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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.

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.—Fœtal 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 fœtal heart.—Funic souffle.—Sound produced by the movements of the fœtus.—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.—Diarrhœa.—Pruritus pupendi.—Salivation,

101   CHAPTER III.

SIGNS OF THE DEATH OF THE FŒTUS.

Difficulty of the subject.—Signs before labour.—Motion of the fœtus.—Sound of the fœtal 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 FŒTUS.

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 fœtus.—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 fœtus,

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 œdematous 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 fœtus 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.

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 fœtal 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.

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]

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.

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.

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.

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 fœtus 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 fœtus 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 fœtal 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 fœtus 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 fœtus, 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.

Uterus duplex.

Before quitting this subject, it will be necessary to point out the changes which the uterus presents at different periods of fœtal 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.

Uterus bicollis.

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.

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.

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.

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 fœtus 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 Rœderer 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.

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.

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.

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.—Fœtal 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 fœtus, are called the fœtal 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.

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.

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]

Decidual cotyledons. From Dr. Montgomery.

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.

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 fœtal membranes, for they are essentially connected with the origin of the fœtus 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 fœtus, 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 fœtus 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 fœtal 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 fœtus.

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 Fœtus, 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 fœtus 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 fœtus. It appears to be a means of nourishment to the fœtus 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 fœtus, it serves many useful purposes; it secures the fœtus 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 fœtus 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 fœtal 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 (fœtal) 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.

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.

Fœtal surface of the placenta.

The fœtal 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 fœtal 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 fœtal. 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 fœtal 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 fœtus 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 fœtal 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 fœtus 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 fœtal into the uterine vessels, or vice versâ. Lobstein has mentioned a mode of illustrating this fact (Essai sur la Nutrition du Fœtus,) 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 fœtus, 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 fœtus 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 fœtus; it consists of two umbilical arteries and one umbilical vein; the former conveying the blood from the common iliac arteries of the fœtus 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 fœtus. 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 fœtus 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 Fœtus. § 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 fœtus, 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 fœtus 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 fœtal 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.

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.

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.”

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.

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 fœtus 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.)

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 fœtal 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 fœtus 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.

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 fœtus, 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 fœtal 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.

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 œsophagus 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.

Diagram of the fœtus 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 fœtal extremity of which, according to Professor Oken’s views, forms the processus vermiformis.

Diagram of the fœtus 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 fœtus 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 fœtus. 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 fœtus.

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 fœtus 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 fœtus 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 fœtus 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 fœtus, 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 fœtus.”

The absorbing power of the umbilical vein continues till the fifth month; during the second or third, the fœtus 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 fœtus 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 fœtus, 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 fœtus 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 fœtal skeleton, would surely lead us to infer that the placenta in some way or other supplies the materials for this process.

Fœtal 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 fœtal 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 fœtus must also be remembered: surrounded by the liquor amnii, the fœtus 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 fœtal 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 fœtal 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 fœtal 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 fœtus, 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 fœtal 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 fœtus 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 fœtal 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 fœtal 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 fœtal 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 fœtal 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 fœtal heart.—Funic souffle.—Sound produced by the movements of the fœtus.—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 dysmenorrhœa, &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 fœtus.

Movements of the fœtus. 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 fœtus 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 fœtal 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 fœtal 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 fœtal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the fœtus 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 fœtal 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 fœtal 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 fœtus 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 fœtal 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 fœtal 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 fœtal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnœa, 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 fœtus. (Naegelé, op. cit. p. 39.) Dr. Kennedy has observed some remarkable cases where the fœtal 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 fœtal 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 fœtus 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 fœtal 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 fœtal 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 fœtal 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 fœtal 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 fœtal 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 fœtal 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 fœtus 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 fœtal 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 fœtal 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 fœtus, 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 fœtus. 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 fœtus 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 fœtus 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 fœtus, 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 fœtuses 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 fœtus 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 fœtal 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.—Diarrhœa.—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 leucorrhœa, 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 fœtus, 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.

Diarrhœa 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 fœtus, but it acts also in a more direct manner by exciting uterine contractions, particularly when accompanied, as is frequently the case, with tenesmus. The diarrhœa 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 FŒTUS.

Difficulty of the subject.—Signs before labour.—Motion of the Fœtus.—Sound of the fœtal 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 fœtus 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 fœtus than she does of her own liver or spleen. The living fœtus obeys the laws of organic life; the dead fœtus 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 fœtal 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 fœtal pulsations, it may be asserted on very safe grounds that the fœtus 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 fœtal 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 fœtal 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. (Rœderer, 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 fœtus 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, leucorrhœa comes on, followed by œdema 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 leucorrhœa, menorrhagia, or dysmenorrhœa, 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.

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 fœtus. 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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’ fœtus, 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 fœtal 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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.

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.) Œtius, 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 fœtus 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 fœtus 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 fœtus 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 dysmenorrhœa 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 FŒTUS.

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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 fœtus 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 dysmenorrhœa 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 fœtus, without its previous death by local causes, as acute leucorrhœa, 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 dysmenorrhœa: 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 fœtus; 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 fœtus 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 fœtus 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 leucorrhœa, menorrhagia, and dismenorrhœa, 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 fœtus, 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 fœtus 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 diarrhœa 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 fœtus, 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 fœtus 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 fœtus 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 leucorrhœa 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 fœtus 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 fœtus for its expulsion; 2dly, the expulsion of the fœtus; 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 fœtus 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 œdematous, 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 œdematous 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 fœtal 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 fœtal 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 diarrhœa 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 ♏ 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 diarrhœa 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, diarrhœa, &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 œdematous 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 fœtus, 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 œdematous 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 fœtus 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 108½. 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.