thereby contracted,
and the sacrum becomes strongly curved forwards. Much riding on horseback
at an early age is said to be injurious; and it is stated that the females
of those American nations who are constantly on horseback bear but few
children, and are frequently three or four days in severe labour.

_Rickets._ Similar effects, only in a much more aggravated form, are
produced by rickets in early life; the pelvic bones having become soft
from the loss of their earthy matter, gradually give way under the
pressure of the superincumbent trunk, to the support of which they were
unequal. In this way the sacrum is forced downwards and forwards towards
the symphysis pubis, the acetabula are driven upwards and backwards, the
pubic arch becomes distorted; and if the disease continues for a
considerable period of time, the whole pelvis becomes so squeezed together
as entirely to lose its original proportions.

The manner in which the distortion takes place varies exceedingly, and
will be more or less influenced by the circumstances under which the child
has been placed. The most constant change is the shortening of the
antero-posterior diameter at the brim. In severe cases the base of the
sacrum has, as it were, sunk down between the illia, so that its
promontory occupies the cavity of the pelvis, the fourth, or third, or
even the second, lumbar vertebræ occupying its former position. The
gradual yielding of the bones seldom takes place with that degree of
uniformity as to allow the sacrum to approach the symphysis pubis in a
straight line: the more common result of rickets is, that the promontory
is, at the same time, wrung more or less to one side.

"If the superior strait does not constantly present the same figure in
deformed pelvis; if it is sometimes larger on one side than the other; if
one of the acetabula is nearer to the sacrum, while the other approaches
less; if the symphysis of the pubes is removed in many cases from a line
which would divide the body into two equal parts, it is because the
rickets has not equally affected all the bones of the pelvis, nor equally
hurt all their junctions; and because the attitude which the child takes
in walking or sitting may change a little the direction of the compressing
power, which I have just mentioned." (_Baudelocque_, translated by Heath,
vol. i. p. 60.) Nor is it necessary that the degree with which the disease
affects the different parts of the pelvis should vary in order to produce
these inequalities of distortion, for there is no reason to suppose that
the promontory of the sacrum would approach the symphysis pubis in a
straight line, even where the softening of the bones was uniform
throughout; the attitude of the child, as above-mentioned, and the manner
in which it supports itself, will have no inconsiderable influence in
determining the direction in which the distortion takes place.

In those instances where the promontory is forced low down into the pelvic
cavity, the sacrum becomes bent upon itself, the upper part of it forming
a sharp curve backwards, while its lower portion together with the coccyx
being confined by their attachments, and more or less compressed by
sitting, are directed forwards. This is not seen where the projection of
the promontory is but slight; the curve of the sacrum so far from being
increased is rather lessened; the sacrum is straighter and flatter than
usual, so that, although the brim of the pelvis is contracted, we not
unfrequently find the outlet even larger than natural: in other cases,
where the softening of the bones has gone to a considerable extent, the
outlet is diminished, from the tubera ischii having been forced inwards.

The degree to which the promontory projects, of course, varies
considerably. The distortion is occasionally so great as not even to leave
an inch of antero-posterior diameter. This excessive deformity, however,
is more frequently the result of mollities ossium coming on after puberty,
for we seldom find children live through this critical period where it has
been the result of rickets. The brim of a deformed pelvis varies
considerably in shape: "sometimes it has the form of a kidney, or that of
the figure eight ([Symbol: infinity]); sometimes it is triangular or
heart-shaped, the sides being curved inwards, from the acetabula having
been pressed backwards or inwards, the ossa pubis are bent forwards and
outwards, and form at their symphysis a sort of beak-like process, which
is the apex of the heart: in this species of deformed pelvis, which is
usually the result of mollities ossium, the outlet also is usually much
distorted: this arises from the tubera ischii being forced nearer to each
other, thus contracting the pubic arch." (Naegelé's _Lehrbuch_, 2te
Ausgabe, p. 247.)

[Illustration: _From_ Naegelé.]

[Illustration]

_Malacosteon_, or _mollities ossium_. An arthritic, rheumatic, or gouty
diathesis is a morbid state, in which softening of the bones may take
place at a much later period of life, and to a most extraordinary extent.
In almost all the cases of extreme pelvic deformity which have been
recorded, the distortion has been owing to this disease, and not to
rickets in early life: in a pathological point of view there is a
considerable analogy between these two diseases. From a variety of causes
there is a superabundant formation of acid in the system, which its
excreting organs are unable to throw off. The effects of this condition
will vary according to circumstances; among them the softened state of the
bones from a deficiency of insoluble bone earth is not the least
remarkable. Mollities ossium seldom attacks women who have had no
children: sometimes it begins shortly after delivery, and very frequently
during pregnancy, during the progress of which it continues to increase.
Hence, it occasionally happens, that a woman has given birth to several
healthy living children without any unusual difficulty in her labours, and
where, after this, the pelvis has gradually become so deformed from
mollities ossium, as to render delivery impossible by the natural
passages, and, therefore, to require the Cæsarean operation. Pelves of
this sort, may be easily distinguished from those which have been deformed
in early life by rickets; they have evidently attained their full adult
growth before the process of softening had commenced: the ilia, for
instance, are of the natural size, but bent across, as if they had been
folded like wet pasteboard; whereas, the bones of the ricketty pelvis have
not attained their full development, they are stunted in growth as well as
distorted in shape, the two processes, viz. of growth and distortion,
having evidently, co-existed.

The form of the pelvis in mollities ossium necessarily varies with the
peculiar circumstances under which the individual is placed: thus, if her
strength allows her to sit up, or even to get about, as is generally the
case more or less, the promontory and the pubic bones are gradually
pressed towards each other, so that the antero-posterior diameter is
greatly diminished:[123] if, however, she is confined entirely to bed for
a considerable period, the distortion takes a different and much rarer
form. From her lying first on one side and then on the other, the pelvis
is laterally compressed; the transverse diameter becomes even shorter than
the antero-posterior; and if the disease continues long enough, the pelvis
is at length so altered and mis-shapen, that nearly all its original
configuration is obliterated. The weight of such a pelvis varies
considerably: where the disease has ceased some time before death, and
bone earth has been again deposited, there will be little difference in
this respect from a natural healthy pelvis; but if the patient has died
with the disease in full activity, its weight will be greatly diminished,
amounting sometimes only to a few ounces.

Mollities ossium, to a slight extent, we believe, is not very uncommon,
although cases of extreme deformity from this cause are of rare
occurrence. Mr. Barlow states, that "eight cases of this species of
progressive deformity have fallen under my notice, in one of which the
projection of the last lumbar vertebra at its union with the angle of the
sacrum was so much bent forwards into the cavity of the pelvis, that on
the introduction of the fore-finger up the vagina, a protuberance was
presented to the touch very much resembling the head of the foetus pretty
far advanced into its cavity. On carrying the finger a little anteriorly
past the projection, I could with difficulty ascertain the head of the
child: but on moving it around, the distortion appeared so great, that the
whole circumference did not exceed that of a half-crown piece. This
occurrence was on the 29th of April, 1792, at which time I delivered the
woman with the crotchet, and the bones of the pelvis receded considerably
to the impulsive efforts during the extraction of the head of the foetus;
yet, notwithstanding, the flexibility of the bones of the pelvis, and the
debilitated state of her constitution, she recovered speedily and without
interruption." On the 2d February, 1794, being in the neighbourhood, and
learning that she was still alive, Mr. Barlow visited her and requested an
examination. "I found her unable to walk without assistance, and as she
sat, her breast and knees were almost in contact with each other. The
superior aperture was nearly in the same state as when I delivered her
with the crotchet, but the outlet appeared more contracted, the rami of
the pubes overreached, leaving a small opening under the symphysis barely
sufficient to admit the finger to pass into the vagina by that passage,
and another aperture below, but rather larger, and parallel with the
junction of the tuberosities of the ossa ischii. From what I learned
afterwards respecting this decrepit female, she survived this period about
two years, at which time she was become still more distorted in the spine;
and after her death it was with difficulty she could be put into her
coffin; this woman bore nine children, and died in the thirty-ninth year
of her age." (Barlow's _Essays_, p. 329.)

Mollities ossium may be feared when, in addition to the general breaking
up of the health and strength, the patient suffers from arthritic pains
and swellings of the limbs, the urine is generally loaded with lithic
secretion: and most of all, where distinct shortening and gradual
distortion of the skeleton is taking place. Where the deformity has been
the result of rickets in early life, a little careful observation of the
patient's external appearance will quickly lead the experienced eye to
suspect the nature of the case.

_Symptoms of deformed pelvis._ Among the external appearances which would
lead us to suspect a deformed pelvis, are "the lower jaw projecting beyond
the upper; the chin very prominent; the teeth grooved transversely;
unhealthy appearance; pale ashy colour of the face; diminutive statue;
unsteady gait; when the woman walks the chest is held back, the abdomen
projects, and the arms hang behind; there is deformity of the spine and
breast, one hip higher than the other, the joints of the hands and feet
are remarkably thick; curvature of the extremities, especially the
inferior, even without distortion of the spine is a very important sign;
wherever the lower extremities are curved, the pelvis is mostly deformed:
it is well to ascertain also if, when a child, it was a long time before
she could walk alone; whether she had any fall on the sacrum; whether as a
girl she was made to carry heavy weights, or to work in manufactories."
(Naegelé's _Lehrbuch_. § 444.)

_Funnel-shaped pelvis._ Besides the above-mentioned species of pelvic
deformity, others are occasionally met with, the origin of which is but
little understood. The funnel-shaped pelvis is of this character, where
the brim is perfectly well formed, but where it gradually contracts
towards the inferior aperture. There are no evidences of its having been
produced by any disease; nor in fact can we assign any satisfactory cause
for this peculiar configuration: it appears to have been a congenital
formation.

[Illustration]

_Obliquely distorted pelvis._ A still more remarkable species of pelvic
deformity is the _pelvis obliqué ovata_, which, of late years, has been
pointed out by Professor Naegelé. In this case the pelvis appears awry,
the symphysis pubis being pushed over to one side; and the sacrum to the
other; one side of the pelvis is more or less flattened, the other bulges
out, so that one oblique diameter is shorter, the other longer than
natural; and this applies not only to the brim, but to the cavity and
outlet of the pelvis. In most cases the sacro-iliac symphysis on that side
which is flattened, and to which the sacrum is inclined, is completely
anchylosed, not a trace of the division between the ilium and sacrum to be
detected, the two bones being completely united into one. In many, the
sacrum on this side is smaller than on the other, as if a portion of it
had been removed by absorption during the process of anchylosis, or at
least not properly developed. When we consider the form of the pelvis, and
the appearances which the sacro-iliac symphysis and the sacrum present, we
are almost led to conclude that ulcerative absorption must at one time
have existed between the sacrum and ilium at this point, probably at an
earlier period, by which means more or less bone had been destroyed before
the termination of the disease in anchylosis; indeed, we can to a certain
extent imitate this peculiar species of pelvic deformity by sawing off the
surfaces of the sacrum and ilium which had formed the symphysis, and then
putting the bones together again. Still, however, in the various cases
which have been collected by Professor Naegelé, no proofs could be
obtained of disease having existed in the pelvis during early life.

"In none of the cases, the particulars of which have come to my knowledge,
has there been any trace of rachitis; nor have any of the symptoms,
appearances, and morbid changes been observed which characterize mollities
ossium coming on after puberty. None of these cases have been traced to
the effects of external violence, as falls, blows, &c.; nor has there been
any complaint of pain in the region of the pelvis, inferior extremities,
&c." (_Das Schräg Verengte Becken_, p. 12.) "With respect to the
strength, colour, structure, &c. of the bones of this species of deformed
pelvis, no difference could be observed between them and the bones of
young and perfectly healthy subjects; not a trace either in form or other
respects could be detected of those changes which usually result from
rachitis or mollities ossium; and but for this distortion and some other
slight irregularities, which required close inspection to detect, these
pelves would have been looked upon as well-shaped, and of sufficient
capacity." (Naegelé, _op. cit._ p. 11.) In some specimens no trace of
anchylosis at the sacro-iliac symphysis has been observed; but whether
this was the case throughout the union of the two bones we cannot say.
Professor Naegelé is inclined to look upon them as modifications of the
_pelvis obliqué ovata_, and certainly in the majority of known cases
anchylosis has been found present.

It is scarcely necessary to do more than enumerate other varieties in the
form of the pelvis, which are occasionally met with: it is sometimes
round, the transverse and antero-posterior diameters being of the same
length; in other cases it possesses many of the characters which
distinguish the male pelvis, being more or less triangular, deep, and with
a contracted angular pubic arch.

_Exostosis._ Lastly, the pelvis may be perfectly well formed, but the
passage through it more or less interrupted by the exostosis: this is,
perhaps, the rarest species of dystocia pelvica. It may arise from wounds
of the periosteum, from fracture of the bones, callus, &c. and may vary in
size from a small protuberance to a large mass, which completely fills up
the pelvis.

_Diagnosis of contracted pelvis._ The difficulty of detecting an abnormal
configuration of the pelvis, will depend, in great measure, upon its
extent: where it is but slight, it may easily be passed over unobserved by
a young practitioner, although it may, nevertheless, be quite sufficient
to render labour both difficult and dangerous. In the ordinary form of
contracted pelvis, where the antero-posterior diameter is shorter than
natural, the being able to reach the projecting promontory of the sacrum
with the finger is of itself a sufficient evidence: but the converse of
this is not true, for we frequently meet with cases of contracted pelvis,
without being able to reach the promontory. The numerous instruments which
have been invented at different times for measuring the pelvis are of such
doubtful accuracy, as to be nearly useless; the experienced finger is the
best pelvimeter; and the power of correctly estimating the dimensions of
the pelvis during examination, can only be acquired by constant practice,
based on a thorough knowledge of them in the healthy pelvis.

The manner in which labour commences is frequently sufficient to make us
suspect the presence of a contracted pelvis. Besides, the general
appearance of the patient, we frequently find that the uterine
contractions are very irregular; that they have but little effect in
dilating the os uteri; the head does not descend against it, but remains
high up; it shows no disposition to enter the pelvic cavity, and rests
upon the symphysis pubis, against which it presses very forcibly, being
pushed forwards by the promontory of the sacrum. It is probably from this
circumstance that the os uteri, more especially its anterior lip, shows so
little disposition to dilate in these cases, for the lower portion of the
uterus being jammed between the head and symphysis pubis in front, and
promontory behind, the contractions of the longitudinal fibres can have
little effect upon the os uteri. Hence we find, that in cases of
diminished antero-posterior diameter requiring perforation, and where the
os uteri in spite of violent pains, bleeding, &c. has refused to dilate
beyond a certain point, on lessening the head, and thus removing its
pressure from the symphysis pubis, it has quickly attained its full degree
of dilatation.

Where the pains have been active, and a portion of the head has forced
itself through the brim, and now projects to a certain extent into the
cavity of the pelvis, it will be still more difficult to reach the
promontory before delivery; and if, as is frequently the case, the sacrum
is bent strongly backwards, so as to render the cavity and outlet very
spacious, the real cause of impediment to the progress of labour may be
entirely overlooked. It is here that the position of the head upon the
symphysis pubis will prove a valuable means of diagnosis. The straightness
of the sacrum will also be a guide in other cases.

In that form of the pelvis which has been called the funnel-shaped pelvis,
and where the brim and upper portion of the cavity are of the natural
dimensions, but where it gradually diminishes towards the outlet, the
appearances are frequently very deceptive, the head advances without
impediment, and descends as far as the inferior aperture, with every
promise of speedy delivery; but here its progress is arrested, and even in
the very last stage may require perforation.

It occasionally happens, also, where the deformity is very considerable,
that the promonotory projects to such an extent as to be even capable of
being mistaken for the head itself; and cases have actually occurred
where, under this impression, the bone has been perforated instead of the
child's head. So gross an error as this may easily be avoided by care in
making the examination; by ascertaining that the projecting mass is
immoveable; that the patient is sensible to the pressure of our finger;
and that the promontory can be traced to be continuous with the adjacent
parts of the pelvis.

The effects which may result from labour protracted by pelvic deformity
are very various, both as regards the mother and her child. The most
common form of injury which is produced by this cause, is the contusion
and consequent inflammation and sloughing of the soft tissues which line
the pelvis from the long continued pressure of the head against the
symphysis pubis in front, and against the promontory of the sacrum behind.
Not only may sloughing of the vagina and lower part of the uterus be the
result, but the mischief may extend through the posterior wall of the
bladder, and thus render the patient incapable of retaining her urine, and
an object of great, and, generally speaking, incurable suffering.

The danger from rupture of the uterus will chiefly depend on the degree of
pressure with which the uterine contractions force the head against the
brim. Where the pains are violent, and yet insufficient to overcome the
obstacle which the contracted pelvis presents to the advance of the head,
there is not safety for a minute, and perforation must be immediately had
recourse to. Where the edge of the promontory is very projecting and
sharp, the structure of the uterus may be seriously injured by the
pressure and contusion. In some cases it has evidently been the cause of
ruptures, the fibres having given way first at this spot.

The constant severe pressure upon the head will be not less injurious to
the child's life; it must inevitably produce a considerable impediment to
the cerebral circulation; and where the liquor amnii has escaped, the
pressure of the uterus upon the body of the child will scarcely be less
prejudicial. The cranial bones frequently become remarkably distorted, so
that after a difficult labour a deep furrow is found on that part of the
head which corresponded to the projecting promontory.

_Fracture of the parietal bone_ may even be produced, a fact of which
practitioners, till lately, have not been sufficiently aware; and cases
have occurred where children have been born dead, with the head greatly
distorted, and one of the bones fractured, from which circumstances the
mothers have been suspected of infanticide. Dr. Michaelis, of Kiel, has
lately reported an interesting case of this kind, where the fracture seems
to have resulted from the great immobility of the coccyx. The head was
much disfigured, and on examining it the frontal bones were uninjured, but
so flattened that the frontal and parietal portions of the sagittal suture
lay nearly in the same place; the fontanelle and anterior two-thirds of
the sagittal suture projected high up, and the sagittal borders of the
parietal bones were firm and well formed. In the posterior third of the
sagittal suture, where the parietal bones were firm and well formed, and
the suture only two lines in width, were seen small livid portions of the
longitudinal sinus forced between the bones. The occipital bone was
flattened and forced deep under the parietal bones, but not otherwise
injured. The right parietal bone, which during birth had been turned
towards the promontory of the sacrum, was covered anteriorly and
superiorly with effused blood, and on removing the periosteum, was found
fractured in five places. (_Neue Zeitschrift für Geburtskunde_, vol. iv.
part 3. 1836.[124])

Where the action of the uterus is not very violent, and the bones
yielding, the head gradually adapts itself to the form of the passage
without destroying the foetus; it elongates itself more and more until it
is enabled to pass, so that after a tedious labour of this sort, we
sometimes find the configuration of the head remarkably altered.
Baudelocque, has mentioned a case recorded by Solayres de Renhac, where
the head was so elongated that the long diameter measured eight inches all
but two lines, the transverse being only two inches and five or six lines.

_Treatment._ Where the pelvic deformity is very considerable, there can be
little difficulty in deciding upon the line of conduct to be adopted. It
is in those cases where the obstruction is but slight that the indications
for treatment are less distinctly marked: nor must we be satisfied with
merely ascertaining the relative proportions of the head and pelvis; for
the hardness or softness of the cranial bones, the disposition which they
manifest to yield to the pressure of the uterus and surrounding parts, the
state of the cranial integuments, and though last not least, of the soft
tissues which line the pelvis, must all be carefully ascertained before a
correct opinion as to the precise mode of treatment can be formed. Nor, if
the woman has already had children, can we altogether be guided by the
history of her previous labours; for where the above-mentioned
circumstances have been favourable, a slight diminution of the pelvis will
scarcely be attended with any perceptible delay or increase of difficulty
beyond the natural degree; whereas, if the head happens this time to be a
little larger, its bones more ossified, the fontanelles smaller, the scalp
and soft linings of the pelvis more swollen, &c. a serious obstruction to
the progress of labour will be the result. Thus it is that we not
unfrequently meet with patients in whom the first labour has been
tolerably easy, the second has been attended with much difficulty and
required the forceps, in the third, the difficulty was so much increased
as to require perforation, and the fourth where the labour was, like the
first, perfectly easy and natural.

It is impossible for the head to remain long in the pelvis (except under
unusually favourable circumstances) without more or less obstruction to
the circulation, both in the scalp itself and in the surrounding soft
tissues. The necessary consequence of this is swelling, by which the head
increases while the passage diminishes in size; and this must still be
more remarkably the case where the pelvis is at all contracted. It is in
these cases that we frequently see such relief produced by venesection;
and it is also as a topical depletion to the overloaded vessels, that we
can explain why a free secretion of mucus is so favourable a symptom.[125]

_Prognosis._ Where the pains are moderate and equable, the os uteri nearly
or quite dilated, the head not large, its bones yielding and overlapping
at the sutures; where the greater portion of it has evidently passed
through the brim, and, although slowly, advances perceptibly with the
pains; where the passages are cool and moist, the pulse good, and the
patient not exhausted, we may safely wait awhile and trust to the efforts
of nature. On the other hand, where the pains are violent, the os uteri
thin and undilatable, the head forced forwards upon the symphysis pubis by
the projecting serum, if the greater part of its bulk has not yet passed
the brim, if the soft parts are much swelled, the vagina hot and dry, the
pulse has become irritable, the abdomen tender, the patient exhausted and
much depressed both in mind and body, the powers of nature are evidently
incompetent to the struggle, and require the assistance of art.

Such cases seldom permit the application of the forceps; the head is
already pressing too firmly against the brim, and its greatest bulk having
not yet passed, a still farther increase of pressure will be required to
effect this object, which therefore cannot be attained without producing
serious mischief. Where, however, the head has fairly engaged in the
cavity of the pelvis, and the case is rather becoming one of deficient
power, the forceps will be justifiable, and generally quite sufficient to
effect the delivery safely.

The young practitioner must be cautious not to mistake an increase in the
swelling of the scalp for an actual advance of the head itself--an error
which may very easily be committed if he merely touches the middle of the
presenting portion: he must carefully examine the circumference of the
presenting part, where the head is pressing against the pelvis, and where
there is little or no swelling, and he will frequently find to his
disappointment, that although the cranial swelling may have even nearly
approached the perineum since his last examination, the head itself has
remained unmoved.

Where the forceps has been determined upon, we should endeavour to render
its action as favourable as possible, viz. by bleeding, by the warm bath,
and by evacuating the bladder and rectum before proceeding to the
operation: we thus improve the condition of the soft parts, and diminish
the chances of its acting injuriously.

From what has now been stated respecting the various circumstances which
may tend to aggravate or alleviate the existing degree of pelvic
deformity, it will be seen how incorrect and unpractical must be the
attempt to classify the means of treatment merely according to the
dimensions of the pelvis. To assert that within certain limits of pelvic
contraction the child can be delivered by the natural powers, and that
beyond these limits the forceps must be used; and that where it proceeds
to a certain extent farther, it can only be delivered by perforation, &c.
is evidently objectionable: for there are no two cases alike, even
supposing that the degree of pelvic contraction is exactly similar; hence,
on the one hand, we might (under such fallacious guidance) be induced to
trust to the natural powers when they are wholly incompetent to the task,
and on the other, to have recourse to art when the real condition of the
case justified no such interference.[126]

With regard to the diagnosis and treatment in the case of obliquely
distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to
enable us to give any decided rules: the immobility of the head, although
the antero-posterior diameter appears of its full length, the shortness of
one oblique diameter, and consequent undue pressure upon the head in this
direction, and the unusual length of the other, are the characteristics
which we have observed in the only case of the kind which has come under
our notice during life. In all the cases of labour rendered difficult by
this condition of the pelvis, which have been collected by Professor
Naegelé, the perforation has been strongly indicated; and where the
forceps has been used, it has either failed, as with us, or if the
delivery has been effected by this means, it has been attended with fatal
consequences.

In _exostosis_ of the pelvis we must be guided by our knowledge of the
healthy pelvis, and by our carefully ascertaining the form and size of the
bony growth, and in what degree it is likely to impede the passage of the
child. As in cases of simple projection of the promontory, the head may be
capable of passing, but in doing so becomes more or less distorted: thus
Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the
pelvis, the left frontal bone was so greatly sunk in, as to make the eye
protrude. Professor Otto, of Breslau, mentions a woman who had pelvic
exostosis being the mother of four children, in each of whom a small
portion of the cranium was depressed and not ossified.

An interesting case has been described by Dr. Kyll, of Cologne, where the
patient was the mother of seven children; her former labours had been
perfectly natural, except that in the last there had been preternatural
adhesion of the placenta, which had required to be removed by the hand; in
six days after she was seized with feverish symptoms and violent pain at
the spot where the placenta had been attached. The attack yielded to
proper treatment, but she continued feverish at night with perspirations,
frequently deranged bowels, difficulty in passing water, and severe pain
in the abdomen, especially when she tried to stand on the right leg. An
abscess formed in the right groin, which was opened and discharged a large
quantity of pus, from which her recovery was very slow, and in three years
afterwards she became again pregnant. When labour came on, no presenting
part could be reached; after a long time the feet came down one after the
other, but the nates would not advance. Dr. Kyll found the child resting
with the hips on the brim of the pelvis, and completely wedged fast by a
hard immoveable tumour as large as a hen's egg, springing from the upper
part of the right sacro-iliac symphysis, and apparently having been a
result of the pelvic abscess; the child was delivered with great
difficulty by embryotomy.

[Illustration: Exostosis of the pelvis.]

Perhaps the most remarkable case of pelvic exostosis is that which has
been described by Dr. Haber of Carlsruhe, and where also the cause was
ascertained to have arisen from a violent fall on the ice when carrying a
heavy load upon the head; on coming to herself the woman found that she
was unable to move, and in this state was conveyed home; she recovered to
all appearances in a few weeks, married, and soon became pregnant. When
labour came on it was found impossible to deliver her, from the pelvis
being entirely filled with a huge exostosis: the Cæsarean section was
performed, but she died, and on examination after death an immense mass of
bony growth was found springing from the sacrum, which had been apparently
fractured, not only filling up the whole cavity of the pelvis, but arising
to a considerable extent above the brim.

In those cases of funnel-shaped pelvis which we have had the opportunity
of observing, perforation has been ultimately required, although the head
had passed easily through the brim and entered the cavity; in one of
these we have subsequently used the artificial premature labour with
success.

We have already stated the doubtful utility of arranging cases of deformed
pelvis according to their degree of contraction, and of classifying the
different modes of treatment by such a scale; still, however, there must
be certain limits beyond which it will be impossible to make the child
pass, even when diminished by embryotomy. To draw the precise line of
demarcation, however, will be nearly if not quite impossible; and, as in
cases of slighter deformity, we must take many other circumstances into
consideration which we have already mentioned. An inch and a half from
pubes to sacrum has been mentioned by many as the extreme degree of
contraction through which a full grown child can be delivered by
embryulcia; generally, however, in these cases of unusually deformed
pelvis, there is much more space on each of the sacrum; and on this, in
great measure, will depend the possibility of effecting the delivery. The
celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and
where he succeeded in delivering the child, although the antero-posterior
diameter "could not exceed three-quarters of an inch," has been looked
upon as being of doubtful accuracy, and that Dr. Osborn had
unintentionally deceived himself. When, however, we learn that on the
right side of the sacrum the antero-posterior diameter was an inch and
three-quarters, the incredible nature of the case diminishes considerably,
the more as the patient was examined by Dr. Denman and others who fully
coincided with Dr. Osborn's statements. To assert that in this case the
antero-posterior diameter was only three-quarters of an inch, as many have
done, is evidently incorrect, and tends to throw doubt upon it: the case
was evidently the closest possible approach to the limits requiring the
Cæsarean operation; its success was mainly attributable to the gradual
manner in which it was performed; the child had become completely soft and
flaccid from putrefaction, and was thus more capable of being moulded to
the contracted passage.



CHAPTER V.

FIRST SPECIES OF DYSTOCIA.

_Obstructed Labour from a Faulty Condition of the soft Passages._

    _Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--Edges of
    the os uteri adherent.--Cicatrices and collosities.--Agglutination of
    the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in
    the vagina.--Hymen.--Fibrous bands.--Perineum.--Varicose and
    oedematous swellings of the labia and nymphæ.--Tumours.--Distended or
    prolapsed bladder.--Stone in the bladder._


In speaking of the uterus itself as a cause of this species of dystocia,
we only mention it here as one of the soft passages, not as the organ by
the contractions of which the child is expelled; we merely refer to those
faulty conditions of the uterus which produce an impediment to the child's
progress, not to those which interfere with the natural condition of its
expelling powers, as this will be considered under the next division of
dystocia.

We have already stated our disbelief that an oblique position of the
uterus can have any influence in producing malposition of the child. With
the exception of extreme anterior obliquity, or pendulous belly, we
equally doubt that it can have any effect in retarding the labour when the
child presents naturally. The highest authorities in midwifery during the
last hundred years unite in asserting that this celebrated opinion of
Deventer, was a misconception.

_Pendulous abdomen._ Where, from great relaxation of the anterior
abdominal wall, (a frequent result of repeated child-bearing,) the fundus
is inclined so forwards as almost to hang over the symphysis pubis, the
child's head does not readily enter the brim of the pelvis, nor can the
uterine contractions act so favourably in dilating the mouth of the womb;
and in this manner the first part of labour may be considerably retarded.
Pendulous abdomen to this great extent is not very common; and in ordinary
cases the horizontal posture, especially upon the back, is quite
sufficient to allow the head to engage in the pelvis. "We have found more
than once," says Dr. Dewees, "in cases of extreme anterior obliquity, that
it is not sufficient for the restoration of the fundus that the woman be
placed simply upon the back; but we are also obliged to lift up and
support by a properly adjusted towel or napkin, the pendulous belly until
the head shall occupy the inferior strait. To illustrate this, we will
relate one of a number of similar cases in which this plan was
successfully employed. Mrs. O., pregnant with her seventh child, was much
afflicted after the seventh month with pain and the other inconveniences
which almost always accompany this hanging condition of the uterus; was
taken with labour pains in the morning of the 10th of October, 1820. We
were sent for about noon. The pains were frequent and distressing, and,
upon examination per vaginam, the mouth of the uterus was found near the
projection of the sacrum, dilated to about the size of a quarter dollar,
but pliant and soft. During the pain, the membranes were found tense
within the os uteri, but did not protrude beyond it.

As this was the first time we had attended this patient, and from the
history she gave of her former labours, in which she represented her
abdomen being in all equally pendulous, with the exception of the first,
we waited several hours (she being placed upon her side) for the
accomplishment of the labour. During the whole of this period the head did
not advance a single line; nor could it, as the direction of the
parturient efforts carried it against the projection of the sacrum. We had
several times taken occasion to recommend her being placed upon her back,
but to which she constantly objected, until we urged its being absolutely
necessary. She at length reluctantly consented to the change of position;
when upon her back it was found that it did not advance the os uteri
sufficiently towards the centre of the superior strait. The abdomen was
therefore raised, and a long towel placed against it, and kept in the
position we had carried it by the hands, by its extremities being firmly
held by two assistants; at the same time we introduced a finger within the
edge of the os uteri, and drew it towards the symphysis pubis, and then
waited for the effects of a pain. One soon showed itself, and with such
decided efficacy, as to push the head completely into the inferior strait,
and three more delivered it." (_Compendious System of Midwifery_, § 224.)

This peculiar displacement of the uterus, which has been called by some
anteversion of the gravid womb, has occasionally given rise to the
suspicion that there was no os uteri, from its being tilted upwards and
backwards towards the promontory of the sacrum: it has been said, in some
cases, to have even contracted adhesions with the posterior wall of the
vagina, from the firmness with which it was pressed against it, and thus
tended still farther to increase the deception. "Within our knowledge,"
says Dr. Dewees in the paragraph preceding the one just quoted, "this case
has been mistaken for an occlusion of the os uteri, and where upon
consultation it was determined that the uterus should be cut to make an
artificial opening for the foetus to pass through. They thought themselves
justified in this opinion, first, by no os uteri being discoverable by the
most diligent search for it; and, secondly, by the head being about to
engage under the arch of the pubes covered by the womb. Accordingly, the
labia were separated, and the uterine tumour brought into view. An
incision was now made by a scalpel through the whole length of the exposed
tumour down to the head of the child, the liquor amnii was evacuated, and
in due course of time the artificial opening was dilated sufficiently to
give passage to the child. The woman recovered, and, to the disgrace of
the accoucheurs who attended her, was delivered per vias naturales of
several children afterwards, a damning proof that the operation was most
wantonly performed." Where, in addition to the anteversion, strong
adhesions have taken place between the os uteri and posterior wall of the
vagina, no trace of os uteri will be felt, and the operation
above-mentioned does become sometimes necessary.

_Rigidity of the os uteri._ The chief way in which the uterus can obstruct
the passage of the child, is, by an undilatable state of its mouth: this
may arise from a variety of causes, which may be chiefly brought under the
two heads of functional and mechanical. Under the first head comes
rigidity of the os uteri, either from a spasmodic contraction of its
circular fibres, or from irregularity or deficiency in the contractions of
the longitudinal fibres of the whole organ. In a slight degree this is
frequently met with, especially in first labours, where the patient is
young, delicate, and irritable, and where, in all probability, there is
some source of irritation in the primæ viæ which tends to disturb and
divert the proper and healthy action of the uterus. We see it also in
robust plethoric primiparæ; the os uteri dilates to a certain degree,
perhaps an inch in diameter, and remains tense and firm, with its edge
thin; the contractions of the uterus produce much suffering, and to all
appearances are very violent; but they are chiefly in front, and produce
little or no effect upon its mouth; the vagina is hot and dry, the patient
becomes exhausted with fruitless pains, and fever or inflammation would
quickly follow, if nothing be done to relieve this state. As this subject,
however, belongs rather to the next species of dystocia, viz. that arising
from a faulty condition of the expelling powers, we shall delay the
consideration of the treatment.

_Belladonna._ It has been recommended, and not very judiciously, to apply
belladonna to the os uteri in cases of great rigidity: it was repeatedly
tried by the celebrated Chaussier in the Maternité, at Paris, and,
according to his observations, it produced a considerable effect upon it.
"The knowledge of the extraordinary powers which this drug possesses in
causing dilatation of the iris, led to its employment for the object of
enlarging the aperture of the uterus; but there is certainly no similarity
in the structure and office of the two organs, and no analogy can be drawn
between their functions. It is not likely that this means will produce the
relaxation we require; and if no good results from its use, it must be
injurious; not in consequence of the poisonous quality resident in the
drug itself, but in the friction which is necessary for its efficient
application. The mucus which naturally lubricates the part must be wiped
away, and this irritation must predispose the tender organ to take upon
itself inflammatory action." (_Dr. F. H. Ramsbotham's Lectures, in Med.
Gaz._ May 3, 1834.)

For our own part we must confess, that, although we have seen this
application tried repeatedly, it has never produced the desired effects,
but has invariably brought on very troublesome and distressing symptoms,
such as sickness, faintness, headach, vertigo, &c.

There is a condition of the os uteri which is occasionally met with, and
which presents a degree of rigidity which we have never seen except where
there have been adhesions and callous cicatrices from former injuries. It
has nothing of the thin edge put strongly on the stretch during the pains;
but it is thick and firm, presenting nothing of the elastic cushiony
softness of the os uteri in a favourable state for dilatation; it dilates
to about an inch across, tolerably regularly, and without much apparent
difficulty, but no efforts of the uterus can dilate it farther. We have
already alluded to two extreme cases of this when speaking of ruptured
uterus, and where in each instance the os uteri entirely separated from
the uterus and came away. Whether there is something peculiar in the
structure of the part which renders it thus undilatable, or whether it
required even still more powerful measures than those employed, is not
very easy to decide.

_Edges of the os uteri adherent._--_Cicatrices_, &c. A serious impediment
to the passage of the child may be produced by adhesions of the sides of
the os uteri to each other; by hard callous cicatrices resulting from
ulcerations, lacerations, &c. in former labours; by abnormal bands, or
bridles, as they have been called; and by tumours and other morbid
growths. Where the structure of the os uteri has been much injured by
previous injuries of this character, the resistance will probably be so
great as to require artificial dilatation with the knife. Generally
speaking, however, the whole circle of the uterine opening is not
involved, portions still remaining of natural structure, and, therefore,
capable of dilatation. On examination, it feels irregular both in shape
and hardness; a part being soft, cushiony, yielding, and forming the
segment of a well-defined circle, the rest of it uneven, knobby, and hard,
being evidently puckered up by cicatrisation.

In many cases, these callous contractions give way more or less when the
head begins to press powerfully against them; but even where this is not
the case, the healthy portion of the os uteri is so dilatable as to yield
sufficiently. It would be difficult to estimate how far an os uteri in
this state, with perhaps, not more than half, or even a third, of its
circle in a healthy condition is capable of dilating. But from cases which
have come under our own observation, and others which have been recorded
by authors in whom we place the greatest reliance, we are quite confident
that with proper treatment a sufficient degree of dilatation can be
effected without resorting to artificial means.

Bleeding to fainting, the warm bath, laxatives, and enemata, will assist
greatly in promoting our object. Where, however, the contracted portion
shows no disposition to yield to this treatment, or to the pressure of
powerful pains, but forms a hard resisting bridle or band, which
effectually impedes the farther advance of the head, it must be divided by
the knife in order to prevent dangerous laceration of the part on the one
hand, or protraction of labour on the other. The mode of doing this will
be described when these conditions as effecting the vagina are considered.

Artificial dilatation of the os uteri by incision has been practised very
rarely, the chief of these operations having had reference to the vagina.
F. Ould considered that mere contraction of the os uteri from former
lacerations did not require this operation; but that where it was in a
state of schirrus, there would be "no chance for saving either mother or
child but by making an incision through the affected part."

We have quoted, on a former occasion, a case of cicatrised os uteri
recorded by Moscati, and where, in consequence of injury in a former
labour, the opening was nearly closed; fearing the laceration which had
occurred in a similar case under his father's care, in consequence of
making merely one incision, he made a number of small incisions round the
whole of the orifice until a sufficient dilatation was produced.

_Agglutination of the os uteri._ Another condition of the os uteri which
may produce very considerable impediment to the passage of the child, is
that which has been called _agglutination_, where by some adhesive
process, apparently that of inflammation, the lips of the opening adhere
and completely close it. These species of imperforate os uteri may occur
in primiparæ as well as in those who have borne children: the
agglutination of its edges takes place during pregnancy, probably shortly
after conception. Upon examination we find no traces of hardness,
rigidity, or any other morbid condition, either in the os uteri itself, or
the parts immediately surrounding it; the os uteri is closed by a
superficial cohesion of its edges, and which in some cases seem to adhere
by means of an interstitial fibrous substance; this when of a firmer
consistence forms a species of false membrane, which in some cases is
capable of resisting the most powerful uterine contractions, and in others
it appears to cover the os uteri so completely as to conceal it most
effectually, and give rise to the erroneous conclusion that the os uteri
is altogether wanting. Baudelocque describes this condition (_Op. cit._ §
1961;) but from the brief mention which he makes of it, as also from the
treatment recommended, it is plain that he had no very distinct notions
about it, for he advises that "in all cases the orifice must be restored
to its original state, and be opened with a cutting instrument as soon as
the labour shall be certainly begun."

In by far the majority of cases which have been recorded, the pains have
after a time been sufficient to dilate the os uteri. Dr. Campbell has
described two of these cases, where no os uteri could be traced for some
time after the commencement of labour: both were first pregnancies: in the
former, uterine action continued about twelve hours before the os uteri
could be distinguished, when it felt like a minute cicatrix; the other
patient had regular pains for two nights and a day before the os uteri
could be perceived, and she suffered so much as to require three persons
to keep her in bed; both these patients were largely bled, gave birth to
living children, and had a good recovery.

We may suspect that the protraction of labour arises from agglutinated os
uteri, when at an early period of it we can discover no vestige of the
opening in the globular mass formed by the inferior segment of the uterus,
which is forced down deeply into the pelvis, or at any rate, where we can
only detect a small fold or fossa, or merely a concavity, at the bottom of
which, is a slight indentation, and which is usually a considerable
distance from the median line of the pelvis. The pains come on regularly
and powerfully; the lower segment of the uterus is pushed deeper into the
cavity of the pelvis, even to its outlet, and becomes so tense as to
threaten rupture; at the same time it becomes so thin, that a practitioner
who sees such a case for the first time would be induced to suppose the
head was presenting merely covered by the membranes. After a time, by the
increasing severity of the pains, the os uteri at length opens, or it
becomes necessary that this should be effected by art: when once this is
attained, the os uteri goes on to dilate, and the labour proceeds
naturally, unless the patient is too much exhausted by the severity of her
labour. Although the obstacle in some cases is capable of resisting the
most powerful efforts of the uterus, a moderate degree of pressure
against it whilst in a state of strong distention, either by the tip of
the finger, or a female catheter, is quite sufficient to overcome it;
little or no pain is produced, and the appearance of a slight discharge of
blood will show that the structure has given way. Two interesting cases of
this kind have been described by the late W. J. Schmitt, of Vienna, under
the title of two cases of closed os uteri which had resisted the efforts
of labour, and where it was easily dilated by means of the finger.[127]

_Contracted vagina._ The vagina may be naturally very small, or unusually
rigid and unyielding: in the first case serious obstruction to the
progress of labour is rarely produced, the expelling powers being
generally sufficient ultimately to effect the necessary degree of
dilatation; the proper precautions must be taken to avoid every species of
irritation and excitement of the circulation; the bowels must be duly
evacuated; the circulation controlled either by sedatives, or, if
necessary, bleeding, and where it is at hand, a warm bath; if this latter
cannot be easily procured, a common hip bath, or sitting over the steam of
warm water will be of great service; the great object will be to ensure a
soft and cool state of the passage with a plentiful supply of that mucous
secretion which is so essential to the favourable dilatation of the soft
passages.

Nauseating remedies, and even tobacco injections, have been tried to a
considerable extent for the purpose of relaxing the mouth of the uterus;
but they produce little or no good effects, and cause much suffering to
the patient. In Dr. Dewees' second case of obstructed labour from the
above causes, a sufficient trial of this remedy was used to satisfy all
doubts as to its effects. "It produced great sickness, vomiting, and
fainting, but the desired relaxation did not take place: we waited some
time longer and with no better success. In the course of an hour, or an
hour and a half, the more distressing effects of the infusion wore off;
and resolving to give the remedy every chance in our power, we prevailed
on our patient with some difficulty to consent to another trial of it: its
effects were the same as before,--great distress without the smallest
benefit, the soft parts remaining as rigid as before its exhibition."
Bleeding was now proposed; the patient became faint after losing ten
ounces, and the most complete relaxation followed: the forceps were
applied, and a living child delivered.

_Rigidity from age._ In women pregnant for the first time at an advanced
period of life, the vagina and os externum are said to oppose considerable
resistance to the passage of the child from their rigid condition, the
parts having lost the suppleness and elasticity of youth; the vessels also
convey less blood to the mucous membrane and adjacent tissues: hence the
secretion of mucus is more sparing; the cellular tissue is more condensed
and firm; still nevertheless, although it is constantly mentioned by
authors as a cause of this species of dystocia, we cannot help declaring
that it exists to a much less degree than has been generally supposed, and
that primiparæ at a very early age are much more liable to have tedious
and difficult labours than those at an advanced age. Still, however, the
circumstance is well worthy of notice; and in such cases we may produce
much relief by the warm bath, or hip bath, by sitting over the steam of
hot water, by warm water enemata, and great attention to the state of the
intestinal canal and of the circulation. Mucilaginous or oleaginous
injections into the vagina have been recommended; but we have no
experience of their effects: we have frequently used lard, &c. to the
edges of the os externum when the head was beginning to distend it, and we
think with relief; at any rate it produces a feeling of comfort to the
patient, being soft and cooling.

_Cicatrices in the vagina._ The most serious impediments to the progress
of labour connected with the vagina are the contractions of this canal
from callous cicatrices, the results of sloughing and other injuries in
former labours. The vagina may be contracted throughout its whole length,
its parietes hard, gristly, and uneven, and so small as not to admit even
the tip of the little finger; the course of the canal from the
irregularity of the contractions and adhesions is frequently much
distorted; in other cases it is obstructed in different places by bands or
septa, which have been produced by similar causes.

Where the condition of the vagina has been ascertained before labour, much
may be done to ameliorate the condition of the parts, not only by the
treatment already mentioned for rigidity of the vagina under other
circumstances, but also by the judicious application of tents, bougies,
and other means for dilating the passage. A case of this kind came under
our notice some years ago; the patient had been married many years without
being pregnant, and was considerably beyond the age of forty. The deranged
health and enlargement of the abdomen which took place excited no
suspicions of pregnancy either in her mind or that of her medical
attendant: the case was suspected to be ovarian dropsy, and a variety of
medicines under this supposition were administered, both internally and
externally: the commencement of actual labour appears to have been equally
mistaken; nor was it until labour had advanced considerably that the real
nature of the case was discovered; from its length and severity, violent
inflammation and sloughing of the vagina was the result, the canal became
much contracted, and was rendered still farther impervious by the
formation of strong bands or septa which were stretched across it, and
which effectually prevented the os uteri from being reached; sponge tents,
and oval gum elastic pessaries of different sizes were introduced, and by
degrees such a state of dilatation was produced as not only permitted the
os uteri to be reached, but restored the vagina in great measure to its
natural size.

The action of labour forcing the head of the child against these
contractions and adhesions is frequently sufficient ultimately, to effect
the necessary degree of dilatation; where, however, this is not the case,
they require to be divided by the knife. The proper moment for doing this
is during a pain, when the parts are put strongly on the stretch: we can
now feel exactly where there is the greatest resistance, and where an
incision will produce the most effect. In this state also the incision can
be effected with most ease, for the stricture being firmly distended, the
knife will more readily divide it than where it is relaxed; the patient
also at this moment is not sensible to the cutting of the knife. The lower
part of the blade well armed with lint or tow should be cautiously
introduced along the side of the finger during an interval of the pains:
in this way the necessary number of incisions may be made: this is usually
followed by a good deal of bleeding, which tends still farther to relax
the parts; and when the head has advanced low enough, a cautious attempt
may be made with the forceps to deliver it.

In recommending dilatation by means of the knife, it must be distinctly
understood, that a sufficient time should be allowed in order to see how
much can be effected by the uterine efforts, for in many of these cases
the stricture has at length yielded after severe and protracted
suffering.[128] In cases of this kind, also, the effects of bleeding are
by no means inconsiderable, and must not be neglected.

The _unruptured hymen_ has been said to be capable of impeding the
progress of the head, but this can only be where the membrane is of
unnatural strength and thickness. It has more than once occurred to us at
the commencement of labour, to find the hymen uninjured; but it has broken
down under the finger, even during examination, and we are convinced would
have produced no obstacle whatever to the child. Where its structure is
abnormal, and the advance of the labour is evidently retarded by it,
division is the simplest and easiest remedy.

Bands of firm fibrous or almost ligamentous tissue are sometimes found
stretched across the vagina or os externum. We described a remarkable case
of this sort in the _Medical Gazette_, Sep. 26, 1835, where it extended
from the symphysis pubis backwards to the perineum; it had resisted the
pressure of the child's head so powerfully as to produce a deep
indentation along the cranial bones; it was divided by a bistouri, and the
head was immediately expelled.

The _perineum_ can rarely, if ever, prove a serious hindrance to the
labour in primiparæ so long as its structure is healthy, even although it
may be unusually broad. With patience and due management the necessary
degree of dilatation may be obtained by the pressure of the head; and
proposals to dilate it artificially, or even to make a slight incision
into it, do not deserve a moment's consideration. Where, however, it has
been extensively lacerated in a previous labour, and has healed again
throughout its entire length (by no means a common occurrence) or when
there has been much sloughing, the cicatrix thus formed may render it
incapable of relaxation, and thus produce much resistance to the passage
of the head. Even here we may do a great deal by warm hip baths,
fomentations, and especially by bleeding; an incision through the callous
portion is by no means desirable where it can be possibly avoided, as it
only endangers a farther laceration during the expulsion of the head.
Cases nevertheless, occur where the contracted ring of the os externum is
so unyielding and gristly as to make this operation necessary.[129] In all
these cases, where, either the adhesion and contractions have given away,
or have been divided during labour, great care should be taken to prevent
them forming again during the process of healing, by using sponge tents
well greased, and other appropriate means.

_Varicose and oedematous swellings of the labia and nymphæ_ also deserve
mention, although they rarely interfere with the progress of labour to any
great extent. Varicose labia seldom annoy the patient during her
pregnancy; the veins of the part may have become somewhat dilated and the
labium swollen; but it is generally not until the commencement of labour,
that they become hard and knotty: at first they feel like a bunch of
currants imbedded in the cellular tissue of the labium, and as labour
advances, and the return of blood from the part is still more impeded, the
swelling continues to increase in size, and frequently obstructs the os
externum very considerably. The danger here is not so much from its acting
as an obstacle to the passage of the child, as from its bursting during
labour and causing loss of blood and other serious consequences. The
tumour seldom bursts directly externally, but first gives way beneath the
skin, producing extravasation, after which, in consequence of still
farther distention, the labium itself ruptures. In some cases the
hæmorrhage is not very profuse externally, while the extravasation
internally, amounts to some pounds, extending not only to the vagina and
perineum, but also to the groin; and instances have occurred where it has
spread to a great distance over the glutæus muscles.

"The extravasation," says Mr. Ingleby, "usually happens during the pain
which expels the child; but sometimes at an early period of labour, as in
the example of severe hæmorrhage here annexed. I had just left a patient
to whom I had been called, in consequence of the difficult transmission of
the child's head through a distorted pelvis, in connexion with an
inordinate varicose enlargement of the labia pudendi (especially the
left,) when a messenger overtook me urging my immediate return. It
appeared that during the violence of the straining, the tumour on the left
side had suddenly burst at the edge of the vagina posteriorly. The patient
lay in a little lake of blood; and as the bleeding recurred in gushes with
the return of every pain, it became essential to complete delivery, and a
child weighing fifteen pounds was extracted with the forceps. A large
slough separated at the end of the third week." p. 109.

Where no laceration has taken place externally, it is seldom that an
opening for the purpose of removing the effused blood will be of use; on
the contrary, the access of external air cannot but be prejudicial in many
cases. The action of the absorbents is generally sufficient for this
purpose, and may be increased by friction with stimulating liniments, and
most remarkably of all by the application of electricity. Where the
extravasation extends beneath the lining membrane of the vagina, so much
swelling may be produced as nearly to close the passage; this, however,
generally takes place after the birth of the child, the rupture of the
varicose vessel having occurred whilst it was passing.

On perceiving, at the commencement of a labour, that there are varicose
veins in the labium, which are beginning to increase in size and hardness
as the head advances, it will be as well to compress them as much as
possible during the intervals of the pains, when there is less impediment
to the blood returning from them: we can, by thus squeezing out their
contents to a certain degree, lessen the size of the swelling, and thus
prevent it from gaining that extent which might endanger laceration. We
may instantly know when this injury has taken place, by the livid
tumefaction of the parts, and our being no longer able to feel the knotty
portions of the varix. In order to check the effusion of blood as much as
possible, we must apply cold, and thus favour its speedy coagulation
beneath the skin. Where the distention is very great, it may become
necessary to evacuate the effused fluid; but, generally speaking, it is
deeper beneath the surface than might, at first sight, be expected. "It
has been proposed," says Mr. Ingleby, "that the swelling should be
punctured, provided there has been no delay, and the puncture is made
whilst the blood is still liquid. On one occasion I promptly carried this
suggestion into effect, but without success; and, considering the
structure of the labium, it is probable that the greater part of the blood
will coagulate almost as rapidly as it is effused." (Ingleby, _op. cit._
p. 109.)

A considerable degree of suffering and annoyance to the patient may arise
from oedematous swelling of the labia and nymphæ, both previous to and
during her labour. The labia are occasionally so distended as not only to
close the os externum, but to require that the legs should be kept as wide
asunder as possible, to prevent the swollen parts being crushed: the
patient is thus rendered very unwieldy and helpless, if she were not
already so previously by an anasarcous state of the lower extremities,
which frequently accompanies this condition.

Oedema of the labia is of less consequence where the patient has had
several children than where she is a primipara, and seldom either retards
labour to any serious extent, or is attended with any troublesome
consequences afterwards: where, however, it is her first labour, and the
swelling is very considerable, laceration may be produced, the results of
which may be sloughing and gangrene: a fatal case of this kind has been
described by Burton.

Where the labia are much swollen, they not only render the patient
incapable of moving, but are apt to become inflamed and excoriated, from
being in such close contact, and constantly moistened by the trickling of
the urine over them. By preserving the horizontal posture, and thus taking
off the pressure of the child from the soft parts of the pelvis, by
keeping the bowels open by saline laxatives, and by using saturnine and
evaporating lotions to the part, a good deal may be done for the patient's
relief. Where there is no disposition to inflammation, and the parts
appear somewhat flabby, warm and gently stimulating applications will be
preferable. Mr. Ingleby remarks that, "if the swollen parts are punctured
(and a particularly fine curved needle answers best,) a load of serum is
drained off, and relief is rapidly obtained. I have not observed any of
the reported bad effects (sloughing and gangrene for instance) succeed
this little operation; nor are they likely to occur in an unimpaired
constitution." The celebrated Wigand of Hamburgh, who strongly opposed
making incisions into the dropsical structure, does not appear to have
tried the plan recommended above. He considered that, as these swellings
are the result of pressure, the less we do with them the better, merely
taking care to keep up the action of the skin.

Oedema, or rather dropsy, of the nymphæ, is not of common occurrence, and,
when it takes place to a considerable extent, produces a singular
alteration in the appearance of the external organs. The nymphæ protrude
beyond the labia, and depend so much as to rest upon the bed on which the
patient lies, forming a soft membranous bag, fluctuating with the fluid
which it contains. If labour has not actually commenced, we would prefer
endeavouring to excite the absorbents of the part, and thus remove the
effused fluid, to its evacuation by puncture: we have perfectly succeeded,
by the use of warm aromatic stimulating fomentations. The "_species
aromaticæ_" of the Continental pharmacopeiæ may be used with much
advantage in these cases: the mode of its application is, to tie some up
in a loose muslin bag, and soak it in hot wine; this forms an excellent
warm stimulating application, and appears to excite the absorbents very
briskly. A very good imitation of this, is to scald some chamomile
flowers, and having squeezed them tolerably dry, to sprinkle some port
wine over, and then apply them as a poultice. A swelling of this sort can
offer but little obstruction to the passage of the head; and if labour
commence before we have been able to reduce its size sufficiently, we may
at the last let off the fluid by puncture, should the pressure of the head
be such as to threaten laceration.

_Tumours_ of different sorts may obstruct the passage of the child, and,
in some cases, produce an impediment of the most serious character.
Fibrous polypi and hard tubercles of the subcartilaginous character
(commonly called the fleshy tubercle) are those which may present the
greatest resistance, while fungoid growths of malignant disease, whether
cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma,
rarely oppose much obstruction. Their structure is soft and spongy, they
therefore yield to the gradual pressure of the head, become more or less
flattened, and thus allow it to pass. But fibrous or chondromatous tumours
are of too firm a structure to admit of this, and are capable of rendering
the labour not only difficult, but very dangerous. The mass being situated
at the lower part of the uterus, or attached to it by means of a pedicle,
is perhaps forced down into the cavity of the pelvis, beyond which its
attachments do not allow it to advance; if it be a fleshy tubercle
imbedded in the structure of the uterus, it will not be able to advance so
far, but will obstruct the brim of the pelvis, and thus prevent the head
descending into it. In many cases, these tumours are merely covered by the
lining membrane of the uterus, which sometimes forms a species of pedicle.
In either case, an early diagnosis is of great importance, as we may thus
have the opportunity of removing the mass either by the scissors or
ligature.

Dr. Merriman has recorded an interesting case of this kind, where the
polypus which arose from the inner surface of the right lip of the os
uteri was tied, and removed rather more than three weeks before labour
came on. A fatal case, communicated to him by the late Dr. Gooch, is
equally valuable, inasmuch as it shows the results of a contrary
practice.[130]

"The class of tumours which most frequently obstruct labour comprise
follicular enlargements and the prolapsed ovarium. The former disease
originates in the vagina, and has been shown by Mr. Heming to consist in a
dilated state of one of the mucous follicles, which acquires a cyst, and
secretes a fluid of varying colour and consistence, from a dark to a
straw-coloured serum, or a deposition purely gelatinous. Owing to the
density of its walls, and its general tension, the fluid contents of the
tumour are not easily distinguished; but the flaccidity which succeeds a
free puncture is very striking."

"There are two forms of ovarian tumour which obstruct the passage of the
child; in the one, a small cyst in connexion with a very bulky cyst; or
else a portion of a large cyst passes into the recto-vaginal septum, and
bulges through the posterior part of the vagina: in the other, and that
which occurs by far the most frequently, the whole ovary, moderately
enlarged, prolapses within the septum. The descent is peculiarly liable to
happen at two periods; the first near the end of gestation, the second
during labour, the prolapsus being promoted by the relaxation of the soft
parts. The changes which the ovary undergoes when long detained in the
septum, will chiefly depend upon the capacity and yielding state of the
parts. If the woman has not previously borne children, it may remain
small, and scarcely retard delivery; but under contrary circumstances, it
acquires a large size, and nearly fills the vagina. In rare instances, the
bulging is said to have appeared at the anterior part of the pelvis."
(Ingleby, _op. cit._ p. 118.)

The contents of these tumours vary a good deal; the hard ones are usually
lipomatous or fatty tumours, not unfrequently containing hair and
rudiments of teeth. Numerous cases have been recorded where ovarian
tumours, which had been pushed down before the child, have at length
burst, discharging their contents, and thus ceasing to act as an obstacle
to the labour. We quite agree with Mr. Ingleby in recommending puncture
under such circumstances; for, independent of pregnancy, it is a
well-known fact, that there is a much better chance of successfully
tapping an ovarian dropsy per vaginam, than through the abdominal
parietes. The same holds good in operating through the rectum; and he has
described two highly interesting cases where this mode of treatment was
completely successful; one in his own practice, the other in that of our
friend Mr. W. Birch.

_Distended or prolapsed bladder_, &c. Lastly, the urinary bladder may
obstruct the passage of the child, from being prolapsed and distended with
water, or from containing a calculus which is forced down below the head.
In the first case, a prolapsus of the distended bladder can scarcely take
place without much inattention on the part of the practitioner, not having
ascertained whether the bladder had been lately evacuated. In case we
find, upon examination, that there is a disposition to this displacement,
the elastic catheter will enable the tumour of the prolapsed bladder to
collapse, and thus remove all farther trouble. The examination in these
cases must be conducted with care; for an elastic fluctuating tumour of
this kind may be mistaken for the distended membranes, or a hydrocephalic
head; and Dr. Merriman has given a melancholy case where, in consequence
of such an error, the bladder was punctured.

_A stone in the bladder_ is sometimes more difficult to manage. If the
head is only just beginning to enter the brim, the stone may be pushed up
above it; but if it has already engaged completely in the pelvic cavity,
it becomes a question whether it will not be necessary to cut down upon
it, and thus remove it. These cases are, however, of very rare occurrence,
and we must be entirely guided by circumstances, it being impossible to
lay down any precise rules for their treatment.



CHAPTER VI.

SIXTH SPECIES OF DYSTOCIA.

_Faulty Labour from a faulty Condition of the expelling Powers._

    I. _Where the uterine activity is at fault--functionally or
    mechanically--from debility--derangement of the digestive organs--
    mental affections--the age and temperament of the patient--plethora--
    rheumatism of the uterus--inflammation of the uterus--stricture of the
    uterus.--Treatment._ II. _Where the action of the abdominal and other
    muscles is at fault.--Faulty state of the expelling powers after the
    birth of the child.--Hæmorrhage.--Treatment._


Although this species includes that condition of the expelling powers,
where their action is excessive, we shall defer this portion of the
subject until we treat of _precipitate labour_, with which it is
essentially connected.

The agency by which the child is expelled during labour is of two kinds:
1st, involuntary action of the uterus, assisted, _secondly_, by the partly
voluntary and partly involuntary action of the abdominal muscles.

On the approach of labour, the uterus, which hitherto had been merely
performing the office of a receptacle and a means of conveying nourishment
to the foetus, now assumes a totally different character; from being in a
nearly passive state, it assumes an entirely opposite condition, viz. of
high irritability and powerful action. We might almost suppose that its
connexion with the nervous system was become more close and intimate; for
it is now sensible to the influence of impressions which had before
produced no effect upon it. Thus, we see, that affections of the mind,
even but of moderate intensity, and to which it was, before labour,
nearly, if not quite, insensible, are now capable either of rousing its
efforts to the utmost violence, or of arresting them in the midst of full
activity; and, on the other hand, we see that where its action has been
deranged or interrupted, it gives rise to serious affections of the
nervous system, or even convulsions.

With all this, it now displays peculiarities of function, which strikingly
distinguish it from all other organs of the body; in some cases it appears
to annihilate or to absorb, by its all-pervading influence, the functional
energies of other organs; and, in spite of its increased nervous power and
susceptibility to various impressions, it seems to possess the faculty of
continuing its efforts uninfluenced by general disease, unimpaired by
exhaustion, and, for a time, almost independent of the life itself of the
mother. In convulsions and paralysis, in general fever and inflammation of
vital organs, its powers appear to be undiminished: on the contrary, where
the patient, from whatever cause, is rendered incapable of assisting its
efforts by the abdominal muscles, the uterus will take upon itself the
whole task of expelling the child, which will be born apparently without a
single effort upon the part of the mother.

We also observe, that organs, the various conditions and derangements of
which have exerted little or no influence upon the uterus in its state of
quiescence during pregnancy, now affect it powerfully, and are capable of
modifying its action very considerably. The stomach, the intestinal canal,
and the skin, are remarkable instances of this, and seldom fail to disturb
or pervert the natural efforts of the uterus, whenever these organs
deviate from a healthy condition. It will be, therefore, of the highest
importance to watch their functions narrowly, in order that we may form a
correct estimate of their effects upon the uterus.

Derangements in the contractile power of the uterus may arise from a
variety of causes, which may be chiefly brought under two heads, viz.
_functional_ and _mechanical_.

The functional derangements may arise from insufficient activity, the
result of general or local debility; from a deranged condition of the
digestive organs; from passions or affections of the mind; from hereditary
temperament, constitution, or peculiarity; from the patient's age, being
either very young or considerably advanced in years, and pregnant for the
first time; from plethora, general or local; from rheumatic affection of
the uterus; and from uterine inflammation.

The contractions of the uterus may be _mechanically_ impeded, by tumours
imbedded in its substance; by organic diseases, as schirrus, cephaloma,
and hæmatoma; cicatrices from former ulcerations or rupture, or by any
other circumstances which interrupt the action of the longitudinal fibres
upon the os uteri.

_From debility._ Where uterine action is insufficient from debility, the
pains are feeble, and do not appear to act in the right direction; they
are frequently attended with much greater suffering than might be
expected from their inefficiency; the intervals between the pains are
unusually long, the pains themselves are very short, or, after a while,
cease altogether.

This condition, when depending on _general_ debility, may be the result of
previous disease, loss of blood, or other debilitating evacuations,
poverty, with its attendant miseries, depressing passions of the mind, and
health broken down by intemperance.

The contractile power of the uterus itself may be injured by previous
leucorrhoea or menorrhagia, by abortions, or by attacks of hæmorrhage
during the latter part of pregnancy; it may be weakened by over-distention
of the uterus, either from plurality of children or too much liquor amnii,
by the patient exerting herself improperly at the commencement of labour,
straining violently, and endeavouring to bear down before she is
involuntarily compelled to do so by the presence of the head in the
vagina. It may also be produced by the membranes giving way too soon, as
is so frequently observed in first labours.

_From derangement of the digestive organs._ We have already described the
change which takes place in the relation between the uterus and other
organs, as soon as it passes into a state of action. The intestinal canal
stands foremost in the influence which it exerts upon the uterus; whether
it be from constipation or diarrhoea, irritation from acrid contents, &c.,
it will greatly modify, and even derange, its contractile power; the pains
cease to be genuine uterine contractions, and assume a spasmodic
character, producing much painful griping and pinching about the front and
lower part of the abdomen, without any of that regularity of interval and
duration, and gradual accession and recession, which mark the presence of
real labour pains, and, we need scarcely add, with little or no effect
upon the progress of the labour itself. These griping colicky pains appear
to supersede the true process of parturition, and either to prevent the
uterus acting with due regularity and effect so long as they last, or so
to pervert its action as to produce a species of metastasis towards other
organs. The pains lose their peculiar character as the expelling powers of
the uterus; they cease entirely, and the patient is suddenly attacked with
dyspnoea, cramps in the extremities, violent shivering, great
restlessness, intense headach, delirium, convulsions, or even mania.

Wherever the action of the uterus is deranged by gastric or intestinal
irritation, the abdomen is generally more or less tender in front,
particularly over the symphysis pubis; the os uteri is thin, tense, and
rigid; the vagina is hotter than natural; the secretion of mucus is
sparing; and both os uteri and vagina are more than usually tender to the
touch.

_From mental affections._ The mind is capable of influencing the action of
the uterus during labour in a remarkable manner, not only where it is
suffering from depressing emotions, as grief, great anxiety, or painful
anticipations as to the result, but from causes of a much slighter
character, which are nevertheless well worthy the attention of the
practitioner: his sudden appearance in the room, without the patient
having been properly warned of his arrival: the dread of an examination;
or annoyances of a much slighter character, as regards his manner, or that
of the nurse, &c., will not unfrequently be quite sufficient to stop the
progress of the pains.

The _age and general temperament of the patient_ will also affect the
character of the pains. When pregnancy occurs for the first time, either
at a very early age, or considerably advanced in life, labour is apt to be
protracted, from defective uterine contraction; in the first case, she has
not yet attained that degree of adult strength which is requisite to
undergo a process requiring so much exertion; the pains are weak, of short
duration, and inefficient, but very exhausting to the patient. From the
irritability both of the nervous and vascular systems, so peculiar to
youth, arises a long train of troublesome symptoms, such as congestion of
blood to the head, spasms, syncope, convulsions, &c. In the other case,
the condition of the system is the reverse, the irritability is
diminished, the uterus is sluggish in its action, the pains are weak and
inefficient, follow each other very slowly, and the course of the labour
is much protracted; besides this, the short passages through which the
child advances are now less capable of dilatation, from having that
elasticity and suppleness peculiar to youth, and therefore oppose a much
greater resistance.

Where the patient is of a slothful phlegmatic habit, the uterus generally
indicates a corresponding state, by the slowness of its action and want of
excitability during labour. The same condition is manifested during the
catamenial periods in the unimpregnated state, by the absence of pain,
weight, throbbing, and other symptoms of local congestion, which are
usually observed at these times; so that, but for the discharge, the
patient has scarcely any guide to mark their recurrence. On the contrary,
where the appearance of the menses is preceded and accompanied by severe
pain in the back and loins, throbbing, heat, weight, &c., indicating
considerable excitement in the uterine system, we usually observe a
similar condition in the uterus during labour, the pains being quick,
energetic, and efficient. It is probably from some peculiarity of
temperament that we can explain the hereditary disposition which some
women show in the unusually lingering or rapid character of their labours.

_From plethora._ A congested or overloaded state of the uterine
circulation, whether from general plethora or from other causes, is not an
uncommon cause of feeble contractions. The spongy tissue of the uterine
parietes is so gorged with blood, as to prevent, in a great measure, the
free action of the pains, and may thus seriously impede the progress of
labour. We have already pointed out, when speaking of the signs of
pregnancy, the disposition which the system manifests for forming a larger
quantity of blood than before; the pulse is stronger and more full, the
animal heat is increased; this is especially observed in the uterus, and
continues so during the whole process. Whilst in the state of inaction
which belongs to pregnancy, but little inconvenience, comparatively, is
felt; but when labour commences, and it contracts, the blood is driven
from its engorged veins and sinuses into the general circulation; if,
however, it cannot do this, from the general state of plethora, its
contractions are rendered very imperfect and inefficient.

Besides the appearances of general plethora, we shall easily recognise
this condition by the following symptoms: "the patient has much heat of
surface and yet but little thirst; the face, eyes, and skin, are red and
considerably swollen; we can feel vessels pulsating in every direction;
she gets but little sleep, and finds the bed and the bedclothes
uncomfortable to her; the uterus is large, thick, tense, and very warm:
the os uteri swollen and cushiony, and the vagina also warm and spacious;
the foetus is very restless, and causes a good deal of pain by its
movements. The pains are short and ineffective, and accompanied with a
peculiar sensation of painful stretching or tension, without any symptoms
of rheumatism, cramp, or other morbid conditions of the uterus being
present." (Wigand, _Geburt des Menschen_, vol. i. p. 138.) This condition
is not unfrequently accompanied with tendency to hæmorrhoids, inactivity,
constipation, varicose veins of the lower extremities, &c.

_Rheumatism of the gravid uterus_ is an affection which, although it has
received but little or no notice in this country, has been long known and
described by the continental authors. It appears to be a similar condition
of the uterine fibres, when developed by pregnancy, to rheumatism in other
muscular tissues, arising from the same causes, connected with the same
conditions of the system, and producing similar effects; hence, therefore,
it must interfere considerably with the healthy action of the uterus, and
greatly diminish or entirely destroy, the efficiency of the pains.

The whole uterus is unusually tender to the touch; the contractions are
excessively painful from their very commencement, the slightest excitement
of the uterus producing a sensation of pain; they come on with a sudden
twinge or dragging pain about the pelvis and loins, and where the
contractions are still powerful, they sometimes rise to an intolerable
degree of intensity. This condition is frequently observed to a slight
extent at the commencement of labour; the mild precursory pains which, in
a healthy state, are merely attended with a sensation of equable pressure
and tightness round the abdomen, now produce much suffering and give rise
to one form of spurious pains, to which we have already, under that head,
alluded. Where the symptoms are of considerable severity and have been
aggravated by improper treatment, this state may easily pass into that of
actual inflammation.

On examining into the history of the case, we shall frequently find that
for several days, or even more than a week, the patient has remarked the
uterus to be unusually tender to the touch, scarcely bearing the pressure
of the clothes; and at night-time the uneasiness has increased to such a
degree that she could scarcely remain in bed. There is a frequent desire
to pass water, which is highly acid, and deposites much red sediment; and
in all probability she complains of rheumatic pains in other parts of her
body.

The causes of this condition are the same as those of rheumatism under
ordinary circumstances: exposure to cold, and alternations of temperature,
particularly when heated; derangement of the stomach, with much prevalence
of acid, &c.: insufficient clothing, and, upon the Continent, especially
in Holland, where it is said to be very frequent, by the use of
chauffe-pieds.

_Inflammation of the uterus_ is another condition which can not only
greatly impair, but entirely suspend, the activity of the uterus. It is
usually brought on by improper treatment during labour, where the real
cause of the lingering ineffective pains at the commencement has been
entirely overlooked, and a state of uterine irritation aggravated into one
of actual inflammation by the abuse of stimuli and other heating drinks,
given with the view to increase the pains; it may be produced by external
violence, improper attempts to dilate the os uteri, rough and too frequent
examination, endeavouring to turn the child or to apply the forceps before
the soft passages were in a fit condition for that purpose.

The whole abdomen becomes extremely tender, and even the slightest
contractions of the uterus produce intense suffering; the vagina is hot
and dry, and very tender to the touch--its mucous secretion suppressed;
the os uteri is swollen, tense, and painful, and the anterior lip is
sometimes so distended as to have been actually mistaken for the bladder
of membranes; the bowels are confined; the urine is suppressed; the
abdomen becomes distended from tympanitis; and general, and probably
fatal, inflammation of its contents follows.

_Treatment._ The causes of insufficient uterine action are so numerous
that the modifications to which they give rise are almost endless, and
demand no little variety of treatment. A great deal may be done to avoid
this state by attention to the patient's health shortly before labour; and
by so carefully regulating it as to ensure a healthy condition of the
whole system. Lingering labour from feeble uterine activity is seen most
frequently in young primiparæ of delicate form and nervous irritable
habit; the pains produce much fruitless suffering, and greatly exhaust the
patient. If the cause continues, the case becomes much protracted, and
serious consequences may ensue; such as hysterical symptoms, or even
convulsions, inflammation of some organ, general fever, or complete and
dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass
contraction of the uterus. In a slight degree this condition is not of
unfrequent occurrence, whether from an enfeebled uterus or general
debility, and requires general, rather than special treatment for its
removal. Change of posture, walking about the room, gentle friction of the
abdomen, and occasionally taking some refreshing or mildly nutrient drink,
as tea, wine and water, or beef-tea, &c., prove serviceable in such cases;
friction of the abdomen, if well applied, frequently produces a great
alteration in the character of the pains, and greatly assist the progress
of labour: if it be still in the first stage (the os uteri not yet fully
dilated,) an enema will not only clear the rectum of any fæcal matter
which may be lodging there, but assist in rousing the uterus to greater
activity.

Where we can satisfy ourselves that none of the above-mentioned causes are
present to protract the labour, we may proceed to the use of those
remedies which are considered to have the power of exciting the uterine
contractions, such as secale cornutum, borax, cinnamon, and the several
diffusible stimulants. This state of uterine inactivity is, however, rare;
and we would earnestly warn young practitioners against too readily
concluding that it is present. They will find that the more carefully they
investigate such cases, the less frequently will they require these
remedies. In using the secale cornutum, we give the preference to the
powder: it should be carefully kept from moisture, air, or light: from
twenty to thirty grains, mixed in cold water, will be the proper dose, and
this may be repeated two or three times, at intervals of half an hour, or
rather more. Borax is also another remedy which appears to possess a
peculiar power in exciting the activity of the uterus: although it is
scarcely ever used for such a purpose in this country, its effects upon
the uterus have been long known in Germany; and in former times, both it
and the secale cornutum entered largely into the composition of the
different nostrums which were used for the purpose of assisting labour. We
have combined these two medicines with the best effects, and generally
give them in the following manner:--[Symbol: Recipe] Secalis Cornuti
[Symbol: scruple] i--ij; Sodæ Subborat. gr x; Aq. Cinnamomi [Symbol:
ounce] jss. M. Fiat haust. Cinnamon, which is a remedy of considerable
antiquity, has also a similar action upon the uterus, although to a less
degree.

Our own conviction with regard to the use of these remedies is, that they
are seldom required _during_ labour, except in nates, or footling
presentations, or in cases of turning, where the head is about to enter
the pelvis, and where, at this critical moment, the action of the uterus
is apt to fail, when it is important to the safety of the child that
there should be brisk pains to force the head through the pelvis and
internal parts with sufficient rapidity. The chief value of these remedies
is for the purpose of exciting uterine contraction _after_ labour, and
thus to promote the safe expulsion of the placenta, where there is a
disposition to inertia uteri, and ensure the patient against hæmorrhage.

Where the contractile power of the uterus is so enfeebled that it becomes
nearly powerless, we deem it much safer and better to apply extractive
force to the head by means of the forceps, and thus overcome the natural
resistance of the soft parts, to using medicines which excite uterine
action, and thus stimulate the exhausted organ to still farther efforts.
The mere cessation of uterine action, however, where the labour has been
tedious and fatiguing, is no proof that the uterus is exhausted, and
incapable of farther efforts: so far from its sinking into a state of
quiescence, being a symptom of exhaustion, experience shows that, in
labours of this character, it indicates a very opposite condition, being
nothing more than a state of temporary repose, during which nature affords
it an opportunity of recruiting its own powers, as also those of the whole
system. The interval of ease which is thus given to the patient is
accompanied by refreshing sleep; the skin grows moist; a gentle
diaphoresis creeps over her; the circulation becomes calm; and after a
time, the uterus awakes again to renewed and astonishing exertions; thus,
Wigand has remarked, "the pains during the same labour may cease once,
twice, or even oftener, and yet after a little rest will return with
renewed strength." (_Geburt des Menschen_, vol. ii. p. 242.) On the other
hand, where the pains, in spite of their becoming more and more
ineffective, continue to exhaust the patient with fruitless suffering, and
prevent her from enjoying that repose which is so desirable under such
circumstances; when the uterus, from increasing irritability, scarcely
ceases to contract even for a moment, but continues tense and more or less
tender during the intervals of the pains, we can have little or no
reasonable expectation that such a labour can be terminated by the natural
powers. If the head be not far advanced in the pelvis, or the passages
fully dilated, if the bowels have been relieved before labour, and there
is no febrile excitement of the circulation, a mild diaphoretic sedative,
like Dover's powder, will be of great service: it calms the irritability
of the system, and induces that state of quiet or actual repose to which
we have just alluded. If, on the other hand, the labour be much farther
advanced, the head approaching the pelvic outlet, and the soft parts well
dilated, a little assistance, by means of the forceps, will quickly
terminate the case, and free the mother and her child from farther
suffering and danger.

Where the uterus is enfeebled by lesion or change of structure, it becomes
very difficult to decide as to what course ought to be pursued: in some
cases, the soft passages partake in the loss of tone, and offer but little
resistance to the advance of the child; in others, however, the uterus is
so powerless as to give us no choice but of employing artificial delivery.

We have already pointed out the importance of paying the strictest
attention to the bowels shortly before and during labour, and how
frequently a neglect of this precaution acts as a means of perverting the
due action of the pains, and giving them that character, already described
under the head of _False Pains_. "After the labour has made much progress,
the rectum, if loaded, should be emptied by clysters; indeed, the utility
of clysters in almost every stage of labour is so apparent that it is to
be lamented they are not more frequently employed." (_Synopsis of
difficult Parturition_, p. 19.) We have seen cases where, although the
bowels had been opened at the commencement of labour, after a time, the
pains have gradually lost their dilating effect upon the os uteri,
although they have increased in severity; the os uteri has remained tense
and hard, and the labour has become very tedious and exhausting; the
administration of an enema, and removal of a quantity of fæcal matter from
the rectum, has been followed by an instantaneous change in all the
symptoms; the pains have become powerful and effective, the os uteri has
quickly dilated, and the whole labour has been completed in a very short
space of time. In like manner, vomiting during the early part of labour
produces the best effects; for it not only assists to relax the parts, by
the nausea which usually precedes it, but, by emptying the stomach of
unhealthy contents, it tends not a little to restore the uterus to its
natural activity.

Where the bowels are distended with flatus, and loaded with acrid and
unhealthy contents; we rarely see the pains become regular and effective
until these sources of irritation are removed: the abdomen is painful with
spasmodic colicky griping, and excites the uterus to partial and very
painful contractions of a cramp-like character, which entirely supersede
the regular pains, and thus exhaust the patient with protracted suffering
without at all advancing the labour itself. If this condition be allowed
to continue uninterfered with, the tenderness of the abdomen increases,
the circulation becomes excited, and inflammation, and fever of a most
serious kind will be the result.

In the management of primiparæ, who are pregnant either at a very early
age or considerably advanced in life, our chief attention must be directed
to the management of them for some little time before labour is expected,
in order that we may place them in as favourable a state of health as
possible, and thus enable them to meet the coming trial with safety.

Where the patient is very young, we should endeavour, by early hours,
regular exercise, good air, and simple nourishing diet, &c., to increase
her strength, and the general tone of health, and thus diminish that
irritability of the nervous system peculiar to females of this early age.
She should lead a country life, be as much as possible in the open air,
enjoy the absence of restraint and excitement, which are almost necessary
consequences of a residence in town, and, by agreeable occupation and
cheerful society, train herself, as it were, to that state of moral as
well as bodily health best adapted to ensure a favourable result. It is in
cases of this kind where the bodily powers have not yet ripened into adult
womanhood, that so much good may be effected by using the tepid or (if the
season permit) cold salt water bath; and we would beg to refer our readers
to our observations on this subject in the chapter on PREMATURE EXPULSION.
In a case which has recently come under our notice, we have had reason to
attribute the remarkably healthy and favourable labour of a young and
delicate primipara solely to the invigorating effects of regular exercise
and the daily use of sea-bathing, which she continued to within a very few
days of her confinement.

It is commonly supposed that women pregnant for the first time, and
advanced in years, always have severe labours: this is not necessarily the
case, although, at the same time, the greater rigidity of the soft parts
considerably increases the resistance to the expelling powers. It will be
equally important in this case, also, to improve her health and strength
as far as possible, and, by exercise, warm hip baths, &c., to give the
parts a greater degree of suppleness and elasticity.

Where the labour is protracted by a state of general plethora or local
congestion, the expelling powers are not only enfeebled by the engorged
state of the uterine circulation preventing effective pains, but the
resistance to the passage of the child is increased by a similar condition
of the soft passages, which are swollen and turgid with blood. It is in
these cases that bleeding effects such a sudden and complete change; the
pulse loses its oppressed character, and rises in point of strength, the
uterus loses the thick solid feel which it had before; its contractions
become active and powerful, the os uteri dilates, the passages become soft
and yielding, and the whole process assumes a different character. By
careful observation, this state can easily be discovered before labour has
actually commenced; in which case much useless suffering may be prevented
by previously reducing the circulation to a proper standard, and thus
fitting the uterus for the exertions it has to undergo: besides bleeding,
mild saline laxatives, with or without antimonials, will be of great
service. The nitrate of potass in these cases has the best effects, either
in farthering the effects of the bleeding, or removing the necessity of
using so powerful a remedy.

In treating rheumatism of the gravid uterus, our practice will differ but
little from that in cases of ordinary rheumatism in other parts: this
condition, we believe, is rarely excited, until the system had been
already predisposed to it by deranged digestion, and that general
prevalence of acid diathesis, which manifests itself in different
individuals and under different circumstances so variously; hence,
therefore, it will always be important to unload the primæ viæ effectually
by an active dose of calomel or some other mercurial, before prescribing
for the immediate symptoms of the complaint: beyond producing a little
occasional nausea, five grains of calomel will act much more comfortably
to the patient's feelings than a smaller dose; there will be less griping
and intestinal irritation, but the effect will be more complete and
general; not only will the bowels be thoroughly evacuated, but the liver
relieved of a large quantity of unhealthy acrid bile, the removal of which
cannot but be highly advantageous. We may now proceed to the use of
diaphoretics and opiates: of these, Dover's powder stands foremost; and if
given in doses of from ten to fifteen grains, accompanied with warm
diluent drinks, rarely fails to induce sleep and a pretty active
perspiration, which gives great relief. As the abdomen is usually more or
less tender on pressure, it should be covered with a piece of soft
flannel, or, still farther to ensure the full diaphoretic effect of the
remedies, a warm bath may be had recourse to. Where calomel in the above
dose has been premised, we seldom fail in procuring a free action of the
skin, and, according to our own experience, with far greater relief to the
system than where the perspiration has been induced merely by diaphoretics
and external warmth.

If this condition of the uterus has been neglected, and the contractions
are beginning to produce intense suffering; if the abdomen is rapidly
becoming more tender to the touch, it should be covered with a hot
poultice of linseed meal, made more stimulating by the addition of mustard
flour, and this should be continued until the skin is considerably
reddened. In the slighter cases of this affection, where the bowels have
been opened, friction upon the abdomen frequently produces the happiest
effects. We presume it is to these cases that Dr. Power alludes when he
says, "in some, the improper action will be removed almost instantly, and,
as it were, by a miracle; so that a case which has been protracted for the
greater part of a week, under the most intense suffering, without the
least progress, has been happily terminated in fifteen or twenty minutes
from the first commencement of the friction." (Power's _Midwifery_, 1819.)

Where inflammation of the uterus takes place during labour, the case
becomes one of the most serious character; for not only is the suffering,
which is produced by every contraction, of the most intense description,
but the presence of the child aggravates the state of inflammatory action,
and excites the uterus to still more violent efforts, while the swollen
and unyielding state of the os uteri, &c., precludes the chance of speedy
delivery. Under such circumstances, we must trust almost entirely to the
lancet in aiding this important object; for, until the circulation has
received an effectual check by fainting, the dilatation of the parts
cannot proceed, nor can any attempt be made to give artificial assistance.
The abdomen should be covered with a hot linseed meal poultice, as above
described, in the treatment of rheumatism of the uterus; warm decoction of
poppies should be thrown up the vagina, or, if this cannot be procured at
the moment, some thin gruel mixed with a little laudanum, or in which a
few grains of Extr. Conii or Hyoscyami have been suspended; the bowels
should be opened by a simple enema, after which a small opiate injection
will be desirable, in order still farther to allay irritation.

_Stricture of the uterus._ We have already had occasion to allude more
than once to that species of violent and continued contraction which we
have denominated stricture of the uterus, but have chiefly considered it
where it affects the os uteri; a somewhat similar condition of spastic
rigidity is occasionally, though rarely, seen in other parts of this
organ, and is capable of producing a most serious obstacle to delivery.
The uniform and regular action of the uterus disappears; its contractions
become partial, both in extent and effect, one part alone contracts whilst
the rest of the uterus is relaxed; its shape thus becomes altered; for, by
these partial contractions of its fibres, it may become elongated,
shortened, flattened, &c.: the spasmodic action frequently varies its
seat, and successively attacks different portions; thus, where it affects
the body of the uterus, it becomes contracted almost like an hour-glass,
having a transverse circular indentation, as if it had been tied with a
cord. Where the contraction affects one side of the organ, it alters the
shape of it materially; the fundus is pulled down equally, and the
position of the child, as we have shown in the first species of dystocia,
may be seriously affected. If the stricture has its seat in the os uteri,
this becomes tightly contracted, hard, unyielding, and painful upon
pressure: it does not dilate sufficiently, and the inferior segment of the
uterus is generally pushed downwards, whilst the os uteri itself is drawn
upwards. In cases of this kind, we find that although the uterus
contracts, the child does not advance, but rather retracts, during a pain;
the contractions are never general, but partial, and even where they are
general, the fundus does not attain its due preponderance over the os
uteri, so that the one contracts as much as the other does; in severe
cases, also, the uterus continues in a state of spasmodic action during
the intervals of the pains: this is frequently accompanied with a painful
and harassing sensation of tension and stretching, very different to that
produced by the action of regular pains upon the os uteri; and in the
worst cases we occasionally observe a peculiar state of the brain, which
manifests itself by attacks of insensibility, faintings, or even
convulsions.

Although the head does not advance in spite of the strongest pains, yet,
upon examination, we find no want of proportion between it and the pelvis;
if the intervals of uterine action be of sufficient duration to allow it,
we shall feel the head quite moveable in the pelvis, or, at any rate, with
plenty of room for the finger to pass round it, and yet when a pain comes
on, the head remains fixed, or if it does descend somewhat, it returns
again to its former situation as soon as the pain is over. This state of
things is usually seen where the body of the uterus is the seat of the
stricture, and is contracted transversely upon that of the child, which it
tightly encircles, and renders all farther advance impossible.

This state of spasmodic action is produced by whatever tends to irritate
the uterus and excite it to irregular action; thus, premature rupture of
the membranes, especially when it has been suddenly drained of a large
quantity of liquor amnii; the irritation arising from acrid matter in the
intestines, or from their being loaded with accumulations of fæces;
improper examination, and more especially, attempts to dilate the os uteri
by the fingers or hand; endeavouring to strain and bear down during the
early part of labour, and when the patient is not involuntarily compelled
to do so; attempting to apply the forceps when the os uteri is not fully
dilated, or whilst the instrument is very cold: malposition of the child,
especially after rupture of the membranes; and lastly, anxiety, fear, and
other affections of the mind. The circulation is generally in an irritable
state, the patient is of a delicate excitable habit, and is apt to be
nervous and hysterical.

The treatment in these cases will be precisely on the same general rules
as we have above described; the bowels must be relieved by a laxative or
by an enema; if necessary, the circulation must be reduced to the proper
standard by bleeding, and the irregular uterine action controlled by
opiates. Besides these means, the warm bath is of the utmost service, and
seldom fails to produce a favourable change. Where the action of the
uterus is impeded, or otherwise rendered faulty by organic disease,
lesions of its structure, &c., we shall in all probability be compelled to
use artificial assistance.

II. _Where the action of the abdominal and other muscles is at fault._
Where the faulty character of the labour arises from a faulty state of the
partly voluntary, partly involuntary, action of the abdominal muscles
which is destined to aid the uterus in expelling the child, this may
equally be a result of general debility from previous disease, exhaustion
from the long duration of the labour, from the abuse of spirituous
liquors, &c. It may also arise from various causes which tend to impede
the respiration; such as excessive corpulence, great deformity of the
spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm,
ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta,
dilatation of the heart, &c.

Where the size is such as renders the patient very unwieldy, or the spine
is much deformed, we must place her in that position in which she can
exert herself with greatest effect, and at the same time experience the
least possible obstruction to her breathing: with deformed people, this is
of great importance; she should be propped up with pillows, &c. into
whatever posture she can lie with most comfort, and the practitioner must
manage to deliver her in this position. Patients suffering from pluerisy
or pneumonia are unable to bear the continued strong inflation of the
lungs which is necessary during the second stage: under these
circumstances, the pain and inflammation are greatly aggravated;
venesection must be used with great promptness, but it does not always
bring relief or remove the danger; for the disease is kept up by the
presence of labour, which, therefore, in all probability, will require to
be terminated by art. In some cases, however, as we have already
mentioned, especially where the disease is of an acute character, the
uterus appears to take upon itself the whole exertion of the labour, so
that the child is born apparently without any effort on the part of the
mother.

_Faulty state of the expelling powers after the birth of the child._ The
last stage of labour, which comprehends the expulsion of the placenta, may
also be retarded by a faulty state of the expelling powers. This not only
arises from the causes which we have already mentioned, but from those
connected with the labour itself; as from premature and immoderate
straining during the pains, misuse of medicines given to increase the
pains; also, where the uterus has been exhausted by the length and
severity of the labour, or where it has been thrown into a state of
inertia by the sudden evacuation of its contents, especially when
previously much distended. This condition is frequently induced by not
supporting the child sufficiently when the shoulders are about to pass
through the os externum; the main bulk of the child is therefore suddenly
expelled, and the uterus is at once thrown into irregular action by the
sudden shock of so great a change, or falls into a state of inertia. The
separation and expulsion of the placenta may be also retarded where the
labour has required the forceps, turning, or perforation, especially the
latter, on account of considerable pelvic deformity; the more so if there
has been considerable delay in giving assistance. Irregular and partial
action of the uterine fibres, after the expulsion of the child, may easily
render the last stage of labour dangerous; for, under such circumstances,
the portion of the uterus to which the placenta is attached may be in a
state of firm contraction in one part, while the other is quite relaxed,
so that incomplete separation of the placenta will be the result, and
hæmorrhage follow: hence we cannot be too cautious in avoiding every cause
which may at all influence the regular action of the uterus during the
last stage of labour, which is far more dangerous than the two others put
together.

In a case of this kind, we do not feel the uterus contracting into the
firm globular mass above the symphysis pubis, as might have been expected;
but if inertia uteri be present, it remains soft and large, the peculiar
pains of the last stage which indicate the speedy separation and expulsion
of the placenta do not make their appearance, or only in a very
insufficient degree. If it be contracting irregularly and only in part, we
shall feel this distinctly, from the unequal shape and hardness of the
uterus, which in some cases will have almost a lobulated feel; in others,
it presents a considerable depression either upon the fundus or anterior
wall.

_Hæmorrhage._ The danger here, chiefly depends upon the occurrence of
hæmorrhage: if the placenta be still attached by its whole surface to the
uterus, no hæmorrhage can ensue; but if the contractions have been of
sufficient power to detach more or less of it from the uterus, large
trunks, which have hitherto conveyed maternal blood into the placental
cells, are torn through, and a profuse discharge must be the result. The
degree of the hæmorrhage will in most instances furnish us with a
tolerable estimate of the extent to which the separation has taken place;
but it is far from easy to ascertain correctly the quantity of blood which
has been lost, and we must rather try to ascertain what are the effects
produced upon the system of the patient. The pulse becomes smaller and
quicker, the column of blood is evidently diminished, and the heart for a
time drives on its contents more rapidly; but as the loss increases, so
does it become enfeebled, and although beating with a very frequent
stroke, it now becomes so weak as to be scarcely or no longer capable at
the wrist of producing such a resistance to the finger as will give the
sensation of a pulse; the necessary consequence of this is, that the
patient at first complains of great weakness, the face becomes pale, the
lips white, the breathing anxious; this is followed by a sense of great
prostration, the perspiration breaks out upon the face and forehead,
tinnitus aurium, confusion of ideas, and sense of darkness before the eyes
succeed; the load at the præcordia, and the oppression of breathing,
become more insupportable; she tosses her arms about, and in some
instances has a sensation that the room is going round with her, or that
she is sinking through the bed; in other cases, the breathing becomes
gradually more feeble, until it is almost imperceptible; she every now and
then takes a deep sobbing grasp, which seems to rouse her to consciousness
for a moment, and then she relapses into a state verging upon
insensibility; the pulse is probably now no longer perceptible at the
wrist, the face is undergoing a rapid change, the features are
contracting, and there is a general expression of death-like collapse
which shows too truly the urgency of the danger. The alterations which are
taking place in the state of the brain and nervous system, vary in
different individuals: in some, there is strabismus; in others, temporary
mania, or at least, delirium; and in more unfavourable cases, even
convulsions; these last are especially formidable, as they not only show
that the system has been severely affected by the loss of blood, but are
apt, from their violence, to extinguish the little spark of life which is
left, or, in other words, to be followed by sudden death.

These are some of the many symptoms indicating a sudden and extensive loss
of blood; others also occur, depending on the external or internal
character of the hæmorrhage. The want of contraction and general
flaccidity of the uterus, as felt through the abdominal parietes, have
been already noticed; if the blood be prevented escaping by the contracted
state of the os uteri, by coagula, or the detached placenta, it begins to
collect in the cavity of the uterus, which therefore swells as the
accumulation continues to increase, so that it may even equal the size
which it had before labour, containing many quarts of blood, and the
patient may be in the most imminent danger of dying from hæmorrhage,
perhaps, without any blood having issued externally: this is the _internal
uterine hæmorrhage_, a form which is justly looked upon as peculiarly to
be dreaded, from the insidious character of its attack. In most cases, the
uterus fills to a certain extent only, and then, as if excited to
contraction by the distention of its parietes, or any slight concussion,
produced by coughing, &c. it expels a large quantity of coagula and half
coagulated blood, and returning to its former state of atony, again begins
to swell from fresh accumulation of blood in its cavity.

_Treatment._ So long as the inertia or atony of the uterus continues
without any symptoms either of external or internal hæmorrhage, we are not
justified in interfering directly, either for the purpose of exciting the
uterus, or still less of removing the placenta. This condition chiefly
occurs where the uterus has been previously much distended, or suddenly
emptied of its contents, where it has been exhausted by long and difficult
parturition, and also, as Leroux has observed, "in women of a phlegmatic
temperament and lax fibre, who, during pregnancy, have suffered much
ill-health, by which the tone of the solids has been weakened; who have
very large pelves, and a soft dilatable os uteri." (_Sur les Pertes de
Sang_, 1776.)

We must therefore give the uterus time to recover from the great and
sudden change which it has undergone, to collect its strength, to remodel
and arrange its forces, until it is at length able, not only to resume its
efforts, but to contract to that extent which shall both ensure the
expulsion of the placenta and the safety of the patient. Whilst this state
of inertia lasts, the patient should be kept as quiet as possible; she
should be placed in a comfortable posture, take a little cool drink from
time to time (as cold tea, toast and water, &c.,) in order to refresh
her;[131] or, if she has been much exhausted by her labour, a glass of
wine may be given with good effect. If, however, hæmorrhage appears, this
shows that a separation of the placenta from the uterus must have taken
place: our great object should now be to excite contraction of the uterus,
for by this means alone can we stop the discharge.

In ordinary cases, a little circular friction with the tips of the fingers
over the fundus will generally be sufficient. If the uterus begins to
swell, we may grasp it with a sudden but moderate degree of force; or we
may give the fundus every now and then a smart jog with our hand. Whilst
these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p.
330,) will be of great service; for even if it does not act soon enough to
aid the expulsion of the placenta, it contributes greatly to ensure the
contraction of the uterus afterwards. If the hæmorrhage nevertheless
continues profuse, it will be necessary to introduce the hand into the
uterus and remove the half-separated placenta: its contractions are too
feeble for that purpose of itself, and the presence of the hand in its
cavity, and the artificial separation of the placenta, act as a stimulus,
and rouse it to greater activity. The opinion that we only increase the
danger by thus increasing the bleeding surface does not hold good, when,
from the profuseness of the hæmorrhage, it has become evident that the
greater part of the placenta is already separated from the uterus; on the
other hand, where there is but a slight discharge, the case is very
different, and would not justify our having recourse to so strong a
measure.

If the contraction which has been excited by the artificial removal of the
placenta be but temporary, we must proceed to the use of other means for
the purpose of rousing the activity of the uterus. The sudden application
of cold is a most valuable means; it acts here solely by the _shock_ which
it produces at the moment, and not by lowering the circulation and
favouring coagulation. Thus we find that a cold wet napkin suddenly
flapped upon the abdomen has an immediate effect upon the uterus; but it
ought not to remain on long, and the skin should be dried with a warm
towel, in order that a fresh application of the cold may produce the
greater effect. A series of such _shocks_ may be produced by using another
wet napkin to the vulva, and a third to the sacrum and loins; an
assistant should remove them in the order in which they have been applied,
and dry the skin, for a repetition of the remedy, if necessary.

A still more powerful mode of producing a sudden shock, and thus rousing
the uterus to activity, is by a douche of cold water upon the abdomen.
This may easily be effected by a teapot or kettle held at some height
above, and slowly emptied upon the lower part of the abdomen; the uterus
will seldom refuse to obey such a stimulus as this, however great may be
the inertia into which it has fallen. The inefficiency of a prolonged
application of cold to the abdomen, however severe, and the efficiency of
the contrary practice, is admirably expressed by Dr. Gooch, in his
description of a dangerous case of hæmorrhage:--"Finding the ice so
inefficient, I swept it off, and taking an ewer of cold water, I let its
contents fall from a height of several feet upon the belly: the effect was
instantaneous; the uterus, which, the moment before, had been so soft and
indistinct as not to be felt within the abdomen, became small and hard;
the bleeding stopped, and the faintness ceased--a striking proof of the
important principle that cold applied with a shock is a more powerful
means of producing contraction of the uterus than a greater degree of cold
without the shock." (_An Account of some of the more important Diseases
belonging to women_, by Robert Gooch, M. D.)

Another mode of applying cold to induce uterine contraction, and little,
if at all, inferior to that above-mentioned, is the injection of cold
water into the uterus itself: this can only be effectually employed after
the removal of the placenta and membranes, and frequently proves of the
greatest assistance, being capable of rousing the uterus when many other
means have failed. If, from the sultriness of the weather, water cannot be
procured of sufficient coldness, or if the case be very urgent, vinegar
and water in equal parts may be used; but the injections of spirit and
water, which some have recommended, can scarcely be considered as a safe
proceeding.

These various means frequently require to be repeated several times before
the contraction of the uterus becomes permanent, nor must we be
discouraged by finding the uterus becoming soft again in a minute or two
after ceasing to use them; for we may feel assured, with few exceptions,
that if we can only keep the uterus, by this means, in a state of
tolerable contraction for half an hour, it will ultimately become
permanent, and remain so of itself.[132]

It is, in these cases, where pressure is of so much importance, not for
the purpose of producing uterine contraction, as of maintaining it when
once excited. By pressure applied at this moment, we may frequently keep
the enfeebled uterus in a state of contraction, which, but for this
support, would have yielded to the general force of the circulation, and
have again expanded. For the same reason, whenever the uterus begins to
swell again from internal hæmorrhage, and by the renewal of the above
remedies, it becomes hard, but does not diminish in size: this shows that
the contraction has not been powerful enough to expel the blood, which, in
all probability, has already begun to coagulate in its cavity: where this
is the case, the hand, or at least two fingers, should be passed, to
dislodge the clots, and assist in their expulsion; after which, a cloth
folded into a thick compress should be placed over the fundus, and firmly
bandaged upon the abdomen by a broad towel.

Where every means has failed to induce a sufficient or permanent degree of
contraction, we believe that the only certain means which remains, is
putting the child to its mother's breast. Under no circumstances do we see
the sympathy between the uterus and the breast so beautifully displayed as
here, and we may most truly affirm that we have never known it fail where
the mother was sufficiently conscious to know that it was her own child.
To a by-stander, ignorant of what was taking place, the sudden gush of
blood mixed with coagula, which follows the application of the child,
would be nothing less than a sign of renewed danger, while, in fact, it is
a proof that the uterus is beginning to contract and expel its contents.

If the pulse has been seriously reduced by the loss of blood which the
patient has sustained, a glass of wine, or a spoonful or two of brandy,
will be of great service in rousing the vital powers; and this must be
repeated or increased, according to the urgency of the circumstances; a
little weak beef-tea, given from time to time, frequently appears to rouse
the system, even more than the brandy, and is more refreshing to the
patient; it can also be taken in larger quantities, for when the
exhaustion is very great, stimuli appear to excite vomiting, which is by
all means to be avoided. Where, however, it occurs spontaneously, it need
not be looked upon in so formidable a light: thus Dr. Denman observes,
"when patients have suffered much from loss of blood, a vomiting is often
brought on, and sometimes under circumstances of such extreme debility
that I have shrunk with apprehension lest they should have been destroyed
by a return or increase of the hæmorrhage, which I concluded was
inevitable, after so violent an effort: but there is no reason for this
apprehension; for, though vomiting may be considered as a proof of the
injury which the constitution has suffered by the hæmorrhage, yet the
action of vomiting contributes to its suppression, perhaps by some
revulsion, and certainly by exciting a more vigorous action of the
remaining powers of the constitution, as is proved by the amendment of the
pulse, and of all other appearances immediately after the vomiting."

When a slight trickling of blood continues, although the uterus is
tolerably hard and contracted, it will be desirable to make an
examination, for we shall frequently find a long slender coagulum hanging
through the os uteri into the vagina, upon the removal of which, the
discharge will cease.

The application of the child to the breast is not less valuable for
preventing any return of the hæmorrhage than for stopping it in the first
instance: we are _never_ perfectly secure against hæmorrhage coming on
during the first few hours after delivery, even where every thing has
turned out as favourably as possible: the exhaustion from the length or
severity of the labour, the warmth of the bed, and in some cases, it would
even seem, the relaxing effects of deep sleep, are all liable to be
followed by inertia uteri and hæmorrhage. In no way can we ensure our
patient so completely against this kind of danger as by putting the child
to the breast; the uterine contraction which it excites is not only
powerful, but permanent; nor do we consider that a practitioner is
justified in leaving a patient in whom the uterus has shown a disposition
to inertia without having ensured her safety by this simple but effectual
safeguard.

There is a form of hæmorrhage after the birth of the child, which seems to
depend upon an over-distended state of the circulation, and where its
activity appears too great for the contractile power of the uterus; so
that, in spite of the uterus being tolerably firm and hard, a profuse
hæmorrhage is almost sure to follow the separation of the placenta. This
condition has been described by the late Dr. Gooch, and still more
recently by Professor Michaelis, of Kiel; to the former, especially, we
are indebted, not only for having first pointed out this important fact,
but for having placed it before us in the simplest and clearest light. "I
had now witnessed," says Dr. Gooch, "two labours in the same person, in
which, though the uterus contracted in the ordinary degree, profuse
hæmorrhage had nevertheless occurred: let me be understood--after the
birth of the child, I laid my hand on the abdomen, and felt the uterus
within, of that size and hardness, which is generally unattended by, and
precludes hæmorrhage; in both instances, the labour had been attended by
an excessively full and rapid circulation. I could easily understand that
a contraction of the uterus, which would preclude hæmorrhage in the
ordinary state of circulation, might be insufficient to prevent it, during
this violent action of the blood-vessels; and the inference I drew was,
that, in this case, the hæmorrhage depended not on a want of contraction
of the uterus, but on a want of tranquillity of the circulation; and that
if ever she became pregnant again, a mode of treatment which would cause
her to fall in labour with a cool skin and a quiet pulse, would be the
best means of preventing a recurrence of the accident." This will be
effected by an occasional venesection during the last weeks of pregnancy,
by the use of saline laxatives; and if there be still much disposition to
heat the surface, and excitement of circulation, by doses of nitre three
times a day, and by strict antiphlogistic regimen.



CHAPTER VII.

INVERSION OF THE UTERUS.

    _Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.--
    Chronic inversion.--Extirpation of the uterus._


The uterus is liable, although rarely, to a peculiar displacement called
inversion, where the fundus is forced down into the cavity of the uterus,
and so through the os uteri into the vagina; or where the whole uterus is
turned wrong side outwards, the fundus appearing at the os externum, the
former being the _partial_, the latter the _complete_ inversion: in the
latter it is not only the entire uterus which is inverted, but it is also
the vagina, so that the whole mass which the uterus forms at the os
externum is attached to the inverted vagina as by a hollow pedicle, and is
encircled by the os uteri close to the labia; the external surface of the
mass is the inner surface of the uterus.

As it is impossible for the fundus to descend through the os uteri when
this is not dilated and open, it is evident that, except in certain cases
of polypus, inversion of the uterus can only take place immediately after
delivery. If, at this moment, especially when the uterus has been too
suddenly emptied of its contents, any force be applied to the fundus, it
may be easily pushed down into the cavity, or, by the continued action of
that force, the fundus may be carried through the os uteri or even through
the os externum.

_Causes._ Where this force has been applied externally, it may be produced
by violent straining during the last pains, violent efforts, as coughing,
vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which
the abdominal muscles are put into powerful action. Where, on the other
hand, it has been applied from within, it may arise from improper attempts
to extract the placenta before the uterus was sufficiently contracted;
where the cord has been unusually short, or twisted round the child, or
where the patient has been suddenly surprised with violent pains, and the
child dashed upon the floor before she could reach her bed, by which means
the cord has received a violent jerk, or has been even broken.

It has been very much the habit to attribute inversion almost solely to
these latter causes, and that, except where it takes place from the
shortness of the cord, or the sudden expulsion of the child whilst the
mother is in the erect posture, it must almost necessarily be a result of
improper pulling at the cord on the part of the practitioner: the cases on
record, however, go to prove that, in by far the majority of instances, no
force of this sort had been applied to the fundus; and in those instances
where the child has been dashed upon the floor and the cord broken (some
six or seven of which have at different times occurred under our own
notice,) the fundus has not once been pulled down, although the force
applied to it must have been very considerable, since the very cord which
had thus given way to the weight of the child resisted afterwards, on more
than one occasion, a considerable effort which we made to break it. In by
far the majority of these cases, the cord has given way nearly at the same
spot, viz. about three inches distance from the umbilicus, apparently
justifying the inference, that it was weaker here than elsewhere. Another
reason why the fundus should not have been pulled down by the weight of
the child might be stated, viz. that the placenta being at that moment
above the brim of the pelvis, the direction in which the strain was made
upon the cord (viz. in that of the outlet, or downwards and forwards,) was
not much calculated to affect the fundus.

"The practice of pulling too early and violently at the cord," says Dr.
Radford, "after the expulsion of the child, before the uterus has
contracted, so as to detach and expel the placenta, has been generally
considered as the cause of inversion; but we know that the accident
happens before any force has been applied to the funis. In case fourth,
the descent was so rapid and forcible through the os externum, that it
would have been quite impossible to have resisted the unnatural action by
which the organ was carried down. It has occurred when the patient was
delivered of a dead child, the funis so putrid as to break with a slight
effort. It has been found before the cord was separated, and the child
given to the nurse. In the practice of Ruysch, this circumstance took
place after he had extracted a dead child."[133]

Still, however, it is not the less important to recommend caution,
especially to young beginners, against pulling at the cord with too much
force, in their hurry to bring the placenta away; the condition of the
uterus at this moment is highly favourable if in a state of inertia.

_Diagnosis and Symptoms._ In cases of _partial_ inversion of the uterus,
we distinguish the disease by the absence of the hard spherical tumour of
the fundus above the pubes, and by the presence of a globular fleshy body
in the os uteri, which is sensible to the touch. This tumour will be found
broader at the base than at its extremity; and surrounded by the os and
cervix uteri, forming, as it were, a tight ring round it. The patient
complains of a sense of dragging amounting to severe pain in the groins
and lumbar region, and which compelling her to strain violently, often
forces the uterus farther down, and sometimes induces complete inversion;
hæmorrhage more or less considerable accompanies it; the pain is more
acute in this than in the complete inversion, and the hæmorrhage more
violent; the patient suffers under an oppressive sense of sinking, with
nausea or vomiting, cold clammy sweats, feeble fluttering or nearly
extinct pulse, faintings or even convulsions.

In the _complete_ form we have neither the hæmorrhage nor that frightful
train of symptoms produced by the strangulated condition of the inverted
uterus; for now that it is fairly turned inside out, it is just, or nearly
as capable of contracting as in its natural state, which it is prevented
from doing when only partially inverted: complete inversion, however, is
not the less to be dreaded, for death may suddenly follow from the shock
which the nervous system has sustained, or from dangerous fainting in
consequence of the sudden evacuation of the abdominal cavity; this latter
circumstance will be aggravated by the inversion of the vagina which is
apt to accompany the complete form, and thus give rise to considerable
displacement of the intestine.

_Treatment._ The sooner we endeavour to return the uterus the better, for
we shall seldom experience much difficulty in effecting our object, if
done immediately upon the occurrence of the accident; indeed, we know of a
case where, under these circumstances, it was successfully returned by a
midwife. If, on the other hand, some hours are permitted to elapse before
the attempt at reduction is made, it will be attended with great
difficulty, or even prove entirely abortive; the os uteri contracts
powerfully, the uterus swells from the obstructed return of the
circulation, inflammation rapidly follows, and diminishes still farther
our chances of success. Dr. Denman says, "The impossibility of replacing
it, if not done soon after the accident, has been proved in several
instances, to which I have been called so early as within four hours, and
the difficulty will be increased at the expiration of a longer time."
Still, however, we must not despair of success, for numerous cases have
been recorded by different authors where the reduction has been effected
after a much longer period.

There has been a considerable discrepancy of opinion as to the management
of those cases where the placenta is still adhering to the uterus, viz.
whether it is not safer to reduce the fundus _with_ the placenta, and
excite the uterus to throw it off afterwards in the usual way, or whether
we ought not to separate the placenta before making the attempt at
reduction. Mr. Newnham, the author of almost the only monograph upon this
subject, recommends the former mode of practice. "It has been recommended
by several respectable authorities to remove first the placenta, in order
to diminish the bulk of the inverted fundus, and thus facilitate the
reduction. But it is surely impossible that this proceeding can be
attended with any beneficial consequences, whilst the irritation of the
uterus will necessarily tend to bring on those bearing down efforts, which
would present a material obstacle to its reduction; and would increase the
hæmorrhage at a period when every ounce of blood is of infinite
importance, besides returning the placenta while it remains attached to
the uterus; and its subsequent _judicious_ treatment as a simply retained
placenta will have a good effect in bringing on that regular and natural
uterine contraction, which is the hope of the practitioner and the safety
of the patient." (_Essay on the Symptoms, Causes, and Treatment of
Inversion of the Uterus_, by W. Newnham, Esq. p. 14.)

On the other hand, many authorities, especially of modern times, advocate
a very opposite practice, and recommend that the placenta should be
removed _before_ attempting to reduce the fundus; as by so doing it will
pass back much more easily than where the bulk of the placenta is added to
it. There can be no doubt that this practice is correct in cases of
complete inversion, where, as we have already observed, there is little or
no danger from hæmorrhage, and where it is of the greatest importance to
avail ourselves of every advantage by lessening the size of the inverted
uterus as much as possible: where, however, it is a case of partial
inversion, it is generally accompanied with hæmorrhage; and here,
therefore, it becomes a question how far we are justified in detaching the
placenta, and therefore increasing the flooding, either before we are
certain that we are able to reduce the fundus, or before we have placed
the uterus in a condition in which it is capable of contracting. In Mr.
Mann's case, quoted by Dr. Radford (_op. cit._,) the inversion was
evidently complete, for the uterus was found to have "passed externally
from the vagina, and the placenta attached to it." "I first peeled the
placenta from the fundus uteri, and then grasping the extruded part with
my hand, I did not find it very difficult to re-introduce it into the
vagina, and to carry it through the os uteri. I followed with my hand, or
rather pushed it forward, when I observed it suddenly start from me as a
piece of India rubber would."

Dr. Merriman, who candidly owns that he has altered his opinion on this
point, since the last edition of his work on difficult parturition, in
favour of removing the placenta, distinctly proves that the presence of
this mass was the chief cause of the difficulty. "I tried," says he, "to
effect the reduction without removing the placenta, but could, by no
possibility, accomplish it till I had first separated the placenta: this
being effected, I succeeded to my entire satisfaction in re-inverting the
fundus." (_Synopsis of Difficult Parturition._)

In reducing the fundus, we must not thrust our fingers collected into a
cone against the tumour, as has been recommended by most authors; for, by
so doing, we only produce a depression in it, and, as it were, re-invert
or double the uterus upon itself, and thus add considerably to the bulk of
the mass, and the difficulty of the reduction. We should grasp the tumour
firmly, and push it bodily upwards in the direction of the pelvic outlet:
at first little or no change is produced, until it has ascended so far,
that the vagina which had been dragged down is returned again to its
natural situation; the hand must follow the tumour, and now that the lower
part of the uterus is fixed, by the vagina being put upon the stretch, the
pressure which is applied to the fundus will act with so much greater
effect. We should endeavour to "return, first, that portion of the uterus
which was expelled last from the os uteri." (Newnham, _op. cit._ p. 616.)
As the hand rises into the cavity of the pelvis, and is no longer able to
grasp the tumour, so far from contracting the points of our fingers into a
cone, it will be desirable to spread them at equal distances round it, and
thus apply the pressure over a larger space: it was to attain this object
that Leroux recommended the application of a cloth to the fundus, as by
this means the force applied to it was more equally divided. (_Sur les
Pertes de Sang_, § 218.) The hand, however, will be far preferable. We
must gradually alter the direction in which we press up the tumour as it
ascends, guiding our hand in the axis of the pelvic cavity, and lastly
bringing it upwards and forwards in that of the superior aperture. When
once the fundus has repassed the os uteri, it usually recedes suddenly
from the hand, as already described in Mr. Mann's case: if we feel the
uterus through the abdominal parietes well contracted, there will be no
need of passing the hand into its cavity; but if it be still flaccid and
soft, the hand should be introduced, not only for the purpose of guarding
against any return of the inversion, but of exciting more active
contractions by its presence. The patient should avoid making any sudden
efforts to raise herself, or to cough, strain, or by any means excite the
abdominal muscles to exert pressure upon the fundus, for it is
occasionally observed, that the disposition to inversion continues some
time after the reduction has been effected.

Where some little time has elapsed before any attempt is made to reduce
the fundus, the inverted portion begins to swell from obstruction to the
return of blood, especially where the inversion is partial, and,
therefore, tightly girded by the os uteri; the passages grow hot and dry,
and the chances of reducing the tumour diminish in proportion. "Is it not
reasonable," as Mr. Newnham observes, "to suppose that the first effect of
the accident will be to bring on inflammatory action and tension of the
parts, and this very state will in itself be a sufficient obstacle to
success." (_Op. cit._ p. 18.) If, under these circumstances, we find that
the attempts at reduction is attended with considerable difficulty, or is
evidently impossible, it will be necessary to wait until the excitement of
the circulation, and the congestion and swelling of the parts are reduced,
and the passages duly relaxed by bleeding; besides this, the external
parts should be well fomented, the patient should use the warm hip bath,
or sit over the steam of hot water, and throw up emollient and sedative
enemata as recommended in our treatment of inflammation of the uterus; the
operation, which was during the state of inflammation and feverish
excitement in which the patient was, strongly contra-indicated, now
becomes practicable and safe, and the difficulties, which before would
have rendered it nearly or quite impossible, are now in a great measure
removed.

Wherever the uterus is completely inverted, and there is reason to expect
considerable difficulty in reducing it, we shall find great benefit in
adopting the mode of practice recommended by Mr. C. White, of Manchester,
viz. of firmly grasping the tumour until we have succeeded in considerably
diminishing its size, and thus removing the chief obstacle to its
reduction. "I grasped the body of it in my hand," says Mr. W., "and held
it there for some time, in order to lessen its bulk by compression. As I
soon perceived that it began to diminish, I persevered, and soon after
made another attempt to reduce it, by thrusting at its fundus; it began to
give way. I continued the force till I had perfectly returned it, and had
insinuated my hand into its body: it was no sooner reduced, than the pulse
in her wrist began to beat: she recovered as fast as we could wish."
(White, _on Lying-in Women_, case, 19. Appendix, p. 429, 2d edit.)

Where the fundus is partially inverted, and the os uteri girds it very
tightly, so as not only to produce very frightful symptoms arising from
the strangulated condition of the organ, but also to render its reduction
a matter of great difficulty, or even impossibility, Dr. Dewees has
advised that, so far from attempting to push up the fundus, we should
rather try to bring it down, and thus render the inversion complete; by
this means, the "pain, faintness, vomiting, delirium, cold sweats,
convulsions, extinct pulse," &c. will not only be relieved, but the
farther danger from hæmorrhage prevented.

"The propriety and safety of this plan is, it must be confessed,
predicated upon the happy result of a solitary case, but, from its entire
and speedy success in this instance, it is rendered more than probable
that it will be of equal advantage if employed in others; "all reasoning
upon the subject" is certainly in its favour; and experience, so far as a
single case may be entitled such, is equally so. The patient is to be
placed upon her back near the edge of the bed, and have her legs supported
by proper assistants; the hand is to be introduced along the interior
part of the vagina, but sufficiently high to seize the uterus pretty
firmly; it is then to be drawn gently and steadily downward and outward,
until the inversion is completed: this will be known by a kind of jerk,
announcing the passing of the confined part through the stricture.
Traction should now cease, and the part be carefully examined; if the
inversion be complete, the mouth of the uterus will no longer be felt, and
there will be an immediate cessation of pain and other distressing
sensations." (Dewees, _Compendious System of Midwifery_, § 1318.)

_Chronic inversion._ Where some time has already elapsed since the
occurrence of the accident, and the more distressing symptoms have
subsided, the inversion now passes into a chronic state, which, although
not immediately dangerous to life, will ultimately be not less fatal. The
form of the tumour gradually alters; it assumes a more polypoid shape,
from the increasing contraction of its mouth narrowing the upper part of
it; and now the diagnosis from polypus sometimes becomes exceedingly
difficult, the more so as the pressure produced by the os uteri diminishes
the sensibility of the fundus. Hence, as Mr. Newnham observes, we may
conclude, "that it is _always difficult_ and _sometimes impossible_, with
our present knowledge, to distinguish _partial and chronic inversion of
the uterus from polypus_; since, in both diseases, the os uteri will be
found encircling the summit of the tumour, and, in either case, the finger
may be passed readily around it. And if, in order to remove this
uncertainty, the entire hand be introduced into the vagina, so as to allow
the finger to pass by the side of the tumour to the extremity of the space
remaining between it and the os uteri; and if we find that the finger
_soon arrives_ at this point, it will be impossible to ascertain whether
it rests against a portion of the uterus which has been inverted in the
_usual way_, or by the long-continued dragging of the polypus upon its
fundus. And if, under these embarrassing circumstances, we call to our
assistance our ideas concerning the _form of polypus_, its enlarged base
and narrow peduncle, we must also recollect the abundant evidence to prove
that the neck of such a tumour is often as large, and sometimes larger,
than its inferior extremity, and we shall still be left in inexplicable
uncertainty."

The periodical hæmorrhages, with profuse leucorrhoea during the intervals
are too common, both to chronic partial inversion and to polypus, to
afford any certain means of diagnosis; and the gradually increasing
debility, from the constant drain upon the system and ultimate breaking up
of the general health, may be as much the result of the one as of the
other. The rugged uneven surface of the inverted uterus, the smoothness of
a polypus, are distinctions not of long continuance; for, after awhile,
the uterus gradually becomes smoother, whereas, a polypus rarely
continues long in the vagina without its surface becoming irregular from
ulceration.

It might be a question whether it would not be possible to detect the
menstrual fluid at the catamenial periods oozing from the surface of the
inverted uterus: that this is quite possible in cases of complete
inversion, is a well-known fact, but how far it can be detected in the
partial form is not so certain, as the position of the tumour pretty high
up in the vagina would prevent our ascertaining it, especially when there
is more or less hæmorrhage going on. In most cases, the history of the
case, and our not being able to pass up a catheter far beyond the os
uteri, which completely surrounds the neck of the tumour without adhering
to it, are the chief points upon which we must found our diagnosis.

"Whilst the inverted uterus remains in the vagina, the discharge
(excepting at the periods of menstruation) will be of a mucous kind; but
if the uterus falls lower, so as to protrude beyond the external parts,
the exposure of that surface, which in a natural state lined the cavity,
to air, as well as to occasional injuries, may induce inflammation and
ulceration over a part or the whole of its surface; and the mucous
discharge may be changed to one of a purulent kind, so considerable in
quantity as to debilitate the constitution, and to cause all the common
symptoms of weakness." (Sir C. M. Clarke, _on the Diseases of Females_,
part i. p. 155.)

Although such a length of time has elapsed since the inversion, that it
has become of the chronic kind, still we are not justified in giving up
all hopes as to the possibility of returning it. Dr. Churchill has given
an interesting summary of cases where many days, and in one case even
twelve weeks, had intervened, and yet, nevertheless, where the reduction
was successfully effected. (_On the Principal Diseases of Females_, p.
331.) We may also add two very remarkable cases related by Boyer (quoted
by Kilian,) viz. where the uterus had resisted every endeavour to reduce
the inversion, which in one case had remained fourteen days, in the other
more than eight years, and where, in consequence of a sudden and violent
fall upon the nates, reduction followed spontaneously and permanently.

_Extirpation of the uterus._ Where, however, the powers of the system are
rapidly breaking, from the profuse hæmorrhages at each menstrual period,
and not less profuse discharge during the intervals, the only means of
saving the patient is by treating the case as one of polypus, or in other
words, removing the uterus by ligature. Numerous cases are on record where
this has succeeded perfectly, although during the process the patient
suffered from several attacks of pain and even inflammation, occasionally
requiring the ligature to be loosened for awhile. In the case recorded by
Mr. Newnham, rather more than three weeks were required before the
separation of the tumour was effected. When once this source of irritation
is removed, the hæmorrhage and other discharges which had so greatly
reduced the patient cease, and, as in cases of polypus, a most striking
and favourable change is produced, the health and strength return, and the
recovery of the patient is complete.



CHAPTER VIII.

ENCYSTED PLACENTA.

    _Situation in the uterus.--Adherent placenta.--Prognosis and
    treatment.--Placenta left in the uterus.--Absorption of retained
    placenta._


By the term _encysted_ placenta, we mean that state of irregular uterine
action after the expulsion of the child, where the lower portion of the
uterus, particularly the os uteri internum, is closely contracted, while
the fundus contains the placenta enclosed in a species of _cyst_ or cavity
formed by itself and the body of the uterus.

Upon examination externally, we find the fundus pretty firmly contracted,
but probably somewhat higher up the abdomen than usual; the vagina and os
uteri externum, or os tincæ, are usually found dilated, the passage
gradually tapering like a funnel to the os uteri internum, or upper end of
the canal of the cervix.

_Situation in the uterus._ This state has been very generally considered
to arise from a spasmodic contraction in the circular fibres of the body
of the uterus, by which it was as if tightly girded by a cord at its
middle, and, from the form it was supposed to take, was called _hour-glass
contraction of the uterus_.

From the observations of later years there is much reason to suppose that
the true hour-glass contraction, as now described, is of very rare
occurrence, even if it does take place at all; and that, in by far the
majority of cases, the stricture is either produced by the upper part of
the cervix, as we have already mentioned, or resides in the os uteri
externum or inferior portion of the cervix.

Baudelocque was the first who pointed out the neck of the uterus as the
real seat of the stricture in these cases: "that circle (says he) of the
uterus which is round the child's neck, according to the general laws of
its contraction, must narrow itself much quicker after delivery than the
other circles which compose that viscus, because it is already narrower,
and its forced dilatation at the instant of the expulsion of the child's
trunk is only momentary, and because it has naturally more tendency to
close than the other circles have, since it is that which constitutes the
neck of the uterus in its natural state." (Baudelocque, _Heath's Trans._
vol. ii. § 969.)

Dr. Douglas, of Dublin, also investigated this subject, and came to a
similar conclusion: he considered that encysted or incarcerated placenta
from hour-glass contraction, resulted either from morbid adhesion of the
placenta, or from inactivity of the uterus, and does not occur as a
primary affection; his observations lead to the conclusion that the
stricture in hour-glass contraction "does not form from the middle
circumference of the uterus; it is formed by the lowest verge of its
thickly muscular substance, at the line of demarcation of its body and
cervix." "Thus, then, it would appear that the upper chamber comprises in
its formation the entire of the body of the fundus; whilst the lower
chamber engages only the cervix uteri and the vagina." (_Medical
Transactions of the Col. of Phys._ vol. vi. p. 393.)

The late W. J. Schmitt of Vienna considered that the stricture was
produced by the os tincæ, or os uteri externum.

From our own experience we would say that the seat of the stricture varies
considerably in different cases; that in the simplest form it is nothing
more than a contracted state of the os uteri externum; that in others it
is formed by the upper portion of the cervix uteri, or os uteri internum;
but in other instances it appears to be formed by the inferior segment of
the uterus itself. The contraction in this part of the uterus, which,
according to the observations of Professor Michaelis, comes on when the os
uteri is fully developed, and, by closely surrounding the head, is one
chief means by which prolapsus of the cord is prevented, may easily
produce a state of stricture after the birth of the child, and thus retain
the placenta; it may, however, be questioned whether this portion of the
uterus, when fully dilated by pregnancy, and which then forms its inferior
segment, would not become the os uteri internum when the uterus is empty
and contracted.

Hour-glass contraction of the uterus is liable to occur where the action
of the uterus has been much deranged or exhausted, either by the unusual
rapidity or excessive protraction of the labour. In all cases where the
child has been rapidly expelled before the uterus has had time to contract
regularly and uniformly, the disposition in the os uteri to contract, as
pointed out by Baudelocque, will manifest itself. This state may also be
induced by great previous distention, as from twins, or too much liquor
amnii; by irritation, as by improperly pulling at the cord, by having used
too much force in artificially delivering the child, by the introduction
of the hand or instruments too cold, &c. The most frequent cause, however,
is over anxiety to remove the placenta; the cord is frequently pulled at,
and at length the os uteri is excited to contract; in this case we
generally find the stricture at the os tincæ, which yields without much
difficulty, either by gentle friction with the hand over the fundus, and
cautiously pulling the placenta in the axis of the superior aperture, or
by introducing the hand and bringing it away.

_Adherent placenta._ When the placenta is still attached either wholly or
in part, there are generally some preternatural adhesions to the uterus,
which, by keeping its upper portion distended, give rise to partial
contractions below. This condition of the placenta is observed to attend
nearly every severe case of hour-glass contraction; in some instances its
whole surface appears as if grown to the uterus, forming an adhesion so
close and intimate as to be overcome with the greatest difficulty: we have
met with cases where the placenta tore up into shreds which still adhered
to the uterus as strongly as before; in others, however, the adhesions are
of smaller extent, varying from the size of a shilling to that of a crown
piece, sometimes there being only one, sometimes two or three in the same
placenta.

The nature of these adhesions is but little understood; it is generally
considered that they have been produced by some inflammatory process
taking place between the uterus and placenta; and certainly the firm feel
and lighter colour of the part which has been adherent might, perhaps,
justify such a conclusion. Cases have occurred where the inflammatory
action has extended in the contrary direction (outwards,) producing
mischief in the neighbouring parts, viz. abscess and injury of the pelvic
periosteum with subsequent pelvic exostosis. (_Neue Zeitschrift für
Geburtskunde_, band v. heft 1.) We may also observe, that these adhesions
of the placenta usually occur several times in the same individual.

_Prognosis and treatment._ The danger in these cases depends chiefly on
the presence or absence of hæmorrhage; in the latter case, we may wait
safely, and give the uterus the opportunity of contracting upon the
placenta, so as ultimately to dilate the stricture and expel it. In most
instances, where the os tincæ is the seat of the contraction, and the
placenta (as is usually the case here) already detached, a little
patience, aided by gentle friction of the fundus, and carefully abstaining
from all irritation of the os uteri, will be sufficient to attain this
object; the os uteri will gradually relax and the placenta slowly exude
into the vagina. Where, from the feel of the fundus, the uterus appears
still unable to exert such a degree of contraction as shall overpower the
os uteri, we may follow the plan of Dr. Dewees, in his section "On the
enclosed and partially protruded Placenta," and rouse its activity by some
doses of ergot: "should this not succeed within an hour, the uterus must
be gently entered, by slowly dilating the os uteri, and the placenta
removed." One finger after the other must be passed through the os uteri,
until it has yielded sufficiently: if the placenta be quite detached, two
fingers will generally be sufficient for this purpose, by which means it
may be gradually brought down into the palm of the hand, and then removed.

Where more or less of it is morbidly adherent, which may be presumed when
it continues for some time at the upper part of the uterus without any
disposition to descend, we must carefully introduce the whole hand, and
endeavour to find the edge of the placenta at which we should begin the
process of separation. Where, however, the edge is very thin, and the
attachment firm, it is not easy to effect this without risk of injuring
the structure of the uterus itself with the nails, nor can we always
distinguish the thin and closely adherent edge of the placenta from the
uterus itself: in these cases it will be safer to plunge the fingers into
the central and thicker portions of the mass, and gradually separate it
towards the circumference. Wherever this close adhesion prevails over a
considerable extent, it becomes nearly impossible to prevent portions
being left adhering to the uterus; thus it not unfrequently happens, where
a placenta under these circumstances has been artificially removed, that
there are one or more large irregular cavities on its uterine surface,
from a portion of its mass having been torn from it, and left adhering.
Cases have occurred to us,[134] where the whole central portion has thus
remained, the amniotic surface of the placenta having come away entire
with the larger umbilical vessels attached to it, and merely a narrow
margin of parenchyma at its edge; in others, the whole mass has broken up,
the cord, the larger branches of the umbilical vessels, and the membranes
have come away, but the greater part of the placenta has remained closely
adhering to the uterus. In such a case it becomes a question, whether it
be safe to persist in our efforts to remove the remains of the placenta,
or whether it will not be better to leave the case to nature: experience
shows that the latter plan is the safer, and that a practitioner is not
justified in running the risk of severely injuring the uterus by repeated
and violent efforts to effect his object.

_Placenta left in the uterus._ Where a portion of placenta has been thus
left in the uterus, the case may terminate in one of three ways: either it
may be expelled in the course of from twelve to twenty-four hours, without
any perceptible marks of putrefaction, and with but little or no
disturbance to the system; or where, after a longer interval, the
discharges have become very offensive, and the placenta has been expelled
in a putrid state, with serious disturbance of the health; or lastly,
where the lochia has been sparing but natural, and where no trace
whatever of the placenta has appeared.

In the first mode of termination it may be presumed that the attachment of
the placenta has yielded either to the continued contraction of the
uterus, or from a slight degree of incipient putrefaction, by which its
union with the uterus was weakened; in the second case, from contact with
the external air, and being constantly kept at a considerable temperature
by the heat of the surrounding parts, the lacerated placenta rapidly
putrefies, putrid matter is carried into the system, producing all the
effects of a deadly poison, and the patient is placed in a state of the
greatest danger; the pulse becomes quick and small, the tongue red and
dry, accompanied with great depression of the vital powers, the uterus
frequently swells, grows hard, and excessively painful, followed by
general peritonitis; it is not, however, the inflammation which
necessarily destroys the patient, but the prostrating effects upon the
nervous system, produced by the introduction of an animal poison into the
circulation.

_Absorption of retained placenta._ Where the placenta has not been much
lacerated, or at any rate where every portion has been removed which could
be separated without violence, where also the uterus has contracted firmly
and closely, the part which is retained does _not_ pass into putrefaction,
little or no inconvenience is experienced by the patient; the lochia, as
we before observed, is sparing but natural, and ceases after the usual
time, but not a trace of the placenta comes away. This fact has been
repeatedly noticed, especially in later years; but the attention of
medical men was first called to the subject by Professor Naegelé, of
Heidelberg, in 1828. In 1802, and again in 1811, cases of premature
expulsion of the foetus occurred to him where the membranes and placenta
did not come away, and where no trace whatever of them appeared
afterwards. In 1828[135] his assistance was required in a case of
unusually firm adhesion of the placenta, and where, from this as well as
other circumstances, the extraction was so difficult that he was compelled
to leave considerably more than one-third in the uterus. (_Med. Gaz._ Jan.
10, 1829.) About the same time, a most interesting case was published by
Professor Salomon, of Leyden, where the _whole_ placenta of a child only
three weeks short of the full time was retained by the firm contraction of
the uterus, and, according to Dr. Salomon's view of it, removed by the
process of absorption. About the end of the third week, the uterus, which
had hitherto been larger than is natural under ordinary circumstances
after labour, and more globular, now diminished considerably, and began to
assume the usual form as in the unimpregnated state. Besides the cases
already alluded to, which we have described in our Midwifery Hospital
Reports, we may again refer to one which was mentioned by Dr. Young,
formerly professor of Midwifery at Edinburgh: "I could get my hand to the
placenta, but no farther, the uterus having formed a kind of pouch for it,
so that I at last was obliged to trust to nature; _what was very
remarkable, the placenta never came away_, yet the woman recovered."

Cases have also occurred where the placenta, after having been retained
many days in the uterus, has been expelled quite fresh, the edges worn or
rather dissolved away by the process of absorption; thus Dr. Denman
mentions one where the whole placenta was retained till the fifteenth day
after labour, and was then expelled with little signs of putrefaction
except upon the membranes, the whole surface which had adhered exhibiting
fresh marks of separation. Cases of abortion have occasionally been
observed where the embryo has escaped, but the secundines have never come
away, although the discharges, &c., have been watched with the greatest
attention; after a time the menses have returned, the patient has again
become pregnant, and has passed through her labour at the full term
without any thing unusual occurring.

The subject has recently been considered very fully, and much interesting
knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the
fact beyond all doubt, he shows that cases of total adhesion are rarely if
ever fatal; and that, where cases have terminated fatally, the placenta
has only partially adhered, and the patient has been either destroyed by
hæmorrhage, or by the effects arising from the absorption of putrid
matter, or from injury of the uterus in attempting to remove the placenta.
He considers that a placenta which is not fixed to the uterus by organic
and intimate adhesions cannot be absorbed, though it may perhaps be
retained for several days without danger, if there is contraction of the
uterus. (_Gazette Médicale de Paris_, July 8, 1840.) It may, however, be
doubted whether this last observation be correct, as it is a
well-established fact that cows which had been supposed with calf, and in
which the symptoms of pregnancy had again subsided, have afterwards been
killed and nothing but the bones of the calf found in the uterus, the soft
parts having been removed by absorption. The same fact has been observed
also in sheep and other animals; and knowing how abundantly the human
uterus is supplied with absorbents, coupled with what has been already
stated, there can be little or no doubt but that the placenta in these
cases had been acted upon by a similar process. Although we strongly
deprecate repeated attempts to remove the adherent portions of placenta,
especially where we have brought away a considerable quantity of its
foetal part, still we would warn our readers against leaving any loose
ragged pieces in the uterus, for these rapidly pass into putrefaction, and
produce the alarming symptoms above-mentioned. The safety of our patient
mainly depends on the firm contraction of the uterus preventing the access
of air, and on our constantly removing, by means of injections, any putrid
discharge which may have collected. The sparing quantity of lochia which
has generally been observed, especially where the _whole_ surface of the
placenta has adhered, can easily be accounted for, the greater portion of
the vessels which ordinarily furnish this discharge being closed up by the
adherent mass: from the same reason we can explain why cases of total
attachment of the placenta are rarely or never attended with hæmorrhage.

Lastly, should any symptoms of fever or abdominal inflammation supervene,
they must be treated according to the rules which we have given under
these heads.[136]



CHAPTER IX.

PRECIPITATE LABOUR.

    _Violent uterine action.--Causes.--Deficient resistance.--Effects of
    precipitate labour.--Rupture of the cord.--Treatment.--Connexion of
    precipitate labour with mania._


The second division of Dystocia comprises those species of labour where it
becomes dangerous for the mother or child, without obstruction to its
progress. Of these we shall first consider precipitate or too rapid
labour, not only because it is liable to be followed by a great variety of
injurious results, but also because it has received little or no notice by
the obstetric authors of this country.

Precipitate labour depends on one of two conditions; either the expelling
powers exceed their ordinary degree of activity, or the resistance to the
passage of the child is less than usual. "Every normal labour has a
certain course, which is neither too slow nor too quick. The passages are
thus dilated gradually and without excessive suffering; the uterus is felt
alternately hard and soft; and the pains have certain and regular
intervals, which become very gradually shorter, during which both mother
and child are enabled to recover themselves." (Wigand, _Geburt des
Menschen_, vol. i. p. 68.)

_Violent uterine action._ In the present case the pains are extremely
violent from the very commencement of the labour; they produce great
suffering; each pain lasts a considerable time, and the intervals between
them are very short. During their presence, the patient is irresistibly
compelled to bear down and strain with all her force; the whole body
partakes of the general excitement: the patient is more restless and less
manageable than usual, her manner is altered and becomes strange; the head
is hot, the face flushed, and the pulse quick and full.

In some cases the intervals between the pains are scarcely perceptible,
for one pain has scarcely left off before the next has already commenced;
or the uterus falls into a state of continued violent contraction, which
does not cease until the child is driven into the world. The abdomen is
very hard during the pain, the whole body stiff and rigid; the patient
expresses her sufferings very loudly, or actually raves with pain. From
the constant and irresistible effort to strain, it seems as if she has
scarcely time to get her breath, for she continues to hold it so long that
respiration might be almost supposed to have stopped altogether. "As long
as consciousness remains, the impulse to lay hold of any object within
reach and pull by it is extraordinarily strong, until at length, in the
midst of a violent scream, or grinding of the teeth, covered with sweat
and with simultaneous evacuation of the rectum and bladder, she is
suddenly delivered." (Wigand, _op. cit._ vol. i. p. 71.)

_Causes._ This storm of uncontrollable uterine action "appears to depend
upon an unusually powerful influence of the nervous system upon the
contractile fibres of the uterus or upon a morbid degree of irritability."
(_Ibid._) In some cases it appears as an individual peculiarity, every
successive labour of the patient being remarkable for its violence and
rapidity. Precipitate labours of this kind are frequently observed to be
hereditary, and like an opposite and equally faulty condition of the
expelling powers, viz. slow and lingering uterine action, are sometimes
peculiar to certain families, the mother and the sisters of the patient
having had all their labours peculiarly rapid and violent.

The character of the catamenial periods before pregnancy is frequently
observed to bear a considerable relation to that of the labours in the
same individual; thus, if she has always suffered much pain and other
symptoms of uterine excitement just before or during these times, so much
so as even to require slight medical treatment to allay the periodical
suffering, the uterus almost invariably manifests a similar degree of
energy and irritability during labour. On the other hand, where the
menstrual periods produce so little suffering or derangement that, but for
the appearance of the discharge itself, the patient has scarcely any means
of determining their recurrence, the uterus betrays a similar want of
activity when labour comes on, which may therefore, _cæteris paribus_, be
expected to be slow and lingering.

Mental affections, which we have already shown to be capable of retarding
labour, occasionally have the opposite effect, and rouse the uterus to
violent action. It is well known that the dread of the forceps, which the
practitioner has declared would be required, has frequently been followed
by so much activity of the uterus as to render its application
unnecessary.

Where the patient is stout, robust, and plethoric, or of a nervous
hysterical habit, this state of unruly uterine action is frequently
attended with great cerebral excitement; during the pains she raves
wildly, and for some time becomes quite unmanageable, or in other cases
this state passes into actual convulsions.

In febrile diseases, especially of the eruptive kind, the labour is
usually of this character; the exertions of the uterus in such cases,
especially in scarlet fever, are sometimes quite extraordinary, so that
the child seems to be born without any effort on the part of the mother.
This is of great importance in inflammation of the lungs, &c. where the
patient would be unable to inflate the lungs to that extent which is
necessary for any violent efforts.

_Deficient resistance._ Where the rapidity of the labour arises from want
of that degree of resistance to the expelling powers which is natural, it
may depend on circumstances connected with the mother or the child; thus,
it may arise from too large a pelvis; the head, covered by the inferior
portion of the uterus, is forced down deeper into the pelvis than usual,
especially if, as is not unfrequently the case, this state be accompanied
with violent and powerful pains; the head may thus be actually forced
through the os externum before it has passed the os uteri: cases have been
recorded where nearly the whole uterus, has been thus protruded. In an
"extraordinary case," as Deventer justly terms it, "the head of the child
had passed the os externum as far as the shoulders, and only the summit of
it was visible, three-quarters at least of the head being still enclosed
in the uterus, although the head and neck had already passed." (_Novum
Lumen_, part. ii. chap. 3.)

In other cases the sudden expulsion of the child appears to depend merely
upon the great dilatability of the soft parts, and may occur quite
independently of any disease. We recollect a case of this sort where the
patient, a healthy woman, had only two pains--the first awoke her out of a
sound sleep and ruptured the membranes, the next drove the child with
great violence into the bed. Where the patient is weakened by previous
disease, and the soft parts are very relaxed and flaccid, they produce no
resistance to the advance of the head: this condition is very
unfavourable, "as it implies a greater state of relaxation, or want of
tone, than is compatible with the welfare of the patient: hence it is
seldom found to take place except when the unfortunate subject is sinking
under the last stage of debility, as in phthisis," &c. (Power's
_Midwifery_, p. 138.)

The want of due resistance to the expelling powers may depend upon the
size and hardness of the head; it is either smaller than usual, from the
child being premature, or, if of the full size, the cranial bones are
imperfectly ossified, the sutures are wide, the fontanelles large, and the
whole head very yielding and soft; or it may depend on some congenital
defect, in which the brain and cranial coverings are more or less
imperfect.

In the ordinary cases of precipitate labour the case depends generally on
a complication of violent pains, wide pelvis, and small child.

_Effects of precipitate labour._ Besides the mischief which may result
from the rapid expulsion of the child causing prolapsus uteri, laceration
of the vagina, perineum, and hæmorrhage from inertia coming on in
consequence of the uterus being so suddenly emptied, dangerous syncope,
or even asphyxia, may follow from the shock which the nervous system has
sustained, or in consequence of the sudden removal of that degree of
pressure which the gravid uterus had exerted upon the abdominal
circulation during pregnancy. Where the patient has been very unruly, and
has exerted herself with great violence, "emphysema of the face and neck
(says Dr. Reid) may suddenly occur during labour, and cause great alarm to
a young practitioner, as it alters and disfigures the countenance in an
extraordinary manner. Great straining or screaming may produce it, and it
probably depends on some partial rupture of the lining membrane of the
larynx. I have seen two or three cases of this description, and one which
occurred to a great extent in the case of an out-patient of the General
Lying-in Hospital, in whom this tumefaction spread to the shoulders and
chest." (_Manual of Pract. Midwifery_, by James Reid, M. D. p. 231.)

The _child_ also may suffer from a precipitate labour, where the pains are
excessively violent and run into each other, so that the whole labour is
effected during one continued storm of uterine action. If the membranes
have given way at an early period, so that the body of the child is
exposed to the immediate pressure of the pains, the abdominal circulation
suffers, and the child is destroyed in the same way as by pressure on the
cord itself; or it may be suddenly dashed upon the floor before the mother
has had time to reach her bed, or even put herself in a recumbent posture
upon the floor: in this way it may receive a severe injury upon the head,
or the cord may be lacerated, and the child die from hæmorrhage before
assistance can arrive: such accidents, however, are not so dangerous to
the child as have been supposed, a fact which has been proved by
medico-legal investigations. The direction of the pelvic outlet and vagina
is such as to expel the child obliquely downwards and forwards when the
mother is in the upright posture, so that the force of the blow is in a
great measure broken by this circumstance; the head also, as well as the
other parts of the body, are soft and yielding, and nearly preclude the
chances of injury taking place; the violence of the fall is generally
diminished in some measure by the patient being almost always compelled to
drop upon her knees at the moment of great suffering, whilst the child is
passing; her clothes also surround it more or less, and thus shield it
from any severe injury.

_Rupture of the cord._ The cord is liable to be torn in these cases,
showing that a considerable jerk had been applied to it, but neither the
child nor its mother have suffered from it. Ten or twelve cases of
ruptured cord have come to our own immediate knowledge, and in none of
them were any unfavourable effects produced. It can scarcely be imagined
possible that so much force could be applied to the cord, at the moment
when the uterus is so suddenly evacuated, without inversion or prolapsus
being the almost unavoidable result, the more so when we recollect that
the cord at the moment of birth requires considerable force to break it.
This circumstance may be partly attributed to the firmness with which the
uterus contracts at the moment that the child is expelled, but chiefly to
the fact that the axis of the brim is nearly at right angles with that of
the outlet, more especially if the fundus, as is usually the case, is
inclined somewhat forwards; the cord passes round the posterior part of
the symphysis pubis as upon a pulley, so that a considerable portion of
the force which is applied to it, is spent here before reaching the fundus
uteri. It is however remarkable, that the umbilicus of the child should
receive no injury from a jerk which breaks the cord, when, if we try
afterwards to break the remaining pieces of the cord, we find that it will
resist very powerful efforts: this fact, and the circumstance that the
cord usually ruptures at about two or three inches from the umbilicus, as
in some animals, seems to imply that this part is weaker than elsewhere,
as if intended by nature to give way with a moderate degree of force.

Wigand considers that patients are particularly disposed to have quick
labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that
such patients are very liable to have adhesion of the placenta after the
birth of the child, with hour-glass contraction: the observation, however,
has not been confirmed by the experience of others, and certainly not by
the cases which have come under our own notice.

_Treatment._ Where, from the smallness of the child or unusual size of the
pelvis, the pains are forcing the lower portion of the uterus down to, or
through, the os externum, it will be necessary to support it carefully,
until the os uteri is sufficiently dilated to let the head pass. A case of
this kind occurred to Professor Naegelé, of Heidelberg, where, during the
patient's former labour, the pains had been so violent, and the uterus had
been detruded to such an extent, that actually the lower half of it
appeared between the labia: to prevent a similar accident occurring this
time, (as the pains were beginning to show the same disposition to violent
action as before,) he applied a broad T bandage very firmly upon her,
coming over the os externum, so as to prevent the uterus being prolapsed
beyond the labia; he cut a hole in it corresponding to the vagina, and the
child was born through this with perfect safety to the mother.

Where we have sufficient warning, opium in effective doses will probably
assist in lulling the irritability of the uterus: if the bowels have been
previously well opened, an opiate enema will be desirable; if not, a large
emollient enema should be premised.

The patient should be made to lie upon her side, and not only strictly
forbidden to resist to her very utmost, the urgent impulse which she feels
to strain and bear down, but must carefully avoid even holding by or
pushing against any fixed body with her hands or feet. Still farther, to
quiet the turbulence of the abdominal muscles, a broad bandage should be
fastened firmly round the abdomen; it not only gives the patient a
comfortable feeling of support, but tends greatly to calm the spasmodic
irritability of these muscles. These precautions will be of so much more
service if they can be used early, as in cases where we have been already
warned by the character of her previous labours: we can thus avoid the
premature rupture of the membranes, which is a thing by all means to be
avoided; the uterus acts with increased power where its bulk has been
diminished by the escape of the liquor amnii, and at the same time becomes
still more irritable and unruly from contracting immediately upon the
child; and not only is there imminent danger of its giving way in some
part, but the child is almost inevitably destroyed by the violence of the
pressure to which it is exposed.

In cases where the vehemence of the expelling powers appears to be quite
beyond our control, Wigand has recommended a copious bleeding to complete
syncope as the only means; in which suggestion, he has been followed by
Froreip: neither of these authors, however, appear to have had any
experience of this mode of treatment, and knowing how much more active the
uterus becomes after a smart bleeding in ordinary cases, and how
powerfully the state of syncope promotes the dilatability of the soft
parts, we should hesitate exceedingly to employ so doubtful a remedy.
Wigand also proposes, in cases of this desperate nature, to use effusion
with ice-cold water to the abdomen and lower extremities, and by this
powerful species of counter-irritation, produce a temporary calm for a few
minutes--a measure we should fear of as doubtful a character as bleeding.

_Connexion of precipitate labour with mania._ Lastly, we may observe, that
the subject of precipitate labour involves a medico-legal question of
great importance and interest, which has as yet excited little or no
notice in this country, viz. as regards acts of child-murder after labours
of this character. The state of mental excitement and frenzy into which a
patient is brought, by a labour of such violence and suffering, in many
cases falls little short of actual mania. We now and then meet with
instances, where, for the first half hour or so after a severe and rapid
labour, the patient takes a most insurmountable antipathy to her child,
and expresses herself towards it in so unnatural a manner, as to contrast
strangely with the tender and affectionate feelings which she had a short
time previously expressed for it. Cases have occurred where the patient
has been without assistance, during labour, and where, in a state of
temporary madness from mental excitement and pain at the moment of the
child's birth, she has committed an act of violence upon it, which has
proved fatal; a circumstance, which, from obvious reasons, would be more
liable to occur with single than with married women. These cases have been
very carefully investigated in Germany of late, and in many of them the
patient has been, we think, very properly acquitted, on the grounds of
temporary insanity, having herself voluntarily confessed the act with the
deepest remorse, at the same time declaring her utter incapacity to
account for the wild and savage fury which seized her at the moment of
delivery.



CHAPTER X.

PROLAPSUS OF THE UMBILICAL CORD.

    _Diagnosis.--Causes.--Treatment.--Reposition of the cord._


Although by no means a common occurrence, it every now and then happens
that a portion of the umbilical cord falls down between the presenting
part of the child and the mother's pelvis either just before or during
labour; so that, as the child advances through the passages, its life is
placed in imminent danger from the pressure to which the cord is exposed,
obstructing the circulation in it.

There is probably no disappointment, which the accoucheur has to meet with
more annoying than a case of this kind; every thing has seemed to promise
a favourable labour; the presentation is natural, the pains are regular,
the os uteri is dilating readily, the mother, and, as far as we can
ascertain, her child, are in perfect health, and yet because a minute loop
of the cord has fallen down by the side of its head, the labour, unless
interfered with by art, will almost necessarily prove fatal to it.

_Diagnosis._ If the membranes be not yet ruptured, we shall probably be
able to feel a small projecting mass like a finger, close to the
presenting part, and possessing a distinct pulsation, which, from not
being synchronous with the mother's pulse, instantly declares its real
nature. When the membranes give way, more of the cord comes within reach,
and probably forms a large coil, which passes through the os uteri into
the vagina, or even appears at the os externum.

_Causes._ The earliest writer that we know of who has given a detailed
account of cord presention was Mauriceau; few, even in hospital practice,
and certainly none in private practice, have exceeded him in the number of
cases described, and very few have surpassed him in the success of his
treatment. He mentions chiefly three conditions as being liable to produce
prolapsus of the cord, viz. a large quantity of liquor amnii, an unusually
long cord, and malposition of the child: later authors have enumerated
several other causes, many of which are imaginary; of these, by far the
most correct list has been given by Boer, of Vienna, who has justly
ridiculed the theoretical views which were maintained by his
cotemporaries.

"If there be a large quantity of liquor amnii present, and especially, as
is not unfrequently the case, the child is at the same time under the
usual size; if the head be not firmly pressed against the brim, and does
not enter it sufficiently, or when the child's position is faulty,
especially if, at the same time, the cord is unusually long; if, under
such circumstances, a large bag of membranes has formed, and the brim of
the pelvis itself is very spacious; if perchance, the rupture of the
membranes takes place at a moment when the patient is moving briskly on in
some unfavourable posture, the cord will be very liable to prolapse.
Nevertheless, cases are occasionally seen which arise without these
predisposing circumstances." (Boer, _von Geburten unter welchen die
Nabelschnur vorfällt_.)

The uterus is the chief means by which the cord is prevented from falling
down between the presenting part of the child and the passages, from the
closeness with which its inferior portion encircles it: without this, from
the erect posture of the human female, there would be a liability to
prolapsus of the arm or cord in every labour.

"The contraction of the uterus, which comes on with the rupture of the
membranes, and sometimes, where they protrude very much, even before, is
of great importance. This contraction takes place in the inferior segment
of the uterus; it surrounds the head, and when fully developed extends
over the whole head of the child. Thus, for instance, if we attempt to
operate at an early stage, it feels more like a hard ring round the head,
of about a finger's breadth, and it may be felt to extend itself higher
up, in proportion as the stimulus of the hand excites the activity of the
uterus." (Michaelis, _Neue Zeiteschrift für Geburtskunde_, band iii. heft.
1.)

Hence, therefore, whatever prevents the uterus from contracting with its
inferior segment upon the presenting part of the child, deprives the cord
of its natural support, and, therefore, renders it liable to prolapse.
Many of the causes enumerated by Boer act in this way; thus, where the
uterus is distended by an unusual accumulation of liquor amnii; where the
contractions at the beginning of labour have been exceedingly irregular;
where the arm, or shoulder, or feet present; or where a large bladder of
membranes is formed, the lower part of the uterus will either not contract
at all upon the head, or so imperfectly as to endanger the descent of the
cord.

Malposition of the child has been mentioned by many authors as a cause of
prolapsus of the cord, and in some cases it may possibly act thus from the
inferior segment of the uterus being unable to surround sufficiently close
so irregular a mass as the shoulder. In the majority of cases, however,
the coincidence of these two circumstances depends upon their being
produced by the same causes; thus an unusually large quantity of liquor
amnii, or irregular contractions of the uterus, will just as much dispose
to the one as the other.

The form or size of the pelvis can have, we think, but little effect upon
the cord, so long as the uterine action is of the right character and the
child alive. Most authors enumerate a large pelvis or small foetal head as
a cause, why should we not, therefore, have prolapsus of the cord in every
case of precipitate labour which arises from such circumstances? Nor are
we at all disposed to consider deformed pelvis as capable of producing it,
so long as the uterus is not immoderately distended and acting naturally:
we do not deny that the cord is occasionally found prolapsed in cases of
dystocia pelvica, but this is chiefly where the child has died from the
severity of the labour, and where the flaccid pulseless cord has gradually
slipped down during the intervals of the pains.

So long as the uterus exerts but a moderate degree of pressure round the
head, it is impossible for the cord of a living child to descend,
particularly as, according to Dr. Michaelis, the circular contraction of
the portio vaginalis commences from below upwards, and would rather push
back the cord if a portion of it had descended during the moments of
uterine relaxation. The pulsating turgor of the cord when the child is
alive will also assist much in preventing its descent, even where the
uterus does not surround the presenting part so closely as usual.

The unusual length of the cord is also a very doubtful cause of its
prolapsus, and will evidently, in great measure, depend upon the causes we
have already alluded to.

We may also allude to another cause of prolapsus of the cord, which,
although noticed nearly a century ago by Levret, and also by two or three
authors after him, had nearly fallen into oblivion until lately, when it
excited the attention of Professor Naegelé, junior. Levret, from the
result of numerous observations on the insertion of the cord into the
placenta, was led to suppose that the lower the situation of the placenta
in the uterus, the lower also was the insertion of the cord into the
placenta, so that if the edge of the placenta touched upon the os uteri,
the cord was usually inserted into that part of its edge which
corresponded with the os uteri.

Although it is certain that the situation of the placenta close to the os
uteri, is by no means necessarily attended by insertion of the cord into
its edge, and, therefore, by prolapsus of it when the membranes give way,
inasmuch, as under such circumstances we ought to have every case of
partial placenta prævia accompanied with the cord presenting: still,
however, there is no doubt that cases of the above-mentioned complication
do every now and then occur, and must necessarily incur no inconsiderable
danger of prolapsus.

"There is no doubt that the situation of the placenta in the vicinity of
the os uteri, may be looked upon as one of the predisposing causes of the
cord presenting during labour; an accident which is the more to be feared,
the nearer the cord is inserted into the inferior edge of the placenta. If
its edge extends quite down to the os uteri, and the cord is inserted into
it, or the umbilical vessels divide, as in the cases we have described, at
some little distance from it, viz. in the membranes, the cord will present
as a necessary result, and prolapse as soon as the membranes give way."
(_Die Geburtshülfliche Auscultation_, von Dr. H. F. Naegelé, p. 114.) The
two cases referred to by Professor Naegelé, jun., of prolapsus of the cord
from this cause, occurred so near after each other, as to render the
circumstance the more remarkable. The fact was noticed by Giffard as early
as in 1728, in a case of flooding from partial placenta prævia; but he
does not appear then to have drawn any inferences from the position of the
placenta, which he did not consider was attached, but was "in part, if not
wholly, separated from the uterus."[137]

Prolapsus of the cord is fortunately not a circumstance of frequent
occurrence. Dr. Churchill, of Dublin, in a valuable paper, (_Edin. Med.
and Surg. Journal_, Oct., 1838,) has collected the results of no less than
90,983 deliveries, amongst which the cord presented in 322 cases, being in
the proportion of one in 282-1/4.[138] That prolapsus of the cord occurs
most frequently in foot presentations, as supposed by Professor Naegelé,
senior, is disproved by the results of Mauriceau's large experience, as
well as of many others since; thus, out of 33 cases which occurred in
labour at the full term, (or nearly so,) 17 presented with the head, 1
with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or
foot, 1 with the hand and breech, and 1 with the hand and head. In the
16,652 births which have been recorded by Dr. Collins, at the Dublin
Lying-in Hospital, the cord prolapsed in 97 instances. "_Twelve_ of the 97
occurred in twin cases, and in seven of the 12 it was the cord of the
second child. _Nine_ occurred where the feet presented, (not including two
met with in twin children,) which was in the proportion of _one_ in every
_fourteen_ of such presentations. _Two_ only where the breech presented,
which was in the proportion of _one_ in every 121 of such presentations:
this approaches nearly the proportional average in all deliveries, which
is _one_ in 171-1/2. _Four_ occurred where the shoulder or arm presented:
this is in the proportion of _one_ in _nine_ of such presentations.
_Seven_ occurred where the hand came down with the head. _Seven_ of the
children were born _putrid_; _three_ of the 97 were premature, viz. _two_
at the seventh and _one_ at the eighth month." (Collins's _Practical
Treatise on Midwifery_, p. 346.) We may, therefore, conclude with safety,
that presentations of the head are by far the most common.

_Treatment._ Left to itself prolapsus of the cord is almost certain
destruction to the child, for unless the labour comes on very briskly, and
the head passes rapidly through the pelvis, the cord is pressed upon so
long as to render it impossible for the child to be born alive. Still,
however, where the passages are yielding, and the pains active; where the
head is of a moderate size, the pelvis spacious, and the cord in a
favourable part of it, viz. towards one of the sacro-iliac synchondroses;
where also the membranes remain unruptured until the last moment, there
will be a very fair chance of the child being born alive. Under no
circumstances is it of such paramount importance to avoid rupturing the
membranes as in these cases, for the bag of fluid which they form dilates
the soft passages and protects the cord from pressure.

"Many methods of relief have been recommended, such as turning, delivering
with the forceps, pushing up the funis through the os uteri with the hand,
and endeavouring to suspend it on some limb of the child, collecting the
prolapsed cord into a bag, and then pushing it up beyond the head, pushing
up, the funis with instruments of various kinds, endeavouring to keep it
secured above the head by means of a piece of sponge introduced; these and
many other similar expedients have been resorted to." (Collins, _op. cit._
p. 344.)

The first two of these means have been chiefly used in cases of prolapsed
funis, the others having, for the most part, been found entirely
inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned
19 times: the children were all born alive, except one, which was dead,
but required turning as it presented with the arm. In later times, turning
or the forceps have been preferred, according to the period of labour at
which the prolapsus was discovered or occurred. Thus Madame Boivin has
recorded 38 cases, 25 of which occurred at the commencement of, and 13
during labour, the former were all turned; in the latter the forceps was
used; 29 children were saved, seven were lost, and the two others were
putrid.

Our practice must be in great measure guided by the circumstances of the
case: where the os uteri is not fully dilated, where the head is still
high and not much engaged in the pelvis, the liquor drained away, and the
cord beginning to suffer pressure during the pains, we dare not wait until
the case be sufficiently advanced to admit the application of the forceps,
but must proceed as soon as possible to turn the child. The operation
should be performed with the greatest possible caution; the cord should
be guided to one of the sacro-iliac symphyses; the expulsion of the trunk
must be very gradual; a dose of secale should be given to ensure the
requisite activity of the uterus when the head enters the pelvis, and the
forceps kept in readiness to apply the instant that its advance is not
sufficiently rapid. On the other hand, where the labour has made
considerable progress before the membranes give way, and the head has
fairly engaged in the cavity of the pelvis, if the os uteri is fully
dilated, it will be no longer advisable to attempt turning; the head is
within reach of the forceps, which should be immediately applied, taking
care that the cord does not get squeezed between the blades and the head.
Where the arm or shoulder presents, this will of itself require that the
child should be turned.

_Reposition of the cord._ Although the reposition of the cord has been
recommended from the time of Mauriceau, and by the majority of authors
since, it has nevertheless met with so little success as to have fallen
into complete disuse until the last few years; one of its strongest
opposers was the celebrated La Motte. "The delivery ought to be attempted
as soon as we find that the string presents before the head, it being to
no purpose to try to reduce it behind the head, which at that time fills
up the whole passage, and can only admit you to push it back into the
vagina, and it will fall down again at every pain; and if you have done so
much as to reduce it into the uterus, what hinders you from finishing the
delivery at once, by seeking for the feet? the chief difficulty is then
over." (_La Motte_, English translation, p. 304.) This mode of delivery
(turning) has been more adopted by practitioners in such cases than any
other, especially in former times, when the forceps was either not at all
or imperfectly known; by none has it been so with more success than by
Mauriceau himself, having saved every living child in which he attempted
the operation. Still, however, he recommended that the attempt should be
made to return the cord wherever it was possible, and has recorded four
cases of this mode of treatment, all of which proved successful, although
one of the children was born so feeble as to die shortly afterwards.
Giffard seems to have attempted the reposition of the cord only once, and
failed, apparently from the unusual size of the child. In later years Sir
R. Croft, "has related two cases in which he succeeded, by carrying the
prolapsed funis through the os uteri, and suspending it over one of the
legs of the child. In both these cases the children were born alive."
(Merriman's _Synopsis_, p. 99.) It is to Dr. Michaelis of Kiel that we are
indebted for much recent and valuable information on the subject of
replacing the prolapsed cord. Having pointed out the fact that it is the
uterus alone which prevents the cord from prolapsing, he shows that, in
order to replace the cord, we must carry it "above that circular portion
of the uterus which is contracted over the presenting part." The
reposition of the cord may be effected by the hand, or by means of an
elastic catheter and ligature. In replacing the cord by means of the hand
alone, Dr. Michaelis remarks that we shall effect this more readily by
merely insinuating the hand between the head and the uterus, and gradually
passing it farther round the head, pushing the cord before it. In this
manner we do not require to rupture the membranes when we have felt the
cord before the liquor amnii has escaped; a point of considerable
importance.

The reposition, by means of the catheter, is effected by passing a silk
ligature, doubled, along a stout thick elastic catheter, from twelve to
sixteen inches in length, so that the loop comes out at the upper
extremity; the catheter is introduced into the vagina, and the ligature is
passed through the coil of the umbilical cord, and again brought down to
the os externum. A stilet with a wooden handle is introduced into the
catheter, the point passed out at its upper orifice, and the loop of the
ligature hung upon it; it is then drawn back into the catheter and pushed
up to the end. The operator has now only to pull the ends of the ligature,
so as to tighten it slightly, passing the catheter up to the cord, which
now becomes securely fixed to its extremity. When the reposition has been
effected, he has merely to withdraw the stilet; the cord is instantly
disengaged.[139] To prevent any injury, the ligature should be brought
away first, and then the catheter.

"Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where
it has been returned by the above means, in nine of which the child was
born alive. In three cases the arm presented also, which was replaced, and
the head brought down; in two of these the child was born alive."
(_British and Foreign Med. Review_, vol. i. p. 588.) A similar plan of
replacing the cord by means of an elastic catheter has been tried by Dr.
Collins, but he had not tried it sufficiently often at the time of
publishing his _Practical Treatise_ to be able to give a decided opinion
about it.

The plan of introducing a piece of sponge after replacing the cord, in
order to prevent its coming down again, is of no use whatever. Dr. Collins
tried it in several instances, and considers that "it is quite impossible,
however, in the great majority of cases, to succeed in this way in
protecting the funis from pressure, as it is no sooner returned, than we
find it forced down in another direction." The plan has been recommended
by several modern authors, but it is by no means a new invention, having
been proposed by Mauriceau; it does not appear, however, that he ever put
it in practice.

Where no pulsation can be felt in the prolapsed funis, which is flabby and
evidently empty, no interference will be required; the child is dead, and
therefore the labour may be permitted to take its course. We should,
however, be cautious in examining the cord where it is without pulsation,
and yet feels tolerably full and turgid, for a slight degree of
circulation may go on nevertheless, sufficient to keep life enough in the
foetus, even for it to recover if the labour be hastened. We should
especially examine the cord during the intervals of the pains, and after
we have guided it into a more favourable part of the pelvis, where it will
not be exposed to so much pressure, for then the pulsation will become
more sensible to our touch, and prove that the child is still alive.

The following case by Dr. Evory Kennedy is an excellent illustration of
what we have now stated:--"The midwife informed me that there was no
pulsation in the funis, which had been protruding for an hour; on
examination made during a pain, a fold of the funis was found protruding
from the vagina, at its lateral part, and devoid of pulsation. As the pain
subsided, I drew the funis backwards towards the sacro-iliac symphysis,
and thought I could observe a very indistinct and irregular pulsation; I
now applied the stethoscope, and distinguished a slight foetal pulsation
over the pubes. Fortunately on learning the nature of the case, I had
brought the forceps, which were now instantly applied, and the patient
delivered of a still-born child, which, with perseverance, was brought to
breathe, and is now a living and healthy boy, four years of age. Had I not
in this case ascertained by the means mentioned, that the child still
lived, I should not have felt justified in interfering; but, supposing the
child dead, would have left the case to nature, and five minutes, in all
likelihood, would have decided the child's fate." (Dr. Evory Kennedy, _on
Pregnancy and Auscultation_, p. 241.)



CHAPTER XI.

PUERPERAL CONVULSIONS.

    _Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.--
    Tetanic species.--Diagnosis of labour during convulsions.--
    Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.--
    Apoplectic species.--Anæmic convulsions.--Symptoms.--Treatment.--
    Hysterical convulsions.--Symptoms._


Women are liable, both before, during, and after labour to attacks of
convulsions, not only of variable intensity, but differing considerably in
point of character. We shall consider them under three separate heads,
viz. epileptic convulsions with cerebral congestion; epileptic convulsions
from collapse or anæmia; and hysterical convulsions. Other species have
been enumerated by authors, but they are either varieties of, or
intimately connected with, those of the first species.

No author has more distinctly pointed out the fact that epilepsy may arise
from diametrically opposite causes than Dr. Cullen; a circumstance which,
in a practical point of view, is of the greatest importance. "The
occasional causes," says he, "may, I think, be properly referred to two
general heads; the first, being those which seem to act by directly
stimulating and exciting the energies of the brain, and the second, of
those which seem to act by weakening the same." "A certain fulness and
tension of the vessels of the brain is necessary to the support of its
ordinary and constant energy in the distribution of the nervous power"
(_Practice of Physic_;) and hence it may be inferred that, on the one
hand, an over-distention, and, on the other, a collapsed state of these
vessels, will be liable to be attended with so much cerebral disturbance
as to produce epilepsy.

_Epileptic convulsions with cerebral congestion._ Epileptic convulsions
connected with pregnancy or parturition, and which are preceded and
attended with cerebral congestion, alone deserve, strictly speaking, the
name of _Eclampsia parturientium_ (which, in fact, signifies nothing more
than the epilepsy of parturient females,) being peculiar to this
condition; whereas, the anæmic and hysterical convulsions may occur at any
other time quite independent of the pregnant or parturient state.

The term "puerperal convulsions" is employed in a much more vague and
extended sense, and applies generally to every sort of convulsive
affection which may occur at this period, and as such, it therefore, forms
the title of the present chapter.

_Causes._ The exciting cause of eclampsia parturientium is the irritation
arising from the presence of the child in the uterus or passages, or from
a state of irritation thus produced, continuing to exist after labour. The
predisposing causes are, general plethora, the pressure of the gravid
uterus upon the abdominal aorta, the contractions of that organ during
labour, by which a large quantity of the blood circulating in its spongy
parietes is driven into the rest of the system, constipation, deranged
bowels, retention of urine, previous injuries of the head or cerebral
disease, and much mental excitement, early youth: also "in persons of
hereditary predisposition, spare habit, irritable temperament, high mental
refinement, and in whom the excitability of the nervous, and subsequently
the sanguiferous system is called forth by causes apparently trivial."
(_Facts and cases in Obstetric Medicine_, by I. T. Ingleby, p. 5.)

_Symptoms._ From the above-mentioned list of causes it will be evident,
that these convulsions will be invariably attended and preceded by
symptoms of strong determination of blood to the head. Previous to the
attack the patient has "drowsiness, a sense of weight in the head,
especially in stooping; beating and pain in the head; redness of the
conjunctiva; numbness of the hands; flushing of the face, and twitching of
its muscles; irregular and slow pulse; ringing in the ears, heat in the
scalp, transient but frequent attacks of vertigo, with muscæ volitantes,
or temporary blindness; derangement of the auditory nerve; embarrassment
of mind and speech; an unsteady gait; constipation and oedematous
swellings." (Ingleby, _op. cit._ p. 12.)

As the attack approaches, the patient frequently complains of a peculiar
dragging pain and sense of oppression about the præcordia, which comes on
and again abates at short intervals, and is attended with much
restlessness and anxiety: this is followed by intense pain, which usually
attacks the back of the head, and upon the accession of which the
præcordial affection apparently ceases; the pulse now becomes smaller and
more contracted. If the convulsions do not make their appearance by this
time, and the headach continues one or more hours, a slight degree of coma
supervenes, the patient loses her consciousness more and more, and wanders
now and then; after a time she becomes restless and evidently uneasy, the
eye becomes fixed and staring, the countenance changes, and the outbreak
of convulsive movements follows.

Sometimes the premonitory symptoms are much less marked; indeed, in some
cases, there is scarcely a sign to warn us of the impending danger; in the
midst of a conversation the patient becomes suddenly silent, and, on
looking to see the cause, we find the expression altered, the muscles of
the face are twitching, the features beginning to be distorted, and the
next moment she falls down in general convulsions.

Wigand (_Geburt des Menschen_, vol. i. § 102,) considers that the two
symptoms which usher in the attack are, the frightful staring followed by
rolling of the eyes, with sudden starts from right to left, and twisting
of the head to the same side by the same sudden movements; as soon as the
convulsions have commenced, the head generally returns to its former
position, or rather is pulled more or less backwards; "the eyes are wide
open, staring, and very prominent, the eyelids twitch violently, the iris
is rapidly convulsed with alternate contractions and dilatations; the face
begins to swell and grow purple, the mouth is open and distorted, through
which the tongue is protruded, brown, and covered with froth; the lips
swell and become purple: in fact, it is the complete picture of one who is
strangled." (_Op. cit._)

These convulsions, as in common epilepsy under other circumstances,
usually if not always commence about the head and face, gradually passing
down to the chest and abdomen, and then attacking the extremities. After
the above-mentioned changes, they pass into the throat and neck, by which
a state of trismus is produced, and the protruded tongue is not
unfrequently caught between the teeth and severely wounded. The neck is
violently pulled on one side, and from the pressure to which the trachea
is subjected, severe dyspnoea is produced. The respiration is nearly
suspended, and from the violent rushing of the air as it is forced through
the contracted rima glottidis, the breathing is performed with a peculiar
hissing sound. The muscles of the chest now become affected, and the
thorax is convulsively heaved and depressed with great vehemence; those of
the abdomen succeed, and the convulsive efforts are here, if possible,
still more violent: such are the contractions of the abdominal muscles,
and so powerfully do they compress the contents of the abdomen, that a
person who had not previously seen the patient would scarcely believe she
was pregnant; the next moment the abdomen is as much protruded as it was
before compressed. From the same cause, the contents of the rectum and
bladder are expelled unconsciously, the extremities become violently
convulsed, and the patient is bedewed with a cold clammy sweat. The
duration of such a fit is variable; it seldom lasts more than five
minutes, and frequently not more than two, and then a gradual subsidence
of the convulsions and other symptoms follow; the swollen and livid face
returns to its natural size and colour, the eyes become less prominent,
the lips less turgid, the breathing is easier and more calm, the viscid
saliva ceases to be blown into foam from the mouth, and the patient is
left in a state of comatose insensibility or deep stertorous sleep, from
which, in the course of a quarter of an hour or twenty minutes, she
suddenly awakes, quite unconscious of what has been the matter; she stares
about with a vacant expression of surprise; she feels stiff and sore as if
she were bruised: this will be especially the case if it has been
attempted to hold her during the fit. The convulsive efforts of the
muscles of the body and extremities are not easily resisted, and thus it
is that we hear of a delicate woman under these circumstances requiring
several strong men to hold her: the result of such treatment is, that her
muscles and joints are severely strained, and continue painful for some
time after. Patients, on recovering their senses, frequently complain of
pain and soreness in the mouth, arising from the tongue having been
bitten; in some cases where the tongue has been much protruded, the injury
is very severe, the tongue being bitten completely across, and hanging
only by a small portion.

The woman may suffer but one attack, and have no return of the fit, or in
half an hour, an hour, or longer, the convulsions again appear as at
first. If this happens several times, she does not recover her
consciousness during the intervals, but remains in a continued state of
coma from one fit to another. Although it rarely happens, that the patient
dies during a fit, still nevertheless, one fit will in some cases be
sufficient to throw her into a state of coma from which she does not
recover; in others, the patient may lie for even twenty-four hours in
strong convulsions and yet recover.

The character of these attacks appears to vary a good deal with the cause;
thus, where plethora has been the predisposing cause, and the fits
frequently repeated, they take on more or less of an apoplectic character,
the coma is more profound and of longer duration, and is frequently
attended with paralysis; the cerebral affection is more severe, the
patient does not recover her senses even where the intervals between the
attacks have been of considerable duration; and when the fits have ceased
and the coma abated, she is occasionally left in a state of imbecility and
blindness, which lasts for several hours or even days.

Where it is connected with constipation or deranged bowels, we think that
we have seen it more frequently attended with delirium or even temporary
mania; the fits are numerous, the convulsions as severe, but the cerebral
congestion is not so intense, the coma less profound; instead of being
left in a state of torpid stupor, the patient is very restless and at
times unmanageable, and when we consider the identity of the causes which
produce these convulsions and one form of purerperal mania, it will be
easily understood why the symptoms should assume this character. The
degree also of determination to the head, will in no slight measure
influence the character of the symptoms which attend these attacks. "One
circumstance," says Dr. Parry, "of increased impetus deserves to be
noticed. The delirium is preceded by a pain in the head, but as the
delirium comes on, the pain ceases, though the impetus remains as before,
or perhaps increases. Diminish in a slight degree the impetus, and you
remove the delirium and renew the pain; diminish the impetus in a greater
degree, and the frown on the forehead is relaxed, the features seem to
open, and the pain entirely ceases." (_Posthumous Medical Writings_, vol.
i. p. 263.)

By far the majority of cases of eclampsia parturientium occur in
primiparæ: thus in thirty cases which occurred to Dr. Collins, during his
mastership at the Dublin Lying-in Hospital, "twenty-nine were in women
with their first children, and the other single case was a second
pregnancy, but in a woman who had suffered a similar attack with her first
child." In two instances, under our own notice, where the disease occurred
in multiparæ, the fits did not appear until _after_ delivery; the patients
were plethoric, and in one especially, the bowels were excessively
deranged; in the other, the attack had much of the apoplectic character,
and the coma did not at once abate until the fatal termination.

Convulsions usually make their appearance towards evening; and if pains
are coming on, they return with every uterine contraction. The patient's
danger will, in great measure, depend upon the severity, frequency, and
duration of the fits; and although they must ever be looked upon as a
disease of the most dangerous character, yet we are justified in saying
that in the majority of instances the patient recovers: thus, of the
forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of
the thirty by Dr. Collins, only five died, "three of which were
complicated with laceration of the vagina, one with twins, and one with
peritoneal inflammation. It is thus evident that the fatal result in these
cases, with the exception of the twin birth, was not immediately connected
with the convulsions; and the danger in all twin deliveries, _no matter
what the attack may be_, is in every instance greatly increased."
(_Practical Treatise_, p. 210.)

Although puerperal convulsions usually occur at the commencement of
labour, it not unfrequently happens that they do not come on until after
the child is born; whereas, in other cases they occur several months
before the full period: these varieties depend entirely upon the
circumstances under which the attack has appeared. "With respect to their
occurrence in the last month of gestation, although the paroxysm mostly
appears during the actual dilatation of the os uteri, or on the first
approach of labour, still when we recollect that in the last week or two
of pregnancy the neck of the uterus is fully developed, the subsequent
changes being confined to the os internum (the most sensitive part of the
organ,) it cannot be surprising that, in very irritable persons, a
serious impression should be made upon the brain at those periods."
(Ingleby, _op. cit._ p. 11.)

Dr. Merriman has called it _dystocia epileptica_: there is, in fact, no
difference between this disease and common epilepsy, beyond that, under
ordinary circumstances, epilepsy is a chronic affection, and, generally
speaking, not attended with much danger, whereas, in the present case, it
is an acute attack, and of a highly dangerous character.

Many phenomena connected with uterine irritation, both in the
unimpregnated state and during pregnancy, prove the intimate nature of the
consent existing between the brain and uterus. Thus it is well known that
menstrual irritation is accompanied with a great variety of nervous and
hysterical symptoms, which are merely a part of the same series of results
to which epilepsy itself belongs: it is occasionally attended with
delirium, spasms, and even coma, and preceded by the oppression at the pit
of the stomach and pain of head, which we have already noticed among the
immediate precursors of puerperal epilepsy; on the other hand, as Dr.
Parry has well remarked, "the beginning and end of each epileptic fit,
before total insensibility begins and after it ceases, is often delirium,
screaming, false impressions, attempt to annoy others under these
impressions," &c. (_Op. cit._ vol. i. p. 396. &c.) Thus also during
labour, either at the termination of the first stage, when the os uteri
has attained its full degree of dilatation, or immediately after the birth
of the child, the patient is frequently seized with a sudden convulsive
rigour so violent as to make her teeth chatter and agitate the whole bed,
and which is nothing more than a harmless modification of convulsive
action arising from uterine irritation; the surface is perfectly warm, and
the patient frequently expresses her surprise to find herself shivering
thus violently and yet not feel cold.

It has been a common opinion that epileptic puerperal convulsions are
almost certainly fatal to the child, especially if they continue for any
length of time: experience, however, proves the contrary, as cases
continually occur where the mother has laid for many hours in a constant
succession of severe convulsions, and yet has been ultimately delivered of
a living child. Still, however, it must be owned, that barely an equal
number of the children are born alive under these circumstances. Thus, in
Dr. Merriman's 48 cases, as already mentioned, only 17 children were born
alive (including the 6 born before the mothers were attacked with
convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32
children (two of the women having had twins) were born dead; of these,
however, it must be observed, that 8 were delivered with the perforator,
and two were born putrid.

_Tetanic species._ There is one modification of eclampsia parturientium,
which, from the spastic rigidity of the uterus which accompanies it, is
peculiarly dangerous to the child's life: it has been called the tetanic
form: the convulsions are incessant, without any apparent interval, and
the uterus actively participates in the state of general spasms: under
such circumstances, the pressure which it exerts upon the body of the
foetus will seriously obstruct the abdominal circulation, and produce the
same effects as pressure on the cord.

In most cases, however, the convulsions have no effect upon the process of
labour, which continues its course uninterrupted; so that, where there has
been no return of consciousness during the intervals between the fits, and
the patient has laid in a continued state of coma for some time, the child
may actually be born before there has even been a suspicion that labour
was present. It is, therefore, of great importance that the practitioner
should be on the watch to detect any symptoms of its coming on, not only
for the purpose of giving her the necessary support at the moment of
expulsion, but also such assistance as may tend to shorten that process.

"By attentively observing what passes in cases of convulsions, we remark
that they do not always interrupt the course of the labour pains, whether
they had excited those pains, or the pains had preceded them. All authors
relate examples of women who have been delivered without help after
several fits of strong convulsions; and others while they were actually
convulsed, whether there were lucid intervals between, or that the loss of
understanding was permanent. The progress of labour in most of these cases
seems even more rapid than in others, since we have often found the child
between its mother's thighs, though an instant before we could discover no
disposition for delivery." (_Baudelocque_, trans. by Heath, § 1109.)

_Diagnosis of labour during convulsions._ Where the patient is in a state
of insensibility, we may infer the presence of labour by a variety of
symptoms; every now and then, from a state of torpor, she becomes
restless, and evidently uneasy; she pushes the bed-clothes from the
abdomen, and gropes about it as if trying to remove something that is
heavy or uncomfortable; she writhes her body, and moans as if in pain;
after awhile, she again relapses into her former state of coma. A little
attention will soon show us that these exacerbations of restlessness are
periodical; and if we examine the abdomen at the moment, we feel the
uterus evidently contracting; the os uteri also will be found tense and
more or less dilated: if the head has already advanced into the vagina,
these contractions will be accompanied by a distinct effort to strain.

It is rare to find convulsions complicated with malposition of the child;
indeed, so uncommon is the occurrence of it under these circumstances,
that we may feel almost certain, on being summoned to a case of
convulsions, that there will be little chance of this additional
difficulty being superadded. "There was but one case," says Dr. Collins,
"of convulsions during my residence in the hospital, where the child
presented preternaturally; there was not one case with a preternatural
presentation during Dr. Clarke's residence; and Dr. Labatt has stated the
same fact in his lectures while master of the hospital. In these three
different periods there were 48,379 women delivered, so that from this we
may infer, where the presentation is preternatural, there is little cause
to dread the attack." (_Practical Treatise_, p. 200.)

_Prophylactic treatment._ Under no circumstances is the old saying of
"Prevention is better than the cure," so well illustrated as in the
prophylactic treatment of puerperal epilepsy: it is only by carefully
watching for and recognising those symptoms which we have already
enumerated as threatening an attack, that we are able to adopt such
measures as shall either keep it off entirely, or at any rate considerably
diminish its violence.

The treatment which we have recommended during the last weeks of
pregnancy, is particularly valuable in keeping off any disposition to
these attacks: regular, and for her condition even tolerably active,
exercise and strict attention to the bowels, should be required,
especially in primiparæ. If any distinct symptoms of cerebral congestion
make their appearance, such as flushed face, headach, or slight wandering;
if, moreover, the pulse be slow and labouring, we must at once relieve the
circulation by bleeding; and by an active dose of calomel and James's
powder at night with a warm pediluvium, and a brisk laxative the next
morning, endeavour to ward off the dreaded attack. Not unfrequently,
however, we have no warning of the danger until the fits burst out, and
are thus debarred the opportunity of preparing against them.

_Treatment._ During the fit itself little can be done beyond placing the
patient in such a situation that she should not injure herself by her
exertions. If she happens to be upon a chair when the attack begins, it
will be as well to let her sink gently upon the floor, and lie there until
the fit is over; if she is in bed when it comes on, we have merely to
watch that she does not roll off during her struggles; her movements
should be restrained as little as possible, and by so doing we shall spare
her the suffering after the fit from strained muscles and half-wrenched
joints, which is so severe where the assistants, from mistaken kindness,
have endeavoured to hold her.

It has been recommended by Dr. Denman to have the patient's face
frequently dashed with cold water during the fit, a remedy which, as Dr.
Merriman observes, is very effectual in ordinary hysterical paroxysms, and
which possibly may have a slight effect in moderating the violence of the
epileptic convulsions; but from what we have seen we are not inclined to
consider it of much use.

_Bleeding._ As soon as the fit is sufficiently over to render the
operation possible, the patient ought to be placed in a half-sitting
posture, and bled from a large orifice in the arm; the quantity of blood
abstracted must be determined by the appearance of the patient, the
severity of the cerebral symptoms, and the condition of the pulse; this
latter will usually be found labouring, and even small, but will rise
considerably in fulness and volume as we gradually relieve the
circulation. Syncope is an effect which, under these circumstances, it
would neither be easy nor safe to produce; but at the same time it will be
highly desirable to produce a powerful effect upon the circulation by so
large and speedy an abstraction of blood as shall be certain of
alleviating the cerebral congestion: this is not often attained until
after a loss of twenty, or five and twenty ounces. She should be supported
in the half-sitting posture by means of a chair turned against the head of
the bed, so that its back forms an inclined plane, which should be covered
with pillows for her to lean upon.

_Purgatives._ An active dose of purgative medicine should be given the
moment the patient is able to swallow; for in case of the fit returning,
it will be sometimes very difficult to make her take any thing. Eight or
ten grains of calomel, with fifteen or twenty of jalap, should be mixed
into a paste with a little thin gruel and laid upon the back of the
tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If
this cannot be taken, a few drops of croton oil will seldom fail to
produce the necessary effect.

It is of the greatest importance to do this as early as possible, not only
for the reason we have just assigned, but also because we find that
purgative medicines frequently take a longer time to operate in these
cases than they do under ordinary circumstances, and require the
repetition of even a powerful dose before the bowels can be made to act.
Where the convulsions appear to depend in great measure upon the deranged
state of the bowels, the indications for the immediate employment of
purgatives become still more urgent, for although we may control the
cerebral congestion by means of the lancet, we shall not remove the source
of irritation; but when once the bowels have been freely evacuated, the
chain of morbid actions is broken, and the disease ceases: hence, in some
cases, we observe much more striking relief produced by purgatives than
even by bleeding. In order, therefore, to ensure a certain and speedy
effect upon the bowels, she should take, about two hours after the powder,
repeated doses of salts and senna, and if necessary, have their action
still farther assisted by a purgative injection.

In the mean time, the hair must be closely shaven from the crown and back
of the head, leaving the front bands, that she may be disfigured as little
as possible, and a large bullock's bladder half filled with pounded ice,
applied to the bare scalp; in lieu of which, an evaporating lotion of
vinegar spirit and water, may be applied until the ice is procured.
Sinapisms to the calves of the legs and soles of the feet will also be
required, so that, on coming into a room where a patient is lying in
puerperal convulsions, the practitioner may quickly find employment for
the numerous friends or assistants, who generally crowd round her on such
occasions, and convert their officiousness into real utility. The air of
the room must be kept as fresh as possible, and no more people allowed to
remain in it than are absolutely necessary.

If she be tolerably conscious during the interval, a hot foot bath,
rendered still more stimulating by some mustard flour, will be of great
service; flannels wrung out of a hot decoction of mustard, and wrapped
round the feet and legs, are also useful, and tend still farther to
diminish the cerebral congestion.

In all cases of convulsions, especially if the patient be near her full
time, it will be necessary to ascertain the state of the bladder; for the
pressure of the head frequently produces much difficulty in evacuating it,
and sometimes causes so much distention and irritation as to be itself
quite capable of exciting the convulsions. Lamotte has given two instances
where the fits had been evidently brought on by retention of urine, and
where relief was immediately given by evacuating the bladder.

Where the patient has still some time to go, and no appearance of uterine
action has been excited, the probability is, that the above-mentioned
treatment, will be sufficient to prevent a return of the attack; and, if
we have succeeded in calming the circulation, we may combine a little
henbane with her medicine to allay irritability. But if she be near her
full time, and labour has distinctly commenced, there will be little
chance of the convulsions permanently ceasing until she is delivered, as
the contractions of the uterus frequently appear to excite a return of
them.

The practice in former times of dilating the os uteri, introducing the
hand and turning the child, has been long since justly discarded, for the
irritation produced by such improper violence would run great risk of
aggravating the convulsions to a fatal degree.

"No cases require more prudence, attention, and sagacity, than the
accident of convulsions in women, with their first children especially.
The state of the os uteri is of immense importance, and when it will admit
of your delivering the woman without violence, trouble, or irritation, no
doubt it ought to be performed with all prudent expedition, as you never
can be sure of her being restored without delivery." (M'Kenzie's
_Lectures_, MS. 1764, quoted by Dr. Merriman.)

Where we are called to a patient, who has been some little time in
convulsions, and where bleeding and other necessary measures have been
already had recourse to, we may, with a tolerable degree of certainty,
expect to find the os uteri fully dilated, and the head in a favourable
state for the application of the forceps. The practitioner should be able
to apply the forceps whether the patient be lying upon her back or her
side, as it is not always possible to choose her position; the former,
will generally be the safest, as she will not only lie more quietly upon
her back, but can be kept with most facility in this posture. Generally
speaking the fits subside immediately after the child is delivered,
although not unfrequently they recur during the first twelve or sixteen
hours after labour, coming on at increasing intervals.

If, however, the state of the os uteri forbids our interfering with art,
we must be content to follow out that plan of antiphlogistic treatment
which has been just laid down, bearing in mind, that in proportion as we
reduce the power of the circulation we increase the disposition of the os
uteri to dilate, and, as Baudelocque justly observes, "while we wait the
favourable moment for operating, we should only employ those means which
we could use after delivery, if the convulsions should continue." (_Op.
cit._ § 1110.)

By the time that the medicine has begun to operate, a considerable change
will usually be observed in all the symptoms--the violence of the
convulsions abates, the coma is less profound, and if the child be not yet
born, the process of labour much more speedy and favourable; but if we
find that the convulsions assume a tetanic character, and that the uterus
actively participates in this state of spasmodic rigidity, we must not
expect any very favourable change until delivery is effected; and there
will be little chance for the child of its being born alive for reasons
already mentioned. Under such circumstances, which are fortunately of rare
occurrence, it will be our duty to perforate rather than run the risk of
losing the mother as well as her child; but before proceeding to this
extremity we must satisfy our minds that the state of the os uteri forbids
the forceps, and that, from the tetanic action of the uterus, there is
little chance of its farther dilatation.

"It does not always happen that the convulsions cease upon the termination
of the labour; on the contrary, they often continue after the birth of the
child, and sometimes increase in violence, and at length produce death.
If, however, the intervals between the fits become longer, a more
favourable prognosis may be formed, but it will be expedient to continue
our exertions in relieving the symptoms." (Merriman's _Synopsis_.)

The after treatment will be little more than a continuation of that which
has been described during the attack, only in a much milder form: the head
must be kept cool by a proper lotion, and the bowels sufficiently open by
gentle laxatives; a little gruel, with or without milk, may be given
occasionally; and if the child be alive, it should by all means be applied
early to the breast, in order to establish a flow of milk as soon as
possible. Where the breasts have been very flaccid, and there were little
or no signs of milk, we have now and then applied a sinapism over them
with very good effect, for the mammary excitement thus produced has been
attended with a copious lochial discharge, which has evidently produced
much relief.

_Apoplectic species._ Dr. Dewees has described a species of convulsions by
the term "apoplectic," but it is perhaps questionable how far he is
correct in calling them "puerperal convulsions;" for, from the cases which
have come under our own notice, the disease has been nothing else than
genuine apoplexy occurring in the pregnant, parturient, or puerperal
state: he justly observes, that "it may be brought on by causes
independent of pregnancy, though this process may with propriety be
regarded as an exciting cause; for it sometimes takes place when this
process is at its height, but is no otherwise accessary to this end, than
increasing by its efforts the determination of blood to the head." (_Op.
cit._ § 1238.)

The treatment will in no respect differ from that of the genuine puerperal
convulsions, except that, as the danger is still greater, so, if possible,
must the treatment be more prompt; indeed, it can scarcely be said that
there is a convulsion, for there is merely loss of motion with
insensibility. It is fortunately of rare occurrence, as the patient seldom
recovers.

_Anæmic convulsions._ The next form of epiplectic puerperal convulsions is
the anæmic form, where, in consequence of serious loss of blood or
debility otherwise induced, the due balance of the nervous system has been
disturbed, and irregular and convulsive actions have been the result.

We have already shown that cerebral congestion is favourable to that state
of irritability, which, by the help of any exciting cause, may easily pass
into a state of epilepsy; an opposite condition, viz. that of exhaustion,
is capable of acting in a similar way, and thus confirms Dr. Cullen's
assertion, "that there are certain powers of collapse, which, in effect,
prove stimulants and produce epilepsy."

"That there are such powers which may be termed indirect stimulants, I
conclude from hence, that several of the causes of epilepsy are such as
frequently produce syncope, which, we suppose, always to depend upon
causes weakening the energy of the brain." "The first to be mentioned,
which I suppose to be of this kind, is hæmorrhage, whether spontaneous or
artificial. That the same hæmorrhage which produces syncope, often at the
same time produces epilepsy, is well known; and from many experiments and
observations it appears, that hæmorrhages occurring to such a degree as
to prove mortal, seldom do so without first producing epilepsy." (_Op.
cit._) It is a well-known fact, that when once a state of exhaustion or
collapse has been carried beyond a certain point, the irritability of the
nervous system increases in proportion: the due balance of its various
actions becomes more and more unsteady; their equilibrium is disturbed by
the slightest impressions, and losing the state of well-adjusted repose
which belongs to health, they continually vibrate between the extremes of
excitement or collapse, which seldom fail to produce some serious
derangement.

"The symptoms of reaction from loss of blood," says Dr. Marshall Hall,
"accurately resemble those of power in the system, and of morbidly
increased action of the encephalon; and, from these causes, the case is
very apt to be mistaken and mistreated by the farther abstraction of
blood. The result of this treatment is, in itself, again apt farther to
mislead us; for all the previous symptoms are promptly and completely
relieved, and this relief, in its turn, again suggests the renewed use of
the lancet. In this manner the last blood-letting may prove suddenly and
unexpectedly fatal."

_Symptoms._ A very little attention, however, will discover the real
features of the disease; the pale face, the glazy eye, the shrunken
features and colourless lip, the cold moist skin, the heaving chest, the
quick, weak, small, and irritable pulse, all betoken a condition of
exhaustion and collapse. The history of the case will also show that the
patient has suffered from profuse hæmorrhage, or some other debilitating
evacuation; and the intense pain on the summit of the head, verging into
actual delirium, the rambling thoughts and confused mental associations,
the restlessness or absolute insomnia, the tinnitus aurium, disposition to
strabismus or other derangements of vision, indicate the defective
condition of the cerebral circulation.

We have already mentioned, in the congestive form of epilepsy, that where
the irritation from gastric derangement is conjoined to a state of body
already predisposed to the disease, that this is frequently sufficient to
excite it into action; still more will this be the case where the system
is rendered irritable by exhaustion; and it will occur under more
formidable circumstances, from our means of treatment being confined
within still narrower limits. Dr. M. Hall justly observes, that
"exhaustion is sooner induced under circumstances of intestinal
irritation:" and again, "paralysis has occurred in a state of exhaustion
from other causes, as undue lactation; and in various circumstances of
debility, as in cases of disorder of the general health, with sallowness
and pallor, and a loaded tongue and breath."

_Treatment._ Our treatment of these cases will not vary essentially from
that of exhaustion from hæmorrhage under the ordinary circumstances; the
patient must be placed with her head low, and as soon as she is able to
swallow, a little hot brandy and water, or ammonia, should be given to
rouse the circulation to a sufficient degree of activity. If the uterus be
still flaccid and disinclined to contract effectively, a dose of ergot
will be advisable, and the abdomen should be tightly bandaged with a broad
towel. When the powers of the circulation have rallied somewhat, a little
plain beef-tea will frequently prove very grateful and appear to revive
her more powerfully than even the stimulants above-mentioned; and now, as
it is of the greatest importance to calm the irritability of the brain and
nervous system, we must proceed to the use of sedatives. Of these, opium
and hyoscyamus have the preference, the latter especially so, from its not
being liable, like opium, to derange the stomach, or contract the bowels.
Moreover, where the exhaustion is very alarming, it is not always easy to
control the sedative action of opium within due bounds; and in such cases
we are sometimes apt to produce so much sopor, as to render it even
difficult to rouse the patient. For this reason, the combination with a
diffusible stimulant is always desirable: five grains of camphor and of
extr. hyosc. in two pills, form, perhaps, the best and safest sedative
which can be given; these may be repeated every hour, and then at longer
intervals of two or more hours, until sleep has been produced. Sleep, in
cases of this kind, is of the greatest importance, and produces the most
favourable change in the patient's condition; the intense headach and
irritability of the mind, of the sight, and of the hearing, all abate; the
circulation becomes calmer, the pulse more full and soft, the heat of the
body more equable; in short, the whole nervous system is returning to a
more natural and regular state of action, the stomach is more capable of
receiving and digesting its food, the bowels are more manageable, and we
may now venture to remove a state of constipation, if present, or any
morbid intestinal contents without running the risk of bringing on
diarrhoea and increasing the debility.

We rarely find that the convulsions return when once the patient has
enjoyed the calm of a sound and refreshing sleep, and consider the victory
as more than half gained when this favourable state has been produced. The
laxative should be of the mildest form, such as will merely excite the
peristaltic action of the intestines without increasing their secretions;
for this purpose a warm draught of rhubarb manna with hyoscyamus, or
castor oil guarded by a little liq. opii. sed., will be the safest. Food
of the blandest and most nutritious quality should be given in small and
frequently repeated doses; it is important not to load the stomach much or
suddenly, for vomiting is easily produced, and when once excited, the
stomach becomes so irritable as to be scarcely capable of retaining any
food whatever.

Where, on the other hand, several hours have passed, not only without
sleep but without even a temporary state of quiet; where the headach
alternates with restless delirium; where the medicines and nourishment
have produced little or no effect, or have been rejected by vomiting;
where the pulse becomes quicker, and the debility increases, we have not
only to dread a return of the fits, but that the stage of actual sinking
is at hand.

"It would perhaps," says Dr. Marshall Hall, "be difficult to offer any
observations on the nature and cause of excessive reaction; but it is
plain that the state of sinking involves a greatly impaired state of the
functions of all the vital organs, and especially of the brain from
defective stimulus. The tendency to dozing, the snoring and stertor, the
imperfect respiration, the impaired action of the sphincters, the
defective action of the lungs, and the accumulation of the secretions of
the bronchia, the feeble and hurried beat of the heart and pulse, the
disordered state of the secretions of the stomach and bowels, and the
evolution of flatus, all denote an impaired condition of the nervous
energy." (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.)

_Hysterical convulsions_ scarcely deserve the name of puerperal
convulsions, being liable to occur under circumstances quite independent
of the puerperal state; they rarely occur during the process of labour
itself, but are chiefly observed during the last few weeks of pregnancy,
and the first week or so after labour, especially when the milk is coming
on.

_Symptoms._ The patient is of a nervous hysterical habit; "she is either
still very young, or is of a slim and delicate make; the face is pale and
interesting; she has full blue eyes and light hair, and was always of a
highly sensitive constitution; the pulse is quick, small, and contracted;
the temperature of the skin is rather cool than otherwise; her spirits are
variable, fretful, and anxious; she starts at the slightest noise, cannot
bear much or loud talking, and misunderstands or takes every thing amiss.
During her slumbers, which are short, there are slight twitchings of the
eyes and mouth, and in her sleep the eyes are in constant restless motion,
and she frequently starts. She complains of sickness, and has frequent
calls to pass water, which is very pale; slight rigours alternate every
now and then with flushing, and she is easily tired, even by trifling
pains, and dozes a good deal during the intervals. She is excessively
sensitive, even to the most gentle and cautious examination; the os uteri
remains thin, hard, tense, and painful to the touch longer than is usually
the case. The ordinary tension and stretching of the os uteri at the
termination of a regular contraction is attended with much more pain, and
with a peculiar feeling of lassitude, although uncomplicated with any
rheumatic affection. The pains follow no regular course, being sometimes
stronger, at others weaker, and frequently cease entirely for
considerable periods. The uterus has a great disposition from the
slightest irritation, to partial and spasmodic contractions." (Wigand,
_Geburt des Menschen_, vol. i. p. 164.)

Before the fit the patient usually passes a large quantity of colourless
and limpid urine; she has oppression at the stomach, anxiety, difficulty
of breathing and palpitation, with globus, sobbing, and other hysterical
symptoms. There are not those precursory symptoms of cerebral congestion
as mark genuine epileptic puerperal convulsions; the headach is neither so
severe, nor is it in the same place, being usually at the temples and
across the forehead; the face is rather pale than flushed, and when the
fit begins, we see little or none of the convulsive twitching among the
small muscles, as is the case with an epileptic attack; the face is less
distorted, but the large muscles of the trunk and extremities are much
more violently affected; the patient struggles furiously, and in severe
cases has more or less of opisthotonos; she screams, and never appears to
lose her senses so entirely as in the epileptic form; her raving may
generally be controlled to a certain extent by suddenly dashing cold water
in her face, and speaking loudly and sharply to her; at any rate it
instantly produces a deep and sudden inspiration, which is frequently
attended with a prolonged hooping sound; this is followed by sobbing,
gasping, choking, and the ordinary phenomena of an hysteric fit, but the
convulsions themselves are usually arrested more or less by this
application: we hold the effects of cold water to be one of the best
diagnostics of the disease from epilepsy, in which the patient is entirely
insensible to such impressions.

A similar fact is observed during vaginal examination; the patient seems
aware of our intention, and resists in every possible way.

"The patient, after the fit, can for the most part be roused to attention
or will frequently become coherent so soon as she recovers from the
fatigue or exhaustion occasioned by her violent struggles; and though she
may lie apparently stupid, she will nevertheless sometimes talk or
indistinctly mutter. After the convulsion has passed over, she will often
open her eyes and vacantly look about, and then, as if suddenly seized by
a sense of shame, will sink lower in the bed, and attempt to hide her head
in the clothes." (Dewees's _Compend. Syst. of Midwifery_, § 1240.)

When sufficiently recovered to be capable of swallowing, she should sip
some cold water, or what is still better, take a dose of spiritus ammoniæ
foetidus in water; this soon produces copious eructations from the
stomach, which are followed with much relief. Where there is a disposition
to vomiting, and other evidences of a deranged stomach, it should be
encouraged by some warm water, chamomile tea, &c. The bowels are almost
always in an unhealthy state, which frequently produces much irritation,
and in plethoric habits so much tendency to cerebral congestion as to
endanger even an attack of the epileptic convulsions. One or two doses of
a pretty brisk purgative should, therefore, be given, and if there be
still heat or pain of head, a bleeding may be required.

Under ordinary circumstances hysterical convulsions are by no means
dangerous, and beyond a little fatigue and exhaustion, the patient
recovers from them almost immediately.



CHAPTER XII.

PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.

    _History.--Dr. Rigby's division of hæmorrhages before labour into
    accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.--
    Turning.--Partial presentation of the placenta.--Treatment._


There are few dangers connected with the practice of midwifery which are
more deservedly dreaded, and which are wont to come more unexpectedly,
both to the patient as well as to the practitioner, than that species of
hæmorrhage which occurs in cases where the placenta is implanted either
_centrally_ or _partially_ over the os uteri. Well has a celebrated
teacher observed, that "there is no error in nature to be compared with
this, for the very action which she uses to bring the child into the world
is that by which she destroys both it and its mother." (Naegelé, _MS.
Lectures_.) In other words, where there is this peculiar situation of the
placenta it becomes gradually detached, either in proportion as the cervix
expands during the latter months of pregnancy, or as the os uteri dilates
with commencing labour, and is thus unavoidably attended with a profuse
discharge of blood, which generally increases as the dilatation proceeds.

The peculiar feature of this species of hæmorrhage, necessarily
accompanying the commencement of every labour where the placenta is
implanted over the os uteri, was first fully described in this country in
1775, by the late Dr. Rigby, in his classical _Essay on the Uterine
Hæmorrhage which precedes the Delivery of the full-grown Foetus_, a work
which has been justly looked upon, both in England and the Continent, as
the great source to which we are indebted for our practical knowledge in
the management of these dangerous cases.

_History._ There is abundant evidence to prove the sudden attacks of
hæmorrhage during pregnancy, attended with circumstances of great danger
to the life of the mother and her child, were known from the earliest
times, and especially noticed by Hippocrates where he says, "that the
after-burden should come forth after the child, for if it come first, the
child cannot live, because he takes his life from it, as a plant doth from
the earth." (_De Morbis Mulierum_, lib. i. quoted by Guillemeau.)

Hippocrates, therefore, evidently supposed that this presentation of the
placenta at the os uteri was owing to its having been separated from its
usual situation in the uterus, and fallen down to the lower part of it.

This view has been closely adopted by Guillemeau, to whom we are indebted
for having called our attention to the above passage. He has devoted his
fifteenth chapter[140] to the management of a case where the placenta
presents, and shows that "the most certain and expedient method is to
deliver the patient promptly, in order that she may not suffer from the
hæmorrhage which issues from the uncovered mouths of the uterine veins, to
which the placenta had been attached; that, on the other hand, the child
being enclosed in the uterus, the orifice of which is plugged up by the
placenta, and unable to breathe any more by the arteries of its mother,
will be suffocated for want of assistance, and also enveloped in the blood
which fills the uterus and escapes from the veins in it which are open."

The operation of turning, which had been newly practised by his teacher,
Ambrose Paré, and still farther brought into notice by himself, at that
time formed a great æra in midwifery, for it furnished practitioners with
a new and successful means of delivering the child in cases where urgent
danger could only be avoided by hastening labour; hence, therefore, in all
cases of profuse hæmorrhage coming on before delivery, it was a general
rule, if the case became at all dangerous, to turn the child.

Guillemeau's explanation of the nature of placental presentations was
still more explicitly adopted by Mauriceau, La Motte, and many others.
Mauriceau invariably speaks of the placenta, when at the os uteri, as
"entirely detached;" and adds that "even a short delay will always cause
the sudden death of the child if it be not quickly delivered; for it
cannot remain any time without being suffocated, as it is now obliged to
breathe by its mouth, for its blood is no longer vivified by the
preparation which it undergoes in the placenta, the function and use of
which cease the moment it is detached from the uterine vessels with which
it was connected: the result of this is the profuse flooding which is so
dangerous for the mother; for if it be not prom