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diff --git a/40654-h/40654-h.htm b/40654-h/40654-h.htm index 79a473e..73622be 100644 --- a/40654-h/40654-h.htm +++ b/40654-h/40654-h.htm @@ -2,7 +2,7 @@ "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> -<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1" /> +<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title>The Project Gutenberg eBook of A System of Midwifery, by Edward Rigby</title> <style type="text/css"> @@ -61,25 +61,9 @@ </style> </head> <body> +<div>*** START OF THE PROJECT GUTENBERG EBOOK 40654 ***</div> <h1>The Project Gutenberg eBook, A System of Midwifery, by Edward Rigby</h1> -<p>This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at <a -href="http://www.gutenberg.org">www.gutenberg.org</a></p> -<p>Title: A System of Midwifery</p> -<p>Author: Edward Rigby</p> -<p>Release Date: September 3, 2012 [eBook #40654]</p> -<p>Language: English</p> -<p>Character set encoding: ISO-8859-1</p> -<p>***START OF THE PROJECT GUTENBERG EBOOK A SYSTEM OF MIDWIFERY***</p> <p> </p> -<h4>E-text prepared by Bryan Ness<br /> - and the Online Distributed Proofreading Team<br /> - (<a href="http://www.pgdp.net">http://www.pgdp.net</a>)<br /> - from page images generously made available by<br /> - Internet Archive/American Libraries<br /> - (<a href="http://archive.org/details/americana">http://archive.org/details/americana</a>)</h4> <p> </p> <table border="0" style="background-color: #ccccff;margin: 0 auto;" cellpadding="10"> <tr> @@ -125,7 +109,7 @@ Completely Revised, with Numerous Additions and Improvements,<br /> MEDICAL SCIENCE AND LITERATURE:</p> <p class="center"><small>CONTAINING</small></p> <p class="note">A concise account of the various Subjects and Terms, with a vocabulary of -Synonymes in different languages, and formulæ for various officinal and empirical +Synonymes in different languages, and formulæ for various officinal and empirical preparations, &c.</p> <p class="center">IN ONE ROYAL 8vo. VOLUME.</p> @@ -291,7 +275,7 @@ pelvis.—Diameters of the pelvis.—Pelvis before puberty.—Axes.& <tr><td> </td></tr> <tr><td align="center"><a href="#PART_I_CHAPTER_II">CHAPTER II.</a></td></tr> <tr><td align="center">FEMALE ORGANS OF GENERATION.</td></tr> -<tr><td>Internal and external.—Ovaria.—Ovum.—Corpus luteum.—Fallopian tubes.—Uterus.—Vagina.—Hymen.—Clitoris.—Nymphæ.—Labia,</td> +<tr><td>Internal and external.—Ovaria.—Ovum.—Corpus luteum.—Fallopian tubes.—Uterus.—Vagina.—Hymen.—Clitoris.—Nymphæ.—Labia,</td> <td align="right"><a href="#Page_22">22</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_I_CHAPTER_III">CHAPTER III.</a></td></tr> @@ -400,8 +384,8 @@ foremost.—Turning with the head foremost.—History of turning,</td> <td align="right"><a href="#Page_230">230</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_IV_CHAPTER_III">CHAPTER III.</a></td></tr> -<tr><td align="center">CÆSAREAN OPERATION.</td></tr> -<tr><td>Indications,—Different modes of performing the operation.—History of the Cæsarean operation,</td> +<tr><td align="center">CÆSAREAN OPERATION.</td></tr> +<tr><td>Indications,—Different modes of performing the operation.—History of the Cæsarean operation,</td> <td align="right"><a href="#Page_243">243</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_IV_CHAPTER_IV">CHAPTER IV.</a></td></tr> @@ -456,7 +440,7 @@ of contracted pelvis.—Effects of difficult labour from deformed pelvis.&md 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,</td> +nymphæ.—Tumours.—Distended or prolapsed bladder.—Stone in the bladder,</td> <td align="right"><a href="#Page_308">308</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_V_CHAPTER_VI">CHAPTER VI.</a></td></tr> @@ -465,7 +449,7 @@ nymphæ.—Tumours.—Distended or prolapsed bladder.—Stone in the <span class="pagenum"><a name="Page_10" id="Page_10">[Pg 10]</a></span>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,</td> +abdominal and other muscles is at fault.—Faulty state of the expelling powers after the birth of the child.—Hæmorrhage.—Treatment,</td> <td align="right"><a href="#Page_324">324</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_V_CHAPTER_VII">CHAPTER VII.</a></td></tr> @@ -493,12 +477,12 @@ labour.—Rupture of the cord.—Treatment.—Connexion of precipita <tr><td align="center">PUERPERAL CONVULSIONS.</td></tr> <tr><td>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,</td> +species.—Anæmic convulsions.—Symptoms.—Treatment.—Hysterical convulsions.—Symptoms,</td> <td align="right"><a href="#Page_376">376</a></td></tr> <tr><td> </td></tr> <tr><td align="center"><a href="#PART_V_CHAPTER_XII">CHAPTER XII.</a></td></tr> -<tr><td align="center">PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.</td></tr> -<tr><td>History.—Dr. Rigby’s division of hæmorrhages before labour into accidental and +<tr><td align="center">PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.</td></tr> +<tr><td>History.—Dr. Rigby’s division of hæmorrhages before labour into accidental and unavoidable.—Causes.—Symptoms.—Treatment.—Plug.—Turning.—Partial presentation of the placenta.—Treatment,</td> <td align="right"><a href="#Page_393">393</a></td></tr> <tr><td> <span class="pagenum"><a name="Page_11" id="Page_11">[Pg 11]</a></span></td></tr> @@ -544,7 +528,7 @@ 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, <i>Art des Accouchemens</i> of the French, the <i>Ostetricia</i>, and <i>Arte della Parteria</i>, -of the Italians and Spaniards, and the <i>Geburtshülfe</i> of the Germans, are +of the Italians and Spaniards, and the <i>Geburtshülfe</i> 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.</p> @@ -650,11 +634,11 @@ still farther strengthened by the support of powerful ligaments.</p> <p>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 +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, <i>Anat. -Méd.</i>) These laminæ of intervening fibro-cartilage are thicker in the +Méd.</i>) 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 @@ -668,11 +652,11 @@ 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, +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 +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 +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.</p> @@ -709,7 +693,7 @@ 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 <i>brim</i>, 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 +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 @@ -759,8 +743,8 @@ afford a beautiful instance of design and adaptation.</p> <p>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°. +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, <i>Handbuch der Embindungs-kunst</i>, cap. iv. p. 58.)</p> <p>From the greater width of the female pelvis, the acetubula are farther @@ -798,10 +782,10 @@ measuring three of their diameters,—1. the <i>straight</i>, <i>antero-posterior</i>, or <i>conjugate</i>; 2. the <i>transverse</i>; and 3. the <i>oblique</i>. 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 +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, +acetabulum, 4·8 inches. The oblique diameters are called right and left, according to the sacro-iliac symphysis from which they are drawn.</p> <p> </p> @@ -821,21 +805,21 @@ diameters.</p> <p>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<span class="pagenum"><a name="Page_20" id="Page_20">[Pg 20]</a></span> the point +symphysis pubis, is 4·8 inches; the transverse, from<span class="pagenum"><a name="Page_20" id="Page_20">[Pg 20]</a></span> 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 +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.</p> +foramen ovale of the other, 5·2.</p> <p>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 +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 +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 +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.</p> +ischium and descending ramus of the pubes on the other 4·8 inches.</p> <p>Although these are the proportions of the brim cavity and outlet of the female pelvis in the skeleton state, their real dimensions during life, @@ -873,7 +857,7 @@ it has assumed the proper proportions of the adult female pelvis.</p> 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 +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 @@ -898,7 +882,7 @@ 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 <i>vice versâ</i>; +less will be that which the axis of the outlet forms, and <i>vice versâ</i>; or, in other words, the angle with the horizon which the axis of the one forms is inversely to that of the other.</p> @@ -919,7 +903,7 @@ anormalities are described.</p> <p class="title">FEMALE ORGANS OF GENERATION.</p> <div class="note"><p class="hang"><i>Internal and external.—Ovaria.—Ovum.—Corpus luteum.—Fallopian -tubes.—Uterus.—Vagina.—Hymen.—Clitoris.—Nymphæ.—Labia.</i></p></div> +tubes.—Uterus.—Vagina.—Hymen.—Clitoris.—Nymphæ.—Labia.</i></p></div> <p>The female organs of generation have been usually classed by the English @@ -1036,7 +1020,7 @@ 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.</p> +firmly grasps the ovary at this point by means of its fimbriæ.</p> <p>These changes begin to take place immediately after impregnation; the inner lining of the vesicle, which Professor von Baer considers to be a @@ -1174,7 +1158,7 @@ advanced age presents a shrivelled appearance.</p> <p>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 +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, @@ -1210,7 +1194,7 @@ 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 +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 @@ -1228,7 +1212,7 @@ 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 +“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.”<a name='fna_6' id='fna_6' href='#f_6'><small>[6]</small></a> From the great degree of vascularity which is observed in the Fallopian tubes at this period, some @@ -1253,7 +1237,7 @@ 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 +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.”<a name='fna_8' id='fna_8' href='#f_8'><small>[8]</small></a></p> @@ -1289,12 +1273,12 @@ 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<span class="pagenum"><a name="Page_31" id="Page_31">[Pg 31]</a></span> 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 <i>os tincæ</i> or <i>os +these there is a transverse fissure known by the name of <i>os tincæ</i> or <i>os uteri externum</i>, 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 <i>arbor vitæ</i>. The lips of the +anterior and posterior wall a number of delicate rugæ diverging obliquely +in an arborescent form, and hence called the <i>arbor vitæ</i>. The lips of the os uteri are smooth, except when slight lacerations have taken place during labour.</p> @@ -1303,7 +1287,7 @@ 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 +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 @@ -1317,7 +1301,7 @@ parallel to the axis of the superior aperture of the pelvis.</p> of peritoneum, which are continuous with that portion of it which covers the fundus. The most considerable are the <i>broad</i> or <i>lateral ligaments</i>: these arise from the sides of the uterus, which is enclosed between their -anterior and posterior layers or laminæ; they proceed transversely +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.</p> @@ -1450,7 +1434,7 @@ which had been detached from the ovary, and conveyed into the cavity of the uterus.</p> <p>The mucous membrane which lines the cervix uteri is corrugated into a -number of rugæ, between which the mucous follicles are chiefly found.</p> +number of rugæ, between which the mucous follicles are chiefly found.</p> <div class="figleft"><img src="images/img07.jpg" alt="" /><br />Uterus duplex.</div> @@ -1532,7 +1516,7 @@ 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 +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 @@ -1602,7 +1586,7 @@ 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<span class="pagenum"><a name="Page_38" id="Page_38">[Pg 38]</a></span> irregular -tufted rugæ, which serve to give a more intimate connexion between the +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 @@ -1680,7 +1664,7 @@ 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 +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,<span class="pagenum"><a name="Page_40" id="Page_40">[Pg 40]</a></span> the @@ -1718,9 +1702,9 @@ 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.</p> -<p>In primiparæ, or women pregnant for the first time, the <span class="pagenum"><a name="Page_41" id="Page_41">[Pg 41]</a></span>margin of the os +<p>In primiparæ, or women pregnant for the first time, the <span class="pagenum"><a name="Page_41" id="Page_41">[Pg 41]</a></span>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 +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.</p> @@ -1773,7 +1757,7 @@ length, being scarcely half an inch in length.</p> <p>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 +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 @@ -1792,7 +1776,7 @@ in a few moments descends and may again be felt.</p> <p>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 +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 @@ -1802,9 +1786,9 @@ distinctly felt.</p> <p>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 +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 +breathing is therefore more marked in them than in multiparæ, for the fundus uteri rising so high prevents in great measure the action<span class="pagenum"><a name="Page_43" id="Page_43">[Pg 43]</a></span> 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 @@ -1832,7 +1816,7 @@ 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.<a name='fna_16' id='fna_16' href='#f_16'><small>[16]</small></a></p> +but remain closed in primiparæ until the commencement of labour.<a name='fna_16' id='fna_16' href='#f_16'><small>[16]</small></a></p> <p>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 @@ -1842,14 +1826,14 @@ 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 +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<span class="pagenum"><a name="Page_44" id="Page_44">[Pg 44]</a></span> 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 +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 @@ -1899,13 +1883,13 @@ undergoes that gradual diminution of size and bulk which we have just alluded to.</p> <p>The copulative or external organs of generation are the <i>vagina</i>, <i>hymen</i>, -<i>clitoris</i>, <i>nymphæ</i>, and <i>labia</i>, the three last being known by the term +<i>clitoris</i>, <i>nymphæ</i>, and <i>labia</i>, the three last being known by the term <i>vulva</i>.</p> <p><i>Vagina.</i> 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 +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 @@ -1916,11 +1900,11 @@ convex, anteriorly concave.</p> <p>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 +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 <i>columna rugarum anterior and posterior</i>, which appear to be a continuation of the corrugations which -form the arbor vitæ of the cervix.</p> +form the arbor vitæ of the cervix.</p> <p>In the upper part of the vagina there are considerable mucous follicles, which moisten the canal with their secretion, and which during sexual @@ -1934,7 +1918,7 @@ 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.</p> +circulation of the nymphæ, bladder, and rectum.</p> <p><i>Hymen.</i> The lining membrane of the vagina is of a reddish-gray colour, interspersed here and there, especially at its upper part, with livid @@ -1947,7 +1931,7 @@ 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 <i>carunculæ myrtiformes</i>, arising from the posterior and +appendages, called <i>carunculæ myrtiformes</i>, arising from the posterior and lateral portions of the os externum.</p> <p>From the identity of its fibrous coat with that of the uterus, the vagina @@ -1961,7 +1945,7 @@ 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 +called the sphincter or constrictor vaginæ, and assists the corpus cavernosum still farther in contracting the os externum.</p> <p><i>Clitoris.</i> The clitoris is an oblong cylindrical body, situated beneath @@ -1991,7 +1975,7 @@ considerable muscles, called the erectores clitoridis, arising<span class="pagen tendons close beneath them from the inner surface of the ascending ramus of the ischium, and extending nearly to their extremity.</p> -<p><i>Nymphæ.</i> The <i>nymphæ</i> or <i>labia pudendi interna</i>, are two long corrugated +<p><i>Nymphæ.</i> The <i>nymphæ</i> or <i>labia pudendi interna</i>, 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 @@ -2007,11 +1991,11 @@ 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.</p> -<p>The space between the nymphæ and edge of the hymen is smooth, without +<p>The space between the nymphæ and edge of the hymen is smooth, without corrugation, and is called <i>vestibulum</i>.</p> <p>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 +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 @@ -2028,7 +2012,7 @@ little in size and depth, as it descends, forming a scaphoid or boat-like cavity, viz. the <i>fossa navicularis</i>.</p> <p>The labia are thicker above, becoming thinner below, and terminate in a -transverse fold of skin, called the <i>frænulum perinei</i>, or <i>fourchette</i>, +transverse fold of skin, called the <i>frænulum perinei</i>, or <i>fourchette</i>, 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, @@ -2230,7 +2214,7 @@ 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 +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<span class="pagenum"><a name="Page_53" id="Page_53">[Pg 53]</a></span> been @@ -2418,7 +2402,7 @@ 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 +shooting out into innumerable floating processes and rugæ, with the most irregular<span class="pagenum"><a name="Page_57" id="Page_57">[Pg 57]</a></span> 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 @@ -2441,7 +2425,7 @@ 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 +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.</p> @@ -2642,7 +2626,7 @@ 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 <i>vice versâ</i>. Lobstein has mentioned a mode of illustrating +vessels, or <i>vice versâ</i>. Lobstein has mentioned a mode of illustrating this fact (<i>Essai sur la Nutrition du Fœtus</i>,) 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 @@ -2691,7 +2675,7 @@ 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, <i>sur la Nutrition -du Fœtus</i>. § 75.)</p> +du Fœtus</i>. § 75.)</p> <p>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 @@ -2830,7 +2814,7 @@ mammalia and man it receives the name of <i>vesicula umbilicalis</i>. Its albuminous covering, which corresponds to the white and membrane of the shell in birds, is called <i>chorion</i>: 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 +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.</p> @@ -2859,8 +2843,8 @@ 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 <i>plicæ primitivæ</i> -of Pander, the <i>laminæ dorsales</i> of Baer:) the canal soon becomes closed +open at both ends, by the junction of its margins (the <i>plicæ primitivæ</i> +of Pander, the <i>laminæ dorsales</i> 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 @@ -2873,14 +2857,14 @@ 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.</p> +the dorsal vertebræ.</p> <p> </p> <p class="figcenter"><img src="images/img25.jpg" alt="" /></p> -<p class="note"><i>a</i> Transparent area. <i>b</i> Laminæ dorsales. <i>c</i> Cephalic -end. <i>d</i> Rudiments of dorsal vertebræ. <i>e</i> Serous layer. <i>f</i> Lateral +<p class="note"><i>a</i> Transparent area. <i>b</i> Laminæ dorsales. <i>c</i> Cephalic +end. <i>d</i> Rudiments of dorsal vertebræ. <i>e</i> Serous layer. <i>f</i> Lateral portion of the primitive trace. <i>g</i> Mucous layer. <i>h</i> Vascular layer. <i>k</i> -Laminæ dorsales united to form the spinal canal.</p> +Laminæ dorsales united to form the spinal canal.</p> <p> </p> <p>“About the same time, or from the twentieth to the <span class="pagenum"><a name="Page_68" id="Page_68">[Pg 68]</a></span>twenty-fourth hour, @@ -2970,7 +2954,7 @@ 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 +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 <span class="pagenum"><a name="Page_70" id="Page_70">[Pg 70]</a></span>elongated form which rises from the inferior or caudal extremity of the embryo, viz. the @@ -2994,7 +2978,7 @@ known by the name of the liquor amnii spurius, which, strictly speaking is the liquor allantoidis.</p> <p>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 +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 @@ -3030,7 +3014,7 @@ entirely in the water.</p> 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 (<i>Acta Naturæ Curios.</i> vol. +processes or gills. It is to Professor Rathke (<i>Acta Naturæ Curios.</i> 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 @@ -3120,9 +3104,9 @@ vermiformis.</p> <p class="center"><i>Diagram of the fœtus and membranes about the sixth week.</i></p> <p class="note"><i>a</i> Chorion. <i>b</i> The larger absorbent extremities, the site of the -placenta. <i>c</i> Allantois. <i>d</i> Amnion. <i>e</i> Urachus. <i>é</i> Bladder. <i>f</i> +placenta. <i>c</i> Allantois. <i>d</i> Amnion. <i>e</i> Urachus. <i>é</i> Bladder. <i>f</i> Vesicula umbilicalis. <i>g</i> Communicating canal between the vesicula -umbilicalis and intestine. <i>h</i> Vena umbilicalis. <i>i i</i> Arteriæ +umbilicalis and intestine. <i>h</i> Vena umbilicalis. <i>i i</i> Arteriæ umbilicales. <i>l</i> Vena omphalo-meseraica. <i>k</i> Arteria omphalo-meseraica. <i>n</i> Heart. <i>o</i> Rudiment of superior extremity. <i>p</i> Rudiment of lower extremity. <i>From Carus.</i></p> @@ -3130,7 +3114,7 @@ extremity. <i>From Carus.</i></p> <p>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.</p> +ossa innominata, the ribs, and scapulæ are cartilaginous.</p> <p>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 @@ -3193,7 +3177,7 @@ they unite into one large mass, an intermediate portion extending across the spine, forming the horse-shoe kidney.</p> <p>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 +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 <i>Gubernaculum testis</i>: they then pass through the openings carrying before them that portion of the peritoneum which is to @@ -3206,11 +3190,11 @@ the vernix caseosa;<a name='fna_28' id='fna_28' href='#f_28'><small>[28]</small> 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, +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 +it soon passes urine and fæces, and greedily takes the nipple. (Naegelé’s <i>Hebammenbuch</i>.)</p> <p>Thus, then, in the space of forty weeks, or ten lunar months, from an @@ -3230,7 +3214,7 @@ 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, +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 @@ -3331,7 +3315,7 @@ 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 +the vena portæ, which supplies the right lobe, it passes at once by a short passage, called <i>canalis venosus</i>, into the vena cava.</p> <p>Thus, then, the peculiarities of the fœtal circulation may be @@ -3456,7 +3440,7 @@ 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 <i>vice versâ</i>; in +cheerful disposition, are now gloomy and reserved, and <i>vice versâ</i>; 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.<a name='fna_30' id='fna_30' href='#f_30'><small>[30]</small></a> Some are liable to spasmodic affections, palpitations, spasmodic cough, @@ -3490,7 +3474,7 @@ the gravid uterus obstructing the peristaltic motion.</p> <p>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 <i>vice versâ</i>; in some the skin assumes +have frequently a high colour, and <i>vice versâ</i>; 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 @@ -3573,10 +3557,10 @@ 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, +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.” (<i>Compendious System of -Midwifery</i>, § 235.)</p> +Midwifery</i>, § 235.)</p> <p>It occasionally happens that the first appearance of the catamenia after conception is more abundant than usual, a circumstance which had been @@ -3613,13 +3597,13 @@ 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.” (<i>Op. cit.</i> § 237.)</p> +of pregnancy.” (<i>Op. cit.</i> § 237.)</p> <p>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 <i>Art des Accouchemens</i>, § +explained as well as confirmed by Levret in his <i>Art des Accouchemens</i>, § 230:—“A woman,” says he, “may conceive, although she has not yet menstruated, provided menstruation would otherwise have made its appearance shortly.”<a name='fna_35' id='fna_35' href='#f_35'><small>[35]</small></a></p> @@ -3630,7 +3614,7 @@ 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<span class="pagenum"><a name="Page_86" id="Page_86">[Pg 86]</a></span> the non-appearance of the menses cannot be looked upon by -itself as a diagnostic of pregnancy, or <i>vice versâ</i>: this is more +itself as a diagnostic of pregnancy, or <i>vice versâ</i>: 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 @@ -3772,7 +3756,7 @@ 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 +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 @@ -3786,7 +3770,7 @@ 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.<a name='fna_40' id='fna_40' href='#f_40'><small>[40]</small></a> In +Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.<a name='fna_40' id='fna_40' href='#f_40'><small>[40]</small></a> In this interesting memoir, the author has described two sounds, which are perfectly distinct from each other in point of <span class="pagenum"><a name="Page_90" id="Page_90">[Pg 90]</a></span>character. One of them consists of single pulsations, synchronous with those of the mother’s @@ -3805,7 +3789,7 @@ fœtal heart.</p> <p><i>Uterine souffle.</i> The uterine sound, or <i>souffle</i>, 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 +sides of the organ; and according to the observations of Professor Naegelé jun.,<a name='fna_42' id='fna_42' href='#f_42'><small>[42]</small></a> 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 @@ -3851,8 +3835,8 @@ 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, <i>op. cit.</i> p. 86,) the placenta is +in cases of fever, or dispositions to hæmorrhage, where the vessels are +usually distended, or where (Naegelé, <i>op. cit.</i> 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 @@ -3870,7 +3854,7 @@ 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 +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 @@ -3910,13 +3894,13 @@ 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 +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, +perceptible change has been observed in that of the fœtus. (Naegelé, <i>op. cit.</i> p. 39.) Dr. Kennedy has observed some remarkable cases where the fœtal pulse appeared to vary in accordance with that of the mother (<i>op. cit.</i> p. 91;) but when we bear in mind the frequent changes in point @@ -3967,13 +3951,13 @@ nature of the case is satisfactorily established beyond all possibility of doubt.</p> <p><span class="pagenum"><a name="Page_94" id="Page_94">[Pg 94]</a></span>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 +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, +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 @@ -4071,7 +4055,7 @@ great importance in the diagnosis of pregnancy.</p> of a peculiar deposite in the urine as described by M. Nauche, or rather by Savonarola (Montgomery, <i>op. cit.</i> 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. +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, @@ -4202,7 +4186,7 @@ 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, <i>Zweifelhafte Schwangerschafts-fälle</i>.) A most extraordinary case +Schmitt, <i>Zweifelhafte Schwangerschafts-fälle</i>.) 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. @@ -4281,7 +4265,7 @@ 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.</p> +indicative of derangement in the functions of the primæ viæ.</p> <p><i>Morning sickness.</i> One of the most troublesome, and by no means the least frequent, is vomiting, which, from coming on<span class="pagenum"><a name="Page_102" id="Page_102">[Pg 102]</a></span> usually in the morning, is @@ -4392,7 +4376,7 @@ 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.” (<i>System of Midwifery</i>, § 275.)</p> +it.” (<i>System of Midwifery</i>, § 275.)</p> <p>The <i>constipation, flatulence, colicky pains, and headach, the spasmodic cough, palpitation, toothach</i>, &c. are symptoms arising from the same @@ -4428,7 +4412,7 @@ 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 +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.</p> @@ -4452,7 +4436,7 @@ 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 +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 @@ -4472,7 +4456,7 @@ 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 +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.</p> @@ -4485,7 +4469,7 @@ 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.<a name='fna_46' id='fna_46' href='#f_46'><small>[46]</small></a></p> -<p>Aphthæ of the vagina are not unfrequently met with in cases of uterine +<p>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.</p> @@ -4511,9 +4495,9 @@ labour where the head presents—where the face, the nates, the arm, or the cord, present.—Fetid liquor amnii.—Discharge of meconium.</i></p></div> -<p>Well has the celebrated Mauriceau observed, “S’il y a occasion où le +<p>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 +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, @@ -4529,7 +4513,7 @@ 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.</p> -<p>The increasing success which has attended the Cæsarean operation of late +<p>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 @@ -4538,7 +4522,7 @@ 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 +performing the Cæsarian operation, as are used upon the Continent, and apply it not only<span class="pagenum"><a name="Page_108" id="Page_108">[Pg 108]</a></span> to those cases where the child cannot be delivered <i>par vias naturales</i>, but also in those cases of minor pelvic obstruction, where, if we could feel sure of the child’s death, we should have recourse @@ -4552,7 +4536,7 @@ his time, have borrowed largely from his observations.</p> <p>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 <i>vice versâ</i>. The most practical +child to be alive and strong, or <i>vice versâ</i>. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occur <i>before</i> labour, and those which occur <i>during</i> labour.</p> @@ -4610,7 +4594,7 @@ 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 +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 @@ -4660,9 +4644,9 @@ 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 +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 +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 @@ -4756,13 +4740,13 @@ 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, <i>Elementa Artis -Obstetricæ</i>, p. 738.)</p> +Obstetricæ</i>, p. 738.)</p> <p>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 +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 +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 @@ -4790,7 +4774,7 @@ 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 +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. @@ -4853,7 +4837,7 @@ 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 +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 @@ -4861,7 +4845,7 @@ ovum have been thickened<span class="pagenum"><a name="Page_115" id="Page_115">[ 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 +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 @@ -4871,11 +4855,11 @@ 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.</p> -<p>The amount of hæmorrhage will chiefly depend upon the extent of surface by +<p>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 +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.</p> @@ -4887,28 +4871,28 @@ Women</i>.</p> <p>“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 +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 +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 +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 +pain, hæmorrhage, and vomiting, having ceased. I was then taken into her dressing-room, and<span class="pagenum"><a name="Page_116" id="Page_116">[Pg 116]</a></span> 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.”</p> <p><i>The treatment</i> 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 +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 @@ -4967,7 +4951,7 @@ 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 +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 @@ -5082,7 +5066,7 @@ 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.</p> -<p>The patient, æt. 32, and the mother of four children, was admitted, May +<p>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 @@ -5379,9 +5363,9 @@ 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 +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<span class="pagenum"><a name="Page_128" id="Page_128">[Pg 128]</a></span> become distended with an accumulation of fæces +and the rectum quickly<span class="pagenum"><a name="Page_128" id="Page_128">[Pg 128]</a></span> 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 @@ -5416,7 +5400,7 @@ uterus.”</p> 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 +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 <i>Anat. of the Gravid Uterus</i>. p. 18.)</p> @@ -5436,7 +5420,7 @@ 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, +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 @@ -5448,7 +5432,7 @@ 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, (<i>Anfangsgründe der Wundarztneikunst</i>, vol. ii. p. 45:) the +pubic bones, (<i>Anfangsgründe der Wundarztneikunst</i>, 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 @@ -5474,11 +5458,11 @@ 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<span class="pagenum"><a name="Page_130" id="Page_130">[Pg 130]</a></span> point of bursting: this is not so much the case -with the rectum, the passage of fæces being generally completely +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 +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 @@ -5486,7 +5470,7 @@ to throw the fundus uteri still more directly downwards.” (Dr. W. Hunter, <i>Med. Obs. and Inquiries</i>, 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 +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 @@ -5575,7 +5559,7 @@ 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, <i>Compend. Syst. of Midwifery, 6th Ed.</i> § 276.) +serious mischief.” (Dewees, <i>Compend. Syst. of Midwifery, 6th Ed.</i> § 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 @@ -5592,7 +5576,7 @@ 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 +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 @@ -5606,7 +5590,7 @@ 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, +Some object to any attempt being made through the rectum. (Naegelé, <i>Erfahrungen und Abhandlungen</i>, 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 @@ -5617,7 +5601,7 @@ 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.<a name='fna_55' id='fna_55' href='#f_55'><small>[55]</small></a> In all cases -where the reposition of the uterus is at all difficult, Professor Naegelé +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, @@ -5669,7 +5653,7 @@ 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 +difficulty in passing fæces; these symptoms had gradually diminished as pregnancy advanced; the os uteri could not be felt,<span class="pagenum"><a name="Page_135" id="Page_135">[Pg 135]</a></span> 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 @@ -5734,7 +5718,7 @@ it has been capable of being determined with any degree of accuracy, is 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, +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 @@ -5877,7 +5861,7 @@ 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<span class="pagenum"><a name="Page_140" id="Page_140">[Pg 140]</a></span> 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 +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 @@ -5895,7 +5879,7 @@ 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 +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.</p> @@ -5948,7 +5932,7 @@ period, until the full term of utero-gestation, they receive the name of 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 +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 @@ -5975,7 +5959,7 @@ 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, <i>Compendious System of -Midwifery</i>, § 929.) Abortions coming on at a later period, viz. from the +Midwifery</i>, § 929.) Abortions coming on at a later period, viz. from the sixteenth to the twenty-eighth week, which corresponds to the second division, or <i>miscarriages</i>, of the continental authors, are not only more dangerous than abortions at an early stage, for the reasons @@ -6084,7 +6068,7 @@ 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 +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 @@ -6097,13 +6081,13 @@ coldness in the lower part of the belly, flaccid breasts, pain in the back and loins, and discharge of blood from the<span class="pagenum"><a name="Page_145" id="Page_145">[Pg 145]</a></span> uterus, are pretty sure signs of abortion: they are those which are “produced by separation of the ovum and contraction of the uterus,” (<i>Burns</i>;) the one is attended by -hæmorrhage, the other by pain. Although these are two chief symptoms which +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, +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 @@ -6112,8 +6096,8 @@ 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. (<i>Mém. de l’Acad. de Chir.</i> vol. i. p. 203.) When, +Puzos considered that neither pain nor hæmorrhage were necessarily +followed by expulsion. (<i>Mém. de l’Acad. de Chir.</i> 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 @@ -6131,15 +6115,15 @@ 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 +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<span class="pagenum"><a name="Page_146" id="Page_146">[Pg 146]</a></span> there will be hæmorrhage without pain, which is +and in all probability<span class="pagenum"><a name="Page_146" id="Page_146">[Pg 146]</a></span> there will be hæmorrhage without pain, which is the contrary when it takes place near the fundus.” (Dewees, <i>Compend. -System of Midwifery</i>, § 981, 982.) The pain during the abortion is +System of Midwifery</i>, § 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 @@ -6161,8 +6145,8 @@ 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 <span class="smcap">Treatment of Pregnancy</span>; 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 +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, @@ -6221,7 +6205,7 @@ security of the fœtus; for it is a remark as familiar as it is well grounded, that <i>very sick women rarely miscarry</i>; 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, <i>on Children</i>, -§ 45.)</p> +§ 45.)</p> <p>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 @@ -6299,7 +6283,7 @@ pregnancy to the full term.</p> <p>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, +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; @@ -6343,7 +6327,7 @@ 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.</p> -<p>If the hæmorrhage be really profuse, it shows that the separation of the +<p>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 @@ -6373,7 +6357,7 @@ 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.” (<i>Baudelocque</i>,) § 2232. Nor is it always easy to decide +and tenesmus.” (<i>Baudelocque</i>,) § 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 @@ -6412,7 +6396,7 @@ 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 +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 @@ -6427,9 +6411,9 @@ 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 +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 +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 @@ -6442,9 +6426,9 @@ diminish the power of the uterus, and interfere with the process of expulsion.</p> <p>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 +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.” (<i>System of Midwifery</i>, § +ergot of rye does upon the uterine fibre.” (<i>System of Midwifery</i>, § 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority however<span class="pagenum"><a name="Page_153" id="Page_153">[Pg 153]</a></span> of such an author demands respect, the more so as it is known to @@ -6494,7 +6478,7 @@ 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.<span class="pagenum"><a name="Page_154" id="Page_154">[Pg 154]</a></span> Dewees has recommended a wire crotchet, which he has used with very good effect. -(<i>Op. cit.</i> § 1011.)<a name='fna_64' id='fna_64' href='#f_64'><small>[64]</small></a> We ought not, however, to be in a hurry to bring +(<i>Op. cit.</i> § 1011.)<a name='fna_64' id='fna_64' href='#f_64'><small>[64]</small></a> 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 @@ -6505,12 +6489,12 @@ 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 +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<span class="pagenum"><a name="Page_155" id="Page_155">[Pg 155]</a></span> of the uterus is -reduced by the escape of liquor amnii, and thus the hæmorrhage checked; +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.</p> @@ -6521,8 +6505,8 @@ 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 <span class="smcap">Hæmorrhage</span>.</p> +mineral springs of chalybeate character. For the treatment of anæmia we +must refer our readers to the chapter on <span class="smcap">Hæmorrhage</span>.</p> @@ -6583,7 +6567,7 @@ mother and her child.</p> <p>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 +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 @@ -6597,12 +6581,12 @@ 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 +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 +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.</p> @@ -6618,7 +6602,7 @@ 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 <i>false pains</i>, hereafter to be described. “The first contractions, says M. Leroux (<i>Sur les Pertes de -Sang</i>, § 41.,) are feeble, and communicate no sensation to the patient; in +Sang</i>, § 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: @@ -6630,7 +6614,7 @@ degree of resistance and contraction.”</p> <p>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 +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 @@ -6644,7 +6628,7 @@ difficulty.</p> 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 +(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.</p> @@ -6712,7 +6696,7 @@ 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.” (<i>Die Geburtshülfliche Exploration</i>, von Dr. A. T. Hohl, +is not observed.” (<i>Die Geburtshülfliche Exploration</i>, von Dr. A. T. Hohl, erster theil, s. 105.)</p> <p><i>Effect of the pains upon the pulse.</i> It is curious to observe the effect @@ -6796,17 +6780,17 @@ and in different stages of the same labour.</p> <p>“The more completely the os uteri is opposite the fundus, and<span class="pagenum"><a name="Page_162" id="Page_162">[Pg 162]</a></span> the more the axis of the uterus corresponds with that of the pelvis, the sooner are -the pains, <i>cæteris paribus</i>, capable of dilating the os uteri.” +the pains, <i>cæteris paribus</i>, capable of dilating the os uteri.” (<i>Wigand</i>, 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 <i>vice versâ</i>, where there is a +congested vessels by its effusion; and <i>vice versâ</i>, 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, +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 @@ -6860,13 +6844,13 @@ uterus,) and the os uteri such a degree of dilatation, as shall ensure its expulsion with the greatest possible ease and safety.</p> <p><i>Duration of the first stage.</i> The duration of the first stage of labour -varies exceedingly, both in primiparæ and those who have had several +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 +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 @@ -6889,7 +6873,7 @@ amongst those in whom the remaining stages of labour were shortest.”</p> <p>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 +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 @@ -6911,7 +6895,7 @@ encourages her to patience and resolution.</p> 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 +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 @@ -7002,10 +6986,10 @@ much so, that even her own attendants would scarcely recognise her.</p> <p><i>Dilatation of the perineum.</i> 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 +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 +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 @@ -7088,12 +7072,12 @@ 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.</p> -<p>The placentæ of twins are usually expelled together, forming one large +<p>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 +membranes; and in one rare instance of triplet placentæ the umbilical +arteries of two placentæ anastomosed with each other, before dividing into smaller branches.</p> <p>Upon the expulsion of the placenta, the uterus, being now emptied of its @@ -7177,19 +7161,19 @@ 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.</p> +predisposes to hæmorrhage.</p> -<p>Moreover, the rectum being distended with fæces, diminishes proportionally +<p>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 +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 +fæcal matter may have been lodging in the rectum will now be unconsciously pressed out.</p> <p>Hence, therefore, for the last few days of pregnancy, the bowels should be @@ -7251,7 +7235,7 @@ depends.</p> 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 +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 @@ -7334,7 +7318,7 @@ demands.</p> <p><span class="pagenum"><a name="Page_174" id="Page_174">[Pg 174]</a></span><i>Management of the first stage.</i> 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, +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 @@ -7412,7 +7396,7 @@ distended, we shall feel the presenting part more distinctly.</p> <p>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 +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 @@ -7437,13 +7421,13 @@ 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 <i>Exodus</i>: this mode was revived in comparatively modern times; -thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined +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 +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 @@ -7457,7 +7441,7 @@ 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 -<i>lit de misére</i>. A modification of the labour chair is the labour cushion +<i>lit de misére</i>. 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 @@ -7469,7 +7453,7 @@ bed, prepared for the purpose as above mentioned: in England she is placed upon her left side, the nates<span class="pagenum"><a name="Page_177" id="Page_177">[Pg 177]</a></span> 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 +introduced by Boer and Naegelé, the patient is delivered upon her back.<a name='fna_67' id='fna_67' href='#f_67'><small>[67]</small></a> 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 @@ -7491,7 +7475,7 @@ position upon her side, as above mentioned.</p> <p>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 +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 @@ -7546,7 +7530,7 @@ 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 +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 @@ -7594,10 +7578,10 @@ taken to encourage her and keep up her spirits.</p> <p><i>Supporting the perineum.</i> 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 +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 <i>frænulum</i>, is, we believe almost invariably ruptured +before, do not yield so readily as in multiparæ. The anterior margin of +the perineum, called <i>frænulum</i>, is, we believe almost invariably ruptured in every first case; but the laceration ought not to extend<span class="pagenum"><a name="Page_180" id="Page_180">[Pg 180]</a></span> 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 @@ -7608,7 +7592,7 @@ 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.</p> -<p>The increasing thinness of the perineum itself, and the frænulum becoming +<p>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 @@ -7631,12 +7615,12 @@ 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 +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 +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 @@ -7645,10 +7629,10 @@ middle finger of the left hand in contact with it, we shall hold the left hand in the desired direction.</p> <p><span class="pagenum"><a name="Page_181" id="Page_181">[Pg 181]</a></span>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 +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 +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 @@ -7676,7 +7660,7 @@ 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 +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 @@ -7697,7 +7681,7 @@ constitute the chief treatment.</p> 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 +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 @@ -7750,7 +7734,7 @@ 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 +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 @@ -7805,7 +7789,7 @@ 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.<a name='fna_70' id='fna_70' href='#f_70'><small>[70]</small></a> If, however, +separation, retention of the placenta, and hæmorrhage.<a name='fna_70' id='fna_70' href='#f_70'><small>[70]</small></a> 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 @@ -7843,7 +7827,7 @@ 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 +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 @@ -7854,7 +7838,7 @@ 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 +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; @@ -7869,14 +7853,14 @@ 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 +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.</p> +for it may again relax and grow soft, and hæmorrhage come on.</p> <p><i>Management of the placenta.</i> The placenta sometimes follows the child immediately, and occasionally is expelled by the same pain; usually, @@ -7916,25 +7900,25 @@ 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.</p> +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.</p> <p><i>Twins.</i> 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, +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 +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 +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 +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 @@ -7963,7 +7947,7 @@ 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. +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 @@ -7986,7 +7970,7 @@ therefore, be desirable to adopt such<span class="pagenum"><a name="Page_189" id 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, +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 @@ -8001,7 +7985,7 @@ 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.</p> +single case of hæmorrhage after the effects of this operation.</p> <p><i>Lactation.</i> When the wet clothing has been removed, and fresh linen substituted, the patient should be left to enjoy perfect quiet both of @@ -8056,7 +8040,7 @@ 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 +as strophulus, aphthæ, colic, &c. from which new-born children are made to suffer so severely.</p> <p>Besides the above advantages in applying the child thus early to the @@ -8083,7 +8067,7 @@ 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 +and the pain and dragging extends to the axillæ, the glands of which are also swollen and painful.</p> <p><i>Milk fever and abscess.</i> By this time, or even earlier, the patient will @@ -8121,7 +8105,7 @@ bowels, as before-mentioned.<a name='fna_74' id='fna_74' href='#f_74'><small>[74 <p>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 +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 @@ -8138,7 +8122,7 @@ 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 +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 @@ -8165,13 +8149,13 @@ 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 +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 +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 @@ -8287,7 +8271,7 @@ 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 +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 @@ -8315,7 +8299,7 @@ symptoms, we must refer the reader to the chapter on <span class="smcap">Puerper 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 <i>after-pains</i>. Women who have already borne children -are more liable to them than primiparæ. They vary considerably in degree: +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 @@ -8342,7 +8326,7 @@ 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 (<i>cæteris paribus</i>) has +patient suckles shortly after labour, she seldom (<i>cæteris paribus</i>) 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 @@ -8480,7 +8464,7 @@ the open space itself is the great or anterior fontanelle.</p> <p>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, +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 @@ -8495,7 +8479,7 @@ perpendicular diameter of the head, instead of corresponding to the axis of the pelvic brim, runs in an oblique direction upwards and forwards.</p> <p>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 +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 @@ -8631,11 +8615,11 @@ 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, +spot upon which the swelling of the integuments forms itself.” (Naegelé, <i>Mechanism of Parturition</i>, transl.)</p> <p>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 +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 @@ -8654,7 +8638,7 @@ 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.</p> -<p>It is to the celebrated Naegelé of Heidelberg that we are indebted for +<p>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 @@ -8812,7 +8796,7 @@ 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.” (<i>Traité des Accouchemens</i>, 1770, § +terminate without the aid of art.” (<i>Traité des Accouchemens</i>, 1770, § 736.)</p> <p>Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still @@ -8834,7 +8818,7 @@ 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 <i>Natürliche Geburtshülfe</i>, erstes buch, p. 137.) In +forceps.” (Boer’s <i>Natürliche Geburtshülfe</i>, 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 @@ -8867,7 +8851,7 @@ 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 +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.</p> @@ -8886,9 +8870,9 @@ 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 <i>nates</i> 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 +former. Professor Naegelé, jun., in his new edition of the admirable essay upon the mechanism of labour, published by his father, in Meckel’s -<i>Archiv. für die Physiologie</i>, has very properly brought these different +<i>Archiv. für die Physiologie</i>, 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 @@ -8907,7 +8891,7 @@ 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, +found alone in the os uteri at the commencement of it.” (H. F. Naegelé, <i>Mechanismus der Geburt</i>, 1838, p. 57.)</p> <p>The nates may present in two ways, either with the back of the child @@ -8923,8 +8907,8 @@ 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, <i>on the Mechanism of -Parturition</i>, transl. § 19. p. 128.) “In every case, whether the nates +parturition, no prejudicial result occurs.” (Naegelé, <i>on the Mechanism of +Parturition</i>, 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 @@ -8993,7 +8977,7 @@ cavity, and when entering the external passages.</p> 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, <i>op. cit.</i> p. 128, 130.)</p> +already been described.” (Naegelé, <i>op. cit.</i> p. 128, 130.)</p> <p>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 @@ -9054,7 +9038,7 @@ the uterus, not having been suddenly emptied of a part<span class="pagenum"><a n 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 +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 <i>assisted</i>, as it is called, at the very moment when it ought rather to be supported and prevented from advancing too suddenly. When @@ -9110,7 +9094,7 @@ General Lying-in-Hospital.</p> <p>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.</p> +the proportion of 1 to 3·8, and in the footling births 1 to 2·8.</p> @@ -9138,7 +9122,7 @@ increasing experience of years has furnished us, of giving artificial assistance in such cases. These may be brought under two heads, first, where delivery can be effected with safety to the mother and her child; secondly, where this can only be effected at the expense of the infant’s -life. Under the first head come the forceps, turning, the Cæsarean +life. Under the first head come the forceps, turning, the Cæsarean operation, and artificial premature labour; under the second are craniotomy or perforation, and embryotomy.</p> @@ -9187,7 +9171,7 @@ some it is nearly equidistant; whereas, in others it is nearer to the lock; the medium between these extremes is the best. The extremities of the blades ought to be at least half an inch apart: in this country they are usually somewhat more; on the Continent they are much less, being -rarely more than one or two lines asunder. The fenestræ, or open spaces in +rarely more than one or two lines asunder. The fenestræ, or open spaces in the blades, should be wide and ample, for not only are the projecting parts of the head allowed to protrude between them, but the pressure of the blades is diffused over a larger extent of surface: this is remarkably @@ -9195,7 +9179,7 @@ seen in the forceps of the late Dr. Hopkins and that of Professor Davis, both of which are extensively used. It is also important that the edge at the extremities of the blades should be well rounded and not too thin; it is thus less liable to catch against corrugations either of the vagina or -fœtal scalp. The greatest breadth of the fenestræ is generally towards +fœtal scalp. The greatest breadth of the fenestræ is generally towards the extremities of the blades; in some, their edges are parallel; whereas, in those of Drs. Orme and Lowder the greatest breadth is near the lock: upon the whole, an<span class="pagenum"><a name="Page_218" id="Page_218">[Pg 218]</a></span> oval shaped fenestra is the best, for it can be easily @@ -9221,15 +9205,15 @@ countries.</p> the forceps of Dr. Hopkins, above alluded to: the head curvature forms an elongated oval, admirably adapted to the form of the fœtal head when considerably compressed during a difficult labour; and from the great -breadth of the fenestræ, the pressure of the blades is applied over a +breadth of the fenestræ, the pressure of the blades is applied over a large extent of surface; the pelvic curve is but slight, being greater on -the posterior edge of fenestræ than on the anterior; the blades themselves +the posterior edge of fenestræ than on the anterior; the blades themselves are thin, their inner surface flat to ensure a firmer hold, their outer surface slightly rounded in order to be introduced with greater ease; and for a similar reason the edges of their extremities are somewhat thicker and carefully rounded in a peculiar manner.</p> -<div class="figleft"><img src="images/img34.jpg" alt="" /><br />Naegelé’s forceps.</div> +<div class="figleft"><img src="images/img34.jpg" alt="" /><br />Naegelé’s forceps.</div> <p>The lock of the modern English forceps consists of two deep grooves, into which the shank of each blade mutually fits, so that the two blades are @@ -9248,9 +9232,9 @@ lock, for the blades can never slip from each other, still the difficulty in locking, and also in separating, the blades at a moment’s notice, render it much inferior to the English lock. An ingenious modification was invented by the late Professor Von Siebold of Berlin, but the most perfect -lock is that of Professor Brüninghausen of Würzburg, first introduced by +lock is that of Professor Brüninghausen of Würzburg, first introduced by ourselves into this country, and commonly known among the -instrument-makers under the name of Professor Naegelé’s forceps. The shank +instrument-makers under the name of Professor Naegelé’s forceps. The shank of one blade has a semicircular indentation, which at the moment of locking fits into a fixed pivot in the other: this, therefore, combines the advantages of the French and English locks. We can safely affirm, from @@ -9329,7 +9313,7 @@ indispensable, and where the head is higher than admits the application of the short forceps.” (<i>Principles of Midwifery</i>, 9th ed. p. 493.)</p> <p>In applying the forceps, whether short or long, there are two conditions -which, <i>cæteris paribus</i>, are requisite in every case; first, that the os +which, <i>cæteris paribus</i>, are requisite in every case; first, that the os uteri shall be fully dilated; secondly, that the pains are within the bounds of what are commonly known as moderate pains. In the first case it will be very difficult and frequently quite impossible to pass the blades @@ -9364,12 +9348,12 @@ either from deficiency in the expelling powers, or from misproportion between the head and pelvis, or from the arm coming down with the head. 2. They are indicated by circumstances or accidental causes, which render labour dangerous for the mother or child, and where the danger can only be -removed by hastening labour, as in cases of hæmorrhage, convulsions, +removed by hastening labour, as in cases of hæmorrhage, convulsions, syncope, alarming debility, faulty condition of the organs of respiration, danger of suffocation, obstinate vomiting, unusually severe pains in nervous irritable habits, hemorrhoids<span class="pagenum"><a name="Page_222" id="Page_222">[Pg 222]</a></span> which have burst, hernia, retention of urine, determination of blood to the head, prolapsus of the cord, (in -certain cases,) inflammation of the uterus, &c. (Naegelé, <i>MS. +certain cases,) inflammation of the uterus, &c. (Naegelé, <i>MS. Lectures</i>.)</p> <p>We have already stated that an intimate acquaintance with the mechanism of @@ -9422,7 +9406,7 @@ accordance with the above rule, the upper blade is to be introduced first. Having passed one or two fingers up to the head, we guide the blade along them, depressing the handle so as to make the extremity of the blade lie closely upon the head, neither allowing the point alone to impinge upon -the head, nor <i>vice versâ</i>, to protrude against the vagina. The extremity +the head, nor <i>vice versâ</i>, to protrude against the vagina. The extremity of the blade, therefore, must be our guide for the direction in which we hold the handle: we must carefully insinuate this by a gentle vibratory motion between the head and passage which surrounds it: the convexity of @@ -9607,7 +9591,7 @@ possession of the secret. He returned to London, in August of the same year, having in vain attempted to sell it to the French government, after having entirely failed in a case of difficult labour which he had asserted he could deliver in a few minutes, although Mauriceau had stated that the -Cæsarean operation would be required. Dr. H. Chamberlen published in 1772, +Cæsarean operation would be required. Dr. H. Chamberlen published in 1772, a translation of Mauriceau’s work, which had appeared four years previously, and in his preface he publicly alludes to this secret, and says, “My father, brothers, and myself (though none else in Europe, as I @@ -9630,7 +9614,7 @@ translating him.” On account of his being attached to the party of James II. he was again obliged to quit England, in 1688, and crossed over to Amsterdam, where he settled, and in five years after succeeded in selling his secret to three Dutch practitioners, viz. Roger <span class="pagenum"><a name="Page_228" id="Page_228">[Pg 228]</a></span>Roonhuysen, Cornelius -Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands, +Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it generally known. It turned @@ -9638,7 +9622,7 @@ out to be a flat bar of iron, somewhat curved at each end: this lever was stated to have been received from Roonhuysen, one of the original purchasers of the Chamberlen secret; but there is no reason to suppose that any such instrument had been communicated by Chamberlen either to him -or the others, as we have distinct evidence that both Ruysch and Bökelman +or the others, as we have distinct evidence that both Ruysch and Bökelman possessed <i>forceps</i>, the blades of which united at their lower end by means of a hinge and pin. It is known also that Roonhuysen used a double instrument consisting of two blades. The above-mentioned flat bar of iron, @@ -9708,7 +9692,7 @@ foremost.—History of turning.</i></p></div> <p>Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os -uteri and vagina, and in this manner the child delivered. (Naegelé, <i>MS. +uteri and vagina, and in this manner the child delivered. (Naegelé, <i>MS. Lectures</i>.)</p> <p>Besides turning with the feet foremost as now described it has also been @@ -9724,8 +9708,8 @@ or for adapting the position of the child for delivering it artificially.</p> <p>The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the -child, it has been very properly recommended by Deleurye, (<i>Traité des -Accouchemens</i>, 1770,) Boer, (<i>Naturliche Geburtshülfe</i>, 1810,) Wigand, +child, it has been very properly recommended by Deleurye, (<i>Traité des +Accouchemens</i>, 1770,) Boer, (<i>Naturliche Geburtshülfe</i>, 1810,) Wigand, (<i>Geburt des Menschen</i>, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling @@ -9754,7 +9738,7 @@ with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;—on the part of the child, prolapsus of the cord under certain circumstances. -(Naegelé, <i>Lehrbuch der Geburtshülfe</i>, §§ 394, 395. 3d edit.) Hence, +(Naegelé, <i>Lehrbuch der Geburtshülfe</i>, §§ 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the fœtus, or which demand a hasty delivery of the child, but @@ -9793,7 +9777,7 @@ thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cushiony, and dilatable.</p> <p>In cases which require turning as a means of hastening labour, as for -instance in flooding from placenta prævia and other causes, the hæmorrhage +instance in flooding from placenta prævia and other causes, the hæmorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand. Where convulsions indicate turning, the bleeding and other depleting @@ -9829,7 +9813,7 @@ left.<a name='fna_88' id='fna_88' href='#f_88'><small>[88]</small></a></p> <p>The directions which are usually given to introduce one hand or the other according to the child’s position, are not practical,<span class="pagenum"><a name="Page_233" id="Page_233">[Pg 233]</a></span> because cases occur where it is impossible to ascertain this point without passing the hand -into the uterus, as in placenta prævia, and occasionally in shoulder +into the uterus, as in placenta prævia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repetition of this operation, merely because the position of the child is such as is stated in books to require the @@ -9864,7 +9848,7 @@ duly supporting the uterus with the other hand; for we thus not only enable the hand to pass the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the vagina from the uterus, in all cases where the turning is at all difficult. “In those -cases (says Professor Naegelé) where artificial dilatation of the os uteri +cases (says Professor Naegelé) where artificial dilatation of the os uteri is required to let the hand pass, it should be done in the following manner:—during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and @@ -9874,12 +9858,12 @@ circumstances of absolute necessity and always with the greatest caution—in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is<span class="pagenum"><a name="Page_234" id="Page_234">[Pg 234]</a></span> sufficiently yielding -or dilated.” (<i>Lehrbuch der Geburtshülfe</i>, p. 212. 3tte ausgabe.) This +or dilated.” (<i>Lehrbuch der Geburtshülfe</i>, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the <i>forcible</i> dilatation of the os uteri is justly deprecated by Madame la Chapelle: “I never attempt to produce this forced dilatation, <i>not even -in cases of hæmorrhage</i>. But we may frequently promote the dilatation of +in cases of hæmorrhage</i>. But we may frequently promote the dilatation of the passages in a remarkable manner by moistening and relaxing them and diminishing their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding.” (p. @@ -9928,15 +9912,15 @@ then turn and deliver as formerly directed.” (<i>Treatise on the Theory an Practice of Midwifery</i>, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us “introduire la main dans la matrice <i>sans</i> percer la poche des -eaux, détacher les membranes des parois de ce viscère, et les percer à -l’endroit où l’on juge que les pieds peuvent le plus naturellement se +eaux, détacher les membranes des parois de ce viscère, et les percer à +l’endroit où l’on juge que les pieds peuvent le plus naturellement se trouver.”<a name='fna_90' id='fna_90' href='#f_90'><small>[90]</small></a> Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye’s mode of practice,<a name='fna_91' id='fna_91' href='#f_91'><small>[91]</small></a> and it -has still farther been confirmed by Professor Naegelé.</p> +has still farther been confirmed by Professor Naegelé.</p> <p>Turning under these circumstances is an easy operation, and a very different affair compared with its performance in cases in which the @@ -9958,12 +9942,12 @@ circumstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the practitioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it.” (Dewees’ -<i>Compendious System of Midwifery</i>, § 629.) “The vagina is never so soft, +<i>Compendious System of Midwifery</i>, § 629.) “The vagina is never so soft, so dilatable, and capable of admitting the hand as during the presence of -an active hæmorrhage, and this is equally the case in primiparæ as in +an active hæmorrhage, and this is equally the case in primiparæ as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient’s sufferings, under -these circumstances delays to introduce his hand until the hæmorrhage +these circumstances delays to introduce his hand until the hæmorrhage shall have ceased. The moment this is the case, the vagina regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state @@ -10160,7 +10144,7 @@ known.</p> of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (<i>L’Art des Accouchemens</i>, -§ 767,) and Smellie on more than one occasion has alluded to bringing down +§ 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,<a name='fna_94' id='fna_94' href='#f_94'><small>[94]</small></a> also by some other continental authors; but @@ -10212,7 +10196,7 @@ became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six.” (<i>Synopsis of Difficult Parturition</i>, 1838, p. 250.) Still more recently turning with the head foremost has been tried by<span class="pagenum"><a name="Page_242" id="Page_242">[Pg 242]</a></span> Dr. Michaelis, of Kiel, (<i>Neue -Zeitschrift für Geburtskunde</i>, vol. iv. 1836.) When once the faulty +Zeitschrift für Geburtskunde</i>, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty.</p> @@ -10227,23 +10211,23 @@ artificial delivery; as it is, we meet with detached allusions to it in their writings, although applying only to cases where the child is dead. In the writings of Aspasia and Philumenus, which, but for the quotations of Œtius, would have been entirely lost to us, we find directions for -turning the child. Thus, Philumenus states, “Si caput fœtûs locum +turning the child. Thus, Philumenus states, “Si caput fœtûs locum obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur.” At a still later period, Celsus gave similar directions, but to all appearance they also merely apply to a dead child. “Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est;” and again he says, “Sed in pedes quoque conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas -manus commode educitur.” (Celsus, <i>de Medicinâ</i>, lib. vii. cap. 29.)</p> +manus commode educitur.” (Celsus, <i>de Medicinâ</i>, lib. vii. cap. 29.)</p> <p>From this time the whole subject seemed to sink into oblivion, until Pierre Franco, in his work on surgery<a name='fna_95' id='fna_95' href='#f_95'><small>[95]</small></a> proposed the extraction of the child with the feet foremost: this was put into practice by the celebrated -French surgeon, Ambrose Paré, (Ambr. Paræus, <i>Opera Chirurgia</i>, 1594,) +French surgeon, Ambrose Paré, (Ambr. Paræus, <i>Opera Chirurgia</i>, 1594,) who, nevertheless, recommended turning with the head foremost, where it was possible. His work was afterwards translated into Latin by Guillemeau, who, although he still adhered to the old plan of bringing down the head, -showed the value of Paré’s mode of turning in hæmorrhages and convulsions. +showed the value of Paré’s mode of turning in hæmorrhages and convulsions. To Francis Mauriceau, a man of great learning and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William @@ -10259,14 +10243,14 @@ the arm which presents.<a name='fna_96' id='fna_96' href='#f_96'><small>[96]</sm <p><span class="pagenum"><a name="Page_243" id="Page_243">[Pg 243]</a></span></p> <h2><a name="PART_IV_CHAPTER_III" id="PART_IV_CHAPTER_III"></a>CHAPTER III.</h2> -<p class="title">CÆSAREAN OPERATION.</p> +<p class="title">CÆSAREAN OPERATION.</p> <div class="note"><p class="hang"><i>Indications.—Different modes of performing the operation.—History -of the Cæsarean operation.</i></p></div> +of the Cæsarean operation.</i></p></div> <p>The next operation in Midwifery for delivering the full-grown fœtus -alive is that of <i>Hysterotomy</i>, commonly called the Cæsarean operation, +alive is that of <i>Hysterotomy</i>, commonly called the Cæsarean operation, viz. where the fœtus is extracted through an artificial opening made through the parietes of the abdomen and uterus.</p> @@ -10285,29 +10269,29 @@ dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother’s life, it is performed for the purpose of saving the child’s life in cases where, by using the perforator, the child -might be brought through the natural passages. The results of the Cæsarean +might be brought through the natural passages. The results of the Cæsarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to practitioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former -times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as +times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. Osborn, &c.)</p> <p>There is no doubt that in England it has been peculiarly unsuccessful. Dr. -Merriman has collected the results of 26 cases of Cæsarean operation: of +Merriman has collected the results of 26 cases of Cæsarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90 -<span class="pagenum"><a name="Page_244" id="Page_244">[Pg 244]</a></span>terminated favourably; and Dr. Hull, in his <i>Defence of the Cæsarean +<span class="pagenum"><a name="Page_244" id="Page_244">[Pg 244]</a></span>terminated favourably; and Dr. Hull, in his <i>Defence of the Cæsarean Operation</i>, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few women, “some of them having submitted to it three or four times, others five or six, and even as far as seven times, which if they were all true, would superabundantly prove that it is not essentially mortal.” (<i>Baudelocque</i>, transl. by -Heath, § 2095.)</p> +Heath, § 2095.)</p> <p>During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German practitioners, so that @@ -10327,7 +10311,7 @@ uterus.</p> <p>There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. “In France and some other nations upon the European Continent,” says Dr. Hull, “the -Cæsarean Operation has been and continues to be performed where British +Cæsarean Operation has been and continues to be performed where British practitioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repetition of tormenting, though unavailing @@ -10343,7 +10327,7 @@ this country, namely, where the female has laboured for years under incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominal<span class="pagenum"><a name="Page_245" id="Page_245">[Pg 245]</a></span> cavity, or been exhausted by labour of a week’s continuance or even longer.” -(Hull’s <i>Defence of the Cæsarean Operation</i>.)<a name='fna_98' id='fna_98' href='#f_98'><small>[98]</small></a></p> +(Hull’s <i>Defence of the Cæsarean Operation</i>.)<a name='fna_98' id='fna_98' href='#f_98'><small>[98]</small></a></p> <p>The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than according @@ -10386,7 +10370,7 @@ examine whether the passages, &c. have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural passages. -(Richter, <i>Anfangsgründe der Wundarztneikunst</i>, band vii. chap. 5.)</p> +(Richter, <i>Anfangsgründe der Wundarztneikunst</i>, band vii. chap. 5.)</p> <p>Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has @@ -10424,7 +10408,7 @@ the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent assistants are necessary, “two to prevent the protrusion of the intestines, and a third to remove the placenta and -fœtus.” (<i>Neue Zeitschrift für Geburtskunde</i>, band iii. heft 1. 1835.) +fœtus.” (<i>Neue Zeitschrift für Geburtskunde</i>, band iii. heft 1. 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air than upon any @@ -10434,7 +10418,7 @@ duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to -this that the great success of the Cæsarean operation in later years is +this that the great success of the Cæsarean operation in later years is chiefly owing.</p> <p>The incision in point of length varies from five to six, seven, or more @@ -10445,7 +10429,7 @@ wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the -uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for +uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when passing through the wound, and thus retain it. It is desirable to remove the membranes as far @@ -10483,7 +10467,7 @@ appear that the patient’s sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.<a name='fna_100' id='fna_100' href='#f_100'><small>[100]</small></a></p> -<p><i>History.</i> Although the early records of the Cæsarean operation are not +<p><i>History.</i> Although the early records of the Cæsarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it @@ -10493,7 +10477,7 @@ advanced in pregnancy to be buried until the operation had been performed.</p> <p>The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: -these were the birth of Bacchus and Æsculapius; but as these traditions +these were the birth of Bacchus and Æsculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circumstance, however, connected with the birth of Bacchus is curious, viz. that his @@ -10502,13 +10486,13 @@ mother Semele died in the seventh month of her pregnancy.</p> <p>The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, <span class="smcaplc">B. C.</span> 508. Scipio Africanus, who lived about 200 years later, is said to have been born in a similar manner. There is -no reason to suppose that Julius Cæsar was born by this operation, or +no reason to suppose that Julius Cæsar was born by this operation, or still less that it<span class="pagenum"><a name="Page_249" id="Page_249">[Pg 249]</a></span> derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather -prefer the explanation of Professor Naegelé, viz. that one of the Julian -family at Rome had been delivered <i>ex cæso matris utero</i>, and had been -named Cæsar from this circumstance, so that the name was derived from the +prefer the explanation of Professor Naegelé, viz. that one of the Julian +family at Rome had been delivered <i>ex cæso matris utero</i>, and had been +named Cæsar from this circumstance, so that the name was derived from the operation, not the operation from the name.</p> <p>“The earliest account of it in any medical work is that in the <i>Chirurgia @@ -10520,7 +10504,7 @@ period; a description of it is given in the <i>Mischnejoth</i>, “which is oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In the <i>Talmud</i> of the Jews, also, their next book in -point of antiquity, the Cæsarean operation is mentioned in such terms as +point of antiquity, the Cæsarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In the <i>Mischnejoth</i> there is the following passage, ‘In the case of twins, neither the first child which @@ -10560,7 +10544,7 @@ performing it.—Description of the operation.</i></p></div> invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circumstances of pelvic contraction, where either the -one must have been exposed to the dangers and sufferings of the Cæsarean +one must have been exposed to the dangers and sufferings of the Cæsarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have @@ -10628,14 +10612,14 @@ upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted -except in those cases of violent hæmorrhage which leave no<span class="pagenum"><a name="Page_252" id="Page_252">[Pg 252]</a></span> chance for the +except in those cases of violent hæmorrhage which leave no<span class="pagenum"><a name="Page_252" id="Page_252">[Pg 252]</a></span> chance for the woman’s life without delivery; the nature of the accident also disposes -the parts properly for it.” (<i>Baudelocque</i>, transl. by Heath, § 1986, +the parts properly for it.” (<i>Baudelocque</i>, transl. by Heath, § 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in -fact, his objections do not apply, but to the <i>accouchement forcé</i> of the +fact, his objections do not apply, but to the <i>accouchement forcé</i> of the French practitioners, where, on account of the sudden accession of -dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri +dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then passed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this @@ -10653,7 +10637,7 @@ that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases -of artificial premature labour. (<i>Operative Geburtshülfe</i>, erster band, p. +of artificial premature labour. (<i>Operative Geburtshülfe</i>, erster band, p. 298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers @@ -10667,7 +10651,7 @@ inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminishing the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less -dangerous than other species of premature labour, for the hæmorrhages, +dangerous than other species of premature labour, for the hæmorrhages, which are so apt to attend them, are never known to occur here.</p> <p>This mode of delivery has not only been proposed in cases of contracted @@ -10693,7 +10677,7 @@ two weeks are found to make in the hardness of the fœtal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made -sufficient difference.” (Naegelé, <i>MS. Lectures</i>.) Still, however, as it +sufficient difference.” (Naegelé, <i>MS. Lectures</i>.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce @@ -10732,9 +10716,9 @@ of those rigours occurring which some practitioners, although erroneously, have supposed, were connected with the death of the child.</p> <p>The practice of dilating the os uteri first, as recommended by -Brüninghausen, Kluge, and others, has, as far as we know, never been +Brüninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the -<i>accouchement forcé</i> of the French authors ever to be permitted.</p> +<i>accouchement forcé</i> of the French authors ever to be permitted.</p> <p>The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing @@ -10782,8 +10766,8 @@ difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. “In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire -and straining off the thin fluid.” (Reisinger, <i>die künstliche -Frühgeburt</i>.)</p> +and straining off the thin fluid.” (Reisinger, <i>die künstliche +Frühgeburt</i>.)</p> <p>One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to @@ -10837,9 +10821,9 @@ Bing, of Copenhagen, is also formed like scissors,<span class="pagenum"><a name= edges outside; the blades are also furnished with rests or shoulders like the Smellie perforator.</p> -<div class="figleft"><img src="images/img36.jpg" alt="" /><br />Naegelé’s perforator.</div> +<div class="figleft"><img src="images/img36.jpg" alt="" /><br />Naegelé’s perforator.</div> -<p>A useful modification has been invented by Professor Naegelé, which +<p>A useful modification has been invented by Professor Naegelé, which supplies a considerable defect in the two above-mentioned instruments, viz. the necessity of using both hands to open the blades, thereby requiring that the hand which guides the instrument in the vagina should @@ -10860,7 +10844,7 @@ the labour is dangerous for the mother, and where the antero-posterior diameter, although more than two inches and a half, is so small that the head which presents, cannot be delivered by the forceps. Secondly, it is indicated where the head is much larger than natural, as in -hydrocephalus.” (Naegelé, <i>MS. Lectures</i>.) For a more detailed and special +hydrocephalus.” (Naegelé, <i>MS. Lectures</i>.) For a more detailed and special account of the precise circumstances under which it will be required, we must refer to those different forms of <span class="smcap">Dystocia</span>, where it is occasionally required, particularly our fourth species, viz. <span class="smcap">Dystocia Pelvica</span>.</p> @@ -10869,7 +10853,7 @@ required, particularly our fourth species, viz. <span class="smcap">Dystocia Pel was justifiable, and has, therefore, given rise to very different results in the practice of different schools. The most obstinately prejudiced against perforation was the late celebrated Benjamin Osiander, of -Göttingen, who asserted, that it was never necessary, for, where others +Göttingen, who asserted, that it was never necessary, for, where others were obliged to open the head, he would deliver the patient by means of his forceps, an instrument which, from its great length and the various hooks &c. for applying additional hands, was capable of exerting a degree @@ -10878,10 +10862,10 @@ using exceedingly powerful forceps to a degree, which in this country and the greater part of Germany would<span class="pagenum"><a name="Page_258" id="Page_258">[Pg 258]</a></span> be looked upon as very injurious, if not dangerous, has tended to render the perforation a comparatively rare operation: thus out of somewhat more than twenty thousand labours at the -Maternité, of Paris, only sixteen were delivered by this means. Of the +Maternité, of Paris, only sixteen were delivered by this means. Of the ninety-six cases in whom the forceps was applied, no mention is made as to the result with respect to the mothers; but, from the description of a -forceps case at the Hôtel Dieu which we have received from an eye-witness, +forceps case at the Hôtel Dieu which we have received from an eye-witness, the force used must have been carried to a most unwarrantable extent.</p> <p>The English practitioners have frequently been accused by their @@ -10940,12 +10924,12 @@ When the perforation is made at a suture, the edges of the bones gradually overlap as the head diminishes in size, and thus close the opening, a circumstance which cannot occur when it is made through a bone. Splintering the bone in making a crucial opening has been objected to on -the ground that the sharp edges and spiculæ are apt to wound the soft +the ground that the sharp edges and spiculæ are apt to wound the soft parts of the mother: of this, however, there will be but little danger so long as they are covered by the scalp, which we should be somewhat cautious of, and not tear or otherwise destroy the cranial integuments unnecessarily, for it has long since been remarked by the celebrated Peter -Frank, that inflammation of the uterus produced by wounds from spiculæ of +Frank, that inflammation of the uterus produced by wounds from spiculæ of bone or sharp instruments becoming blunt, &c., usually prove fatal: it is also desirable to disfigure the head as little as possible. Still, however, we are far from recommending the trepan-shaped perforators which @@ -11125,7 +11109,7 @@ her child, without any obstruction to its progress, may arise from,</p> <p>3. From accidental circumstances, which render the labour dangerous, viz. convulsion, syncope, dyspnœa, severe and continued vomiting, -hæmorrhage, &c.</p> +hæmorrhage, &c.</p> <p>We propose to consider the different species of dystocia in the order above enumerated.</p></div> @@ -11182,7 +11166,7 @@ back, belly, breast or sides, properly speaking, never constitute the presenting part.”</p> <p>The two greatest Continental authorities of modern times, viz. Madame La -Chapelle and Professor Naegelé, confirm this opinion: the former points +Chapelle and Professor Naegelé, confirm this opinion: the former points out one of the sources of error which has induced practitioners to suppose that they had met with other species of faulty presentation besides those of the arm or shoulder. “In the greater number of shoulder presentations,” @@ -11214,13 +11198,13 @@ following results will show:—At the Westminster General Dispensary (1781) it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr. Merriman, once in 155: “calculated from a great number of cases,” to -Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr. -Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle, +Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr. +Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle, once in 230.</p> <p>In arm and shoulder presentations the back of the child is turned towards the anterior part of the uterus more than twice as frequently as it is in -the contrary direction, from which circumstance Professor Naegelé has +the contrary direction, from which circumstance Professor Naegelé has called this the first position of<span class="pagenum"><a name="Page_266" id="Page_266">[Pg 266]</a></span> the shoulder to distinguish it from the other, which, as being rarer, he calls the second.</p> @@ -11250,14 +11234,14 @@ variation as to the length of its diameter in any direction.</p> <p>The form of the uterus is no less worthy of attention as a cause of malposition, and is also in a great measure influenced by the character of its early contractions. Thus in a uterus for the first time pregnant, they -generally act equally on all sides: hence it is why in primiparæ the +generally act equally on all sides: hence it is why in primiparæ the uterus is so exactly oval, and why we so rarely meet with faulty presentations. Sir Fielding Ould, of Dublin, was the first and almost the only practitioner in this country who noticed the influence which the early contractions of the uterus have in determining the position of the child. “The first labour pains, which are very short, continue their repetition for two or three hours, or perhaps for more, before there is -the least effect produced upon the os tincæ, which time must certainly be +the least effect produced upon the os tincæ, which time must certainly be employed in turning the head towards the orifice.” (<i>Treatise of Midwifery</i>, p. 14.)</p> @@ -11301,7 +11285,7 @@ usually come on towards night-time; and, in some instances, it is felt for the time hard and uneven from irregular contraction. It was the circumstance of this symptom having preceded five successive labours of a patient, in all of which the child had presented with the arm or shoulder, -which induced Professor Naegelé, when attending her in her sixth +which induced Professor Naegelé, when attending her in her sixth pregnancy, to endeavour to allay these cramp-like pains, which had begun to show themselves as severely as on former occasions. Having tried opium by itself, and also in combination with ipecacuanha or valerian without @@ -11369,7 +11353,7 @@ they are no longer exclusively confined either to one side or the other. Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, during which it is more or less distorted with violent movements, apparently of the child, as if it were trying to force its way through the -abdominal parietes at this spot.” (Naegelé, <i>Lehrbuch</i>, p. 223.)</p> +abdominal parietes at this spot.” (Naegelé, <i>Lehrbuch</i>, p. 223.)</p> <p>Upon examination <i>per vaginam</i>, either no presentation is to be reached at all, or only small parts can be indistinctly felt, such as the hand, the @@ -11646,10 +11630,10 @@ without any injury to the subjacent tissue.</p> <p>From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the -uterus would be more frequently seen among primiparæ: this, however, is +uterus would be more frequently seen among primiparæ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) -proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, +proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy.</p> @@ -11796,10 +11780,10 @@ is doubly interesting from the operation having been twice performed with a favourable result in consequence of a repetition of the injury in the patient’s succeeding pregnancy.<a name='fna_112' id='fna_112' href='#f_112'><small>[112]</small></a> Mr. Ingleby, of Birmingham, gives a similar opinion in favour of the operation: “The result of two cases of -Cæsarean operation in which I have been engaged, leads me to view the mere +Cæsarean operation in which I have been engaged, leads me to view the mere abdominal incision with very different feelings. The operation is not half -so dangerous as the Cæsarean, whilst the celerity with which it is done, -the absence of hæmorrhage, and the facility with which the intestines are +so dangerous as the Cæsarean, whilst the celerity with which it is done, +the absence of hæmorrhage, and the facility with which the intestines are confined within the abdomen, tend to divest it of much of its terror.” (<i>Op. cit.</i> p. 201.)</p> @@ -12012,7 +11996,7 @@ impossible to extract the child, he perforated the abdomen in two places, but could not extract it; in a few minutes after it came away of itself. The abdomen had been distended with small hydatids; these gradually escaped, and thus diminished the size of the abdomen. (<i>Neue Zeitschrift -für Geburtshülfe</i>, band iv. heft 1, 1836.) Where the child has been dead +für Geburtshülfe</i>, band iv. heft 1, 1836.) Where the child has been dead some time in the uterus, the abdomen is frequently tympanic, and thus retards its expulsion.</p> @@ -12049,7 +12033,7 @@ traction was made, with a repetition of the cracking sound, and the child was delivered. On examination it was found that all the joints of the extremities were anchylosed in the usual position of the fœtus in utero, so that the ossa humeri and then the ossa femoris had given way. -The child had been dead some time.” (<i>Neue Zeitschrift für Geburtskunde</i>, +The child had been dead some time.” (<i>Neue Zeitschrift für Geburtskunde</i>, vol. xv. 1837; and <i>British and Foreign Med. Rev.</i> April 1838, p. 579.)</p> <p>No precise rules can be given for the treatment of these cases of @@ -12080,7 +12064,7 @@ cord.—Placenta.</i></p></div> <p>In describing this species of dystocia, according to the arrangement of -Professor Naegelé, which we have adopted, it will be necessary to observe +Professor Naegelé, which we have adopted, it will be necessary to observe that serious obstructions to the passage of the child is seldom produced by it, although, at the same time, many slight derangements in the progress of labour are liable to result, which demand the care of the @@ -12117,7 +12101,7 @@ very easy to prove: in most instances, it is observed where the uterus is but moderately distended, and where it has that oval or pyriform shape which we have already pointed out as being best adapted for acting efficiently upon the os uteri. This, perhaps, is one reason, why too early -rupture of the membranes so frequently occurs in primiparæ; and this may +rupture of the membranes so frequently occurs in primiparæ; and this may be one cause, among many others, why first labours are generally so much more tedious and severe. The membranes may also be prematurely ruptured by violent exertions, coughing, sneezing, vomiting, &c. by straining @@ -12203,7 +12187,7 @@ very insertion; so that in this case the cord could not have been much more than two inches long.” (Printed Lectures in Renshaw’s <i>Lond. Med. and Surg. Journ.</i> May 1835, p. 426.)</p> -<p>We quite agree with Professor Naegelé, that unusual shortness of the cord +<p>We quite agree with Professor Naegelé, that unusual shortness of the cord can rarely if ever retard labour; and that where the cord really produces an impediment to its progress, it is from being twisted round the neck, or some other part of the child. (<i>Lehrbuch</i>, 2d ed. p. 289.) This generally @@ -12211,7 +12195,7 @@ arises from its unusual length, and from its having formed several coils around the child: we have met with it forty-eight inches long, and twisted four times round the child’s neck; but Baudelocque mentions a case where it actually measured fifty-seven inches, “forming seven turns round the -child’s neck.” (Heath’s <i>Transl.</i> vol. i. § 516.) Mauriceau has given an +child’s neck.” (Heath’s <i>Transl.</i> vol. i. § 516.) Mauriceau has given an instance (<i>Obs.</i> 401.,) where the cord had “longueur d’une aune et un tiers de notre mesure de Paris:” which, converted into English measure, amounts to somewhat more than sixty-one inches.</p> @@ -12355,10 +12339,10 @@ perforation; this also terminated fatally, the forceps having been previously applied, and considerable efforts made without success. On examination after death, every diameter of the pelvis was three quarters of an inch smaller than usual: in appearance it resembled that of a -child.” (<i>Neue Zeitschrift für Geburtskunde</i>, vol. xv. 1837.)</p> +child.” (<i>Neue Zeitschrift für Geburtskunde</i>, vol. xv. 1837.)</p> <p><i>Unequally contracted pelvis.</i> The unequally contracted pelvis (<i>pelvis -inæqualiter justo minor</i>) may exist under a variety of forms; the most +inæqualiter justo minor</i>) may exist under a variety of forms; the most common is where the antero-posterior diameter is defective, or, in other words, where the distance between its anterior and posterior parietes is less than usual. In a slight degree, it is frequently met with among the @@ -12409,7 +12393,7 @@ has been placed. The most constant change is the shortening of the antero-posterior diameter at the brim. In severe cases the base of the sacrum has, as it were, sunk down between the illia, so that its promontory occupies the cavity of the pelvis, the fourth, or third, or -even the second, lumbar vertebræ occupying its former position. The +even the second, lumbar vertebræ occupying its former position. The gradual yielding of the bones seldom takes place with that degree of uniformity as to allow the sacrum to approach the symphysis pubis in a straight line: the more common result of rickets is, that the promontory @@ -12459,10 +12443,10 @@ outwards, and form at their symphysis a sort of beak-like process, which is the apex of the heart: in this species of deformed pelvis, which is usually the result of mollities ossium, the outlet also is usually much distorted: this arises from the tubera ischii being forced nearer to each -other, thus contracting the pubic arch.” (Naegelé’s <i>Lehrbuch</i>, 2te +other, thus contracting the pubic arch.” (Naegelé’s <i>Lehrbuch</i>, 2te Ausgabe, p. 247.)</p> -<div class="figleft"><img src="images/img37.jpg" alt="" /><br /><i>From</i> Naegelé.</div> +<div class="figleft"><img src="images/img37.jpg" alt="" /><br /><i>From</i> Naegelé.</div> <div class="figleft"><img src="images/img38.jpg" alt="" /></div> @@ -12484,7 +12468,7 @@ Hence, it occasionally happens, that a woman has given birth to several healthy living children without any unusual difficulty in her labours, and where, after this, the pelvis has gradually become so deformed from mollities ossium, as to render delivery impossible by the natural -passages, and, therefore, to require the Cæsarean operation. Pelves of +passages, and, therefore, to require the Cæsarean operation. Pelves of this sort, may be easily distinguished from those which have been deformed in early life by rickets; they have evidently attained their full adult growth before the process of softening had commenced: the ilia, for @@ -12567,7 +12551,7 @@ wherever the lower extremities are curved, the pelvis is mostly deformed: it is well to ascertain also if, when a child, it was a long time before she could walk alone; whether she had any fall on the sacrum; whether as a girl she was made to carry heavy weights, or to work in manufactories.” -(Naegelé’s <i>Lehrbuch</i>. § 444.)</p> +(Naegelé’s <i>Lehrbuch</i>. § 444.)</p> <p><i>Funnel-shaped pelvis.</i> Besides the above-mentioned species of pelvic deformity, others are occasionally met with, the origin of which is but @@ -12581,8 +12565,8 @@ formation.</p> <div class="figleft"><img src="images/img39.jpg" alt="" /></div> <p><i>Obliquely distorted pelvis.</i> A still more remarkable species of pelvic -deformity is the <i>pelvis obliqué ovata</i>, which, of late years, has been -pointed out by Professor Naegelé. In this case the pelvis appears awry, +deformity is the <i>pelvis obliqué ovata</i>, which, of late years, has been +pointed out by Professor Naegelé. In this case the pelvis appears awry, the symphysis pubis being pushed over to one side; and the sacrum to the other; one side of the pelvis is more or less flattened, the other bulges out, so that one oblique diameter is shorter, the other longer than @@ -12602,7 +12586,7 @@ the termination of the disease in anchylosis; indeed, we can to a certain extent imitate this peculiar species of pelvic deformity by sawing off the surfaces of the sacrum and ilium which had formed the symphysis, and then putting the bones together again. Still, however, in the various cases -which have been collected by Professor Naegelé, no proofs could be +which have been collected by Professor Naegelé, no proofs could be obtained of disease having existed in the pelvis during early life.</p> <p>“In none of the cases, the particulars of which have come to my knowledge, @@ -12611,7 +12595,7 @@ appearances, and morbid changes been observed which characterize mollities ossium coming on after puberty. None of these cases have been traced to the effects of external violence, as falls, blows, &c.; nor has there been any complaint of pain in the region of the pelvis, inferior extremities, -&c.” (<i>Das Schräg Verengte Becken</i>, p. 12.) “With respect to<span class="pagenum"><a name="Page_300" id="Page_300">[Pg 300]</a></span> the +&c.” (<i>Das Schräg Verengte Becken</i>, p. 12.) “With respect to<span class="pagenum"><a name="Page_300" id="Page_300">[Pg 300]</a></span> the strength, colour, structure, &c. of the bones of this species of deformed pelvis, no difference could be observed between them and the bones of young and perfectly healthy subjects; not a trace either in form or other @@ -12619,11 +12603,11 @@ respects could be detected of those changes which usually result from rachitis or mollities ossium; and but for this distortion and some other slight irregularities, which required close inspection to detect, these pelves would have been looked upon as well-shaped, and of sufficient -capacity.” (Naegelé, <i>op. cit.</i> p. 11.) In some specimens no trace of +capacity.” (Naegelé, <i>op. cit.</i> p. 11.) In some specimens no trace of anchylosis at the sacro-iliac symphysis has been observed; but whether this was the case throughout the union of the two bones we cannot say. -Professor Naegelé is inclined to look upon them as modifications of the -<i>pelvis obliqué ovata</i>, and certainly in the majority of known cases +Professor Naegelé is inclined to look upon them as modifications of the +<i>pelvis obliqué ovata</i>, and certainly in the majority of known cases anchylosis has been found present.</p> <p>It is scarcely necessary to do more than enumerate other varieties in the @@ -12751,7 +12735,7 @@ flattened and forced deep under the parietal bones, but not otherwise injured. The right parietal bone, which during birth had been turned towards the promontory of the sacrum, was covered anteriorly and superiorly with effused blood, and on<span class="pagenum"><a name="Page_303" id="Page_303">[Pg 303]</a></span> removing the periosteum, was found -fractured in five places. (<i>Neue Zeitschrift für Geburtskunde</i>, vol. iv. +fractured in five places. (<i>Neue Zeitschrift für Geburtskunde</i>, vol. iv. part 3. 1836.<a name='fna_124' id='fna_124' href='#f_124'><small>[124]</small></a>)</p> <p>Where the action of the uterus is not very violent, and the bones @@ -12852,7 +12836,7 @@ and on the other, to have recourse to art when the real condition of the case justified no such interference.<a name='fna_126' id='fna_126' href='#f_126'><small>[126]</small></a></p> <p>With regard to the diagnosis and treatment in the case of obliquely -distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to +distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to enable us to give any decided rules: the immobility of the head, although the antero-posterior diameter appears of its full length, the shortness of one oblique diameter, and consequent undue pressure upon the head in this @@ -12860,7 +12844,7 @@ direction, and the unusual length of the other, are the characteristics which we have observed in the only case of the kind which has come under our notice during life. In all the cases of labour rendered difficult by this condition of the pelvis, which have been collected by Professor -Naegelé, the perforation has been strongly indicated; and where the +Naegelé, the perforation has been strongly indicated; and where the forceps has been used, it has either failed, as with us, or if the delivery has been effected by this means, it has been attended with fatal consequences.</p> @@ -12905,7 +12889,7 @@ heavy load upon the head; on coming to herself the woman found that she was unable to move, and in this state was conveyed home; she recovered to all appearances in a few weeks, married, and soon became pregnant. When labour came on it was found impossible to deliver her, from the pelvis -being entirely filled with a huge exostosis: the Cæsarean section was +being entirely filled with a huge exostosis: the Cæsarean section was performed, but she died, and on examination after death an immense mass of bony growth was found springing from the sacrum, which had been apparently fractured, not only filling up the whole cavity of the pelvis, but arising @@ -12942,7 +12926,7 @@ coincided with Dr. Osborn’s statements. To assert that in this case the antero-posterior diameter was only three-quarters of an inch, as many have done, is evidently incorrect, and tends to throw doubt upon it: the case was evidently the closest possible approach to the limits requiring the -Cæsarean operation; its success was mainly attributable to the gradual +Cæsarean operation; its success was mainly attributable to the gradual manner in which it was performed; the child had become completely soft and flaccid from putrefaction, and was thus more capable of being moulded to the contracted passage.</p> @@ -12962,7 +12946,7 @@ the contracted passage.</p> the os uteri adherent.—Cicatrices and collosities.—Agglutination of the os uteri.—Contracted vagina.—Rigidity from age.—Cicatrices in the vagina.—Hymen.—Fibrous bands.—Perineum.—Varicose and -œdematous swellings of the labia and nymphæ.—Tumours.—Distended +œdematous swellings of the labia and nymphæ.—Tumours.—Distended or prolapsed bladder.—Stone in the bladder.</i></p></div> @@ -13025,7 +13009,7 @@ held by two assistants; at the same time we introduced a finger within the edge of the os uteri, and drew it towards the symphysis pubis, and then waited for the effects of a pain. One soon showed itself, and with such decided efficacy, as to push the head completely into the inferior strait, -and three more delivered it.” (<i>Compendious System of Midwifery</i>, § 224.)</p> +and three more delivered it.” (<i>Compendious System of Midwifery</i>, § 224.)</p> <p>This peculiar displacement of the uterus, which has been called by some anteversion of the gravid womb, has occasionally given rise to the @@ -13062,9 +13046,9 @@ circular fibres, or from irregularity or deficiency in the contractions of the longitudinal fibres of the whole organ. In a slight degree this is frequently met with, especially in first labours, where the patient is young, delicate, and irritable, and where, in all probability, there is -some source of irritation in the primæ viæ which tends to disturb and +some source of irritation in the primæ viæ which tends to disturb and divert the proper and healthy action of the uterus. We see it also in -robust plethoric primiparæ; the os uteri dilates to a certain degree, +robust plethoric primiparæ; the os uteri dilates to a certain degree, perhaps an inch in diameter, and remains tense and firm, with its edge thin; the contractions of the uterus produce much suffering, and to all appearances are very violent; but they are chiefly in front, and produce @@ -13077,7 +13061,7 @@ consideration of the treatment.</p> <p><i>Belladonna.</i> It has been recommended, and not very <span class="pagenum"><a name="Page_311" id="Page_311">[Pg 311]</a></span>judiciously, to apply belladonna to the os uteri in cases of great rigidity: it was repeatedly -tried by the celebrated Chaussier in the Maternité, at Paris, and, +tried by the celebrated Chaussier in the Maternité, at Paris, and, according to his observations, it produced a considerable effect upon it. “The knowledge of the extraordinary powers which this drug possesses in causing dilatation of the iris, led to its employment for the object of @@ -13166,7 +13150,7 @@ may produce very considerable impediment to the passage of the child, is that which has been called <i>agglutination</i>, where by some adhesive process, apparently that of inflammation, the lips of the opening adhere and completely close it. These species of imperforate os uteri may occur -in primiparæ as well as in those who have borne children: the +in primiparæ as well as in those who have borne children: the agglutination of its edges takes place during pregnancy, probably shortly after conception. Upon <span class="pagenum"><a name="Page_313" id="Page_313">[Pg 313]</a></span>examination we find no traces of hardness, rigidity, or any other morbid condition, either in the os uteri itself, or @@ -13177,7 +13161,7 @@ consistence forms a species of false membrane, which in some cases is capable of resisting the most powerful uterine contractions, and in others it appears to cover the os uteri so completely as to conceal it most effectually, and give rise to the erroneous conclusion that the os uteri -is altogether wanting. Baudelocque describes this condition (<i>Op. cit.</i> § +is altogether wanting. Baudelocque describes this condition (<i>Op. cit.</i> § 1961;) but from the brief mention which he makes of it, as also from the treatment recommended, it is plain that he had no very distinct notions about it, for he advises that “in all cases the orifice must be restored @@ -13261,7 +13245,7 @@ secretion of mucus is more sparing; the cellular tissue is more condensed and firm; still nevertheless, although it is constantly mentioned by authors as a cause of this species of dystocia, we cannot help declaring that it exists to a much less degree than has been generally supposed, and -that primiparæ at a very early age are much more liable to have tedious +that primiparæ at a very early age are much more liable to have tedious and difficult labours than those at an advanced age. Still, however, the circumstance is well worthy of notice; and in such cases we may produce much relief by the warm bath, or hip bath, by sitting over the steam of @@ -13348,7 +13332,7 @@ indentation along the cranial bones; it was divided by a bistouri, and the head was immediately expelled.</p> <p>The <i>perineum</i> can rarely, if ever, prove a serious hindrance to the -labour in primiparæ so long as its structure is healthy, even although it +labour in primiparæ so long as its structure is healthy, even although it may be unusually broad. With patience and due management the necessary degree of dilatation may be obtained by the pressure of the head; and proposals to dilate it artificially, or even to make a slight incision @@ -13368,7 +13352,7 @@ or have been divided during labour, great care should be taken to prevent them forming again during the process of healing, by using sponge tents well greased, and other appropriate means.</p> -<p><i>Varicose and œdematous swellings of the labia and nymphæ</i> also deserve +<p><i>Varicose and œdematous swellings of the labia and nymphæ</i> also deserve mention, although they rarely interfere with the progress of labour to any great extent. Varicose labia seldom annoy the patient during her pregnancy; the veins of the part may have become somewhat dilated and the @@ -13383,14 +13367,14 @@ labour and causing loss of<span class="pagenum"><a name="Page_318" id="Page_318" tumour seldom bursts directly externally, but first gives way beneath the skin, producing extravasation, after which, in consequence of still farther distention, the labium itself ruptures. In some cases the -hæmorrhage is not very profuse externally, while the extravasation +hæmorrhage is not very profuse externally, while the extravasation internally, amounts to some pounds, extending not only to the vagina and perineum, but also to the groin; and instances have occurred where it has -spread to a great distance over the glutæus muscles.</p> +spread to a great distance over the glutæus muscles.</p> <p>“The extravasation,” says Mr. Ingleby, “usually happens during the pain which expels the child; but sometimes at an early period of labour, as in -the example of severe hæmorrhage here annexed. I had just left a patient +the example of severe hæmorrhage here annexed. I had just left a patient to whom I had been called, in consequence of the difficult transmission of the child’s head through a distorted pelvis, in connexion with an inordinate varicose enlargement of the labia pudendi (especially the @@ -13436,7 +13420,7 @@ will coagulate almost as rapidly as it is effused.” (Ingleby, <i>op. cit.< p. 109.)</p> <p>A considerable degree of suffering and annoyance to the patient may arise -from œdematous swelling of the labia and nymphæ, both previous to and +from œdematous swelling of the labia and nymphæ, both previous to and during her labour. The labia are occasionally so distended as not only to close the os externum, but to require that the legs should be kept as wide asunder as possible, to prevent the swollen parts being crushed: the @@ -13472,16 +13456,16 @@ tried the plan recommended above. He <span class="pagenum"><a name="Page_320" id are the result of pressure, the less we do with them the better, merely taking care to keep up the action of the skin.</p> -<p>Œdema, or rather dropsy, of the nymphæ, is not of common occurrence, +<p>Œdema, or rather dropsy, of the nymphæ, is not of common occurrence, and, when it takes place to a considerable extent, produces a singular -alteration in the appearance of the external organs. The nymphæ protrude +alteration in the appearance of the external organs. The nymphæ protrude beyond the labia, and depend so much as to rest upon the bed on which the patient lies, forming a soft membranous bag, fluctuating with the fluid which it contains. If labour has not actually commenced, we would prefer endeavouring to excite the absorbents of the part, and thus remove the effused fluid, to its evacuation by puncture: we have perfectly succeeded, by the use of warm aromatic stimulating fomentations. The “<i>species -aromaticæ</i>” of the Continental pharmacopeiæ may be used with much +aromaticæ</i>” of the Continental pharmacopeiæ may be used with much advantage in these cases: the mode of its application is, to tie some up in a loose muslin bag, and soak it in hot wine; this forms an excellent warm stimulating application, and appears to excite the absorbents very @@ -13498,7 +13482,7 @@ in some cases, produce an impediment of the most serious character. Fibrous polypi and hard tubercles of the subcartilaginous character (commonly called the fleshy tubercle) are those which may present the greatest resistance, while fungoid growths of malignant disease, whether -cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, +cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, rarely oppose much obstruction. Their structure is soft and spongy, they therefore yield to the gradual pressure of the head, become more or less flattened, and thus allow it to pass. But fibrous or chondromatous tumours @@ -13601,7 +13585,7 @@ organs—mental affections—the age and temperament of the patient—plethora—rheumatism of the uterus—inflammation of the uterus—stricture of the uterus.—Treatment.</i> II. <i>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.</i></p></div> +expelling powers after the birth of the child.—Hæmorrhage.—Treatment.</i></p></div> <p>Although this species includes that condition of the expelling powers, @@ -13666,7 +13650,7 @@ the uterus; and from uterine inflammation.</p> <p>The contractions of the uterus may be <i>mechanically</i> impeded, by tumours imbedded in its substance; by organic diseases, as schirrus, cephaloma, -and hæmatoma; cicatrices from former ulcerations or rupture, or by any +and hæmatoma; cicatrices from former ulcerations or rupture, or by any other circumstances which interrupt the action of the longitudinal fibres upon the os uteri.</p> @@ -13683,7 +13667,7 @@ poverty, with its attendant miseries, depressing passions of the mind, and health broken down by intemperance.</p> <p>The contractile power of the uterus itself may be injured by previous -leucorrhœa or menorrhagia, by abortions, or by attacks of hæmorrhage +leucorrhœa or menorrhagia, by abortions, or by attacks of hæmorrhage during the latter part of pregnancy; it may be weakened by over-distention of the uterus, either from plurality of children or too much liquor amnii, by the patient exerting herself improperly at the commencement of labour, @@ -13791,7 +13775,7 @@ movements. The pains are short and ineffective, and accompanied with a peculiar sensation of painful stretching or tension, without any symptoms of rheumatism, cramp, or other morbid conditions of the uterus being present.” (Wigand, <i>Geburt des Menschen</i>, vol. i. p. 138.) This condition -is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, +is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, constipation, varicose veins of the lower extremities, &c.</p> <p><i>Rheumatism of the gravid uterus</i> is an affection which, although it has @@ -13859,12 +13843,12 @@ demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient’s health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most -frequently in young primiparæ of delicate form and nervous irritable +frequently in young primiparæ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes much<span class="pagenum"><a name="Page_330" id="Page_330">[Pg 330]</a></span> protracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and -dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass +dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its @@ -13874,7 +13858,7 @@ as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully -dilated,) an enema will not only clear the rectum of any fæcal matter +dilated,) an enema will not only clear the rectum of any fæcal matter which may be lodging there, but assist in rousing the uterus to greater activity.</p> @@ -13898,7 +13882,7 @@ and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:—℞ Secalis Cornuti -℈ i—ij; Sodæ Subborat. gr x; Aq. Cinnamomi ℥ +℈ i—ij; Sodæ Subborat. gr x; Aq. Cinnamomi ℥ jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree.</p> @@ -13912,7 +13896,7 @@ there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contraction <i>after</i> labour, and thus to promote the safe expulsion of the placenta, where there is a -disposition to inertia uteri, and ensure the patient against hæmorrhage.</p> +disposition to inertia uteri, and ensure the patient against hæmorrhage.</p> <p>Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive @@ -13970,7 +13954,7 @@ bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the -administration of an enema, and removal of a quantity of fæcal matter from +administration of an enema, and removal of a quantity of fæcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short @@ -13991,7 +13975,7 @@ to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result.</p> -<p>In the management of primiparæ, who are pregnant either at a very early +<p>In the management of primiparæ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as @@ -14049,7 +14033,7 @@ condition, we believe, is rarely excited, until<span class="pagenum"><a name="Pa already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, -therefore, it will always be important to unload the primæ viæ effectually +therefore, it will always be important to unload the primæ viæ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably @@ -14151,7 +14135,7 @@ tightly encircles, and renders all farther advance impossible.</p> the uterus and excite it to irregular action; thus, premature rupture of the membranes, especially when it has been suddenly drained of a large quantity of liquor amnii; the irritation arising from acrid matter in the -intestines, or from their being loaded with accumulations of fæces; +intestines, or from their being loaded with accumulations of fæces; improper examination, and more especially, attempts to dilate the os uteri by the fingers or hand; endeavouring to strain and bear down during the early part of labour, and when the patient is not involuntarily compelled @@ -14226,7 +14210,7 @@ render the last stage of labour dangerous; for, under such circumstances, the portion of the uterus to which the placenta is attached may be in a state of firm contraction in one part, while<span class="pagenum"><a name="Page_338" id="Page_338">[Pg 338]</a></span> the other is quite relaxed, so that incomplete separation of the placenta will be the result, and -hæmorrhage follow: hence we cannot be too cautious in avoiding every cause +hæmorrhage follow: hence we cannot be too cautious in avoiding every cause which may at all influence the regular action of the uterus during the last stage of labour, which is far more dangerous than the two others put together.</p> @@ -14242,13 +14226,13 @@ uterus, which in some cases will have almost a lobulated feel; in others, it presents a considerable depression either upon the fundus or anterior wall.</p> -<p><i>Hæmorrhage.</i> The danger here, chiefly depends upon the occurrence of -hæmorrhage: if the placenta be still attached by its whole surface to the -uterus, no hæmorrhage can ensue; but if the contractions have been of +<p><i>Hæmorrhage.</i> The danger here, chiefly depends upon the occurrence of +hæmorrhage: if the placenta be still attached by its whole surface to the +uterus, no hæmorrhage can ensue; but if the contractions have been of sufficient power to detach more or less of it from the uterus, large trunks, which have hitherto conveyed maternal blood into the placental cells, are torn through, and a profuse discharge must be the result. The -degree of the hæmorrhage will in most instances furnish us with a +degree of the hæmorrhage will in most instances furnish us with a tolerable estimate of the extent to which the separation has taken place; but it is far from easy to ascertain correctly the quantity of blood which has been lost, and we must rather try to ascertain what are the effects @@ -14263,7 +14247,7 @@ patient at first complains of great weakness, the face becomes pale, the lips white, the breathing anxious; this is followed by a sense of great prostration, the perspiration breaks out upon the face and forehead, tinnitus aurium, confusion of ideas, and sense of darkness before the eyes -succeed; the load at the præcordia, and the oppression of breathing, +succeed; the load at the præcordia, and the oppression of breathing, become more insupportable; she tosses her arms about, and in some instances has a sensation that the room is going round with her, or that she is sinking through the bed; in other cases, the breathing becomes @@ -14284,16 +14268,16 @@ left, or, in other words, to be followed by sudden death.</p> <p>These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal -character of the hæmorrhage. The want of contraction and general +character of the hæmorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the accumulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the -patient may be in the most imminent danger of dying from hæmorrhage, +patient may be in the most imminent danger of dying from hæmorrhage, perhaps, without any blood having issued externally: this is the <i>internal -uterine hæmorrhage</i>, a form which is justly looked upon as peculiarly to +uterine hæmorrhage</i>, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, @@ -14302,7 +14286,7 @@ coagulated blood, and returning to its former state of atony, again begins to swell from fresh accumulation of blood in its cavity.</p> <p><i>Treatment.</i> So long as the inertia or atony of the uterus continues -without any symptoms either of external or internal hæmorrhage, we are not +without any symptoms either of external or internal hæmorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly @@ -14322,7 +14306,7 @@ of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;<a name='fna_131' id='fna_131' href='#f_131'><small>[131]</small></a> or, if she has been much exhausted by her labour, a glass of -wine may be given with good effect. If, however, hæmorrhage appears, this +wine may be given with good effect. If, however, hæmorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.</p> @@ -14334,14 +14318,14 @@ may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see <span class="smcap">Dystocia</span>, p. 330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the -contraction of the uterus afterwards. If the hæmorrhage nevertheless +contraction of the uterus afterwards. If the hæmorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, -from the profuseness of the hæmorrhage, it has become evident that the +from the profuseness of the hæmorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a @@ -14369,7 +14353,7 @@ will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his -description of a dangerous case of hæmorrhage:—“Finding the ice so +description of a dangerous case of hæmorrhage:—“Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and @@ -14405,7 +14389,7 @@ once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to -swell again from internal hæmorrhage, and by the renewal of the above +swell again from internal hæmorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this @@ -14438,10 +14422,10 @@ not be looked upon in so formidable a light: thus Dr. Denman observes, “when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circumstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed -by a return or increase of the hæmorrhage, which I concluded was +by a return or increase of the hæmorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the -injury which the constitution has suffered by the hæmorrhage, yet the +injury which the constitution has suffered by the hæmorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a<span class="pagenum"><a name="Page_343" id="Page_343">[Pg 343]</a></span> more vigorous action of the remaining powers of the constitution, as is proved by the amendment of the @@ -14454,13 +14438,13 @@ through the os uteri into the vagina, upon the removal of which, the discharge will cease.</p> <p>The application of the child to the breast is not less valuable for -preventing any return of the hæmorrhage than for stopping it in the first -instance: we are <i>never</i> perfectly secure against hæmorrhage coming on +preventing any return of the hæmorrhage than for stopping it in the first +instance: we are <i>never</i> perfectly secure against hæmorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be -followed by inertia uteri and hæmorrhage. In no way can we ensure our +followed by inertia uteri and hæmorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a practitioner is @@ -14468,26 +14452,26 @@ justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.</p> -<p>There is a form of hæmorrhage after the birth of the child, which seems to +<p>There is a form of hæmorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse -hæmorrhage is almost sure to follow the separation of the placenta. This +hæmorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. “I had now witnessed,” says Dr. Gooch, “two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse -hæmorrhage had nevertheless occurred: let me be understood—after the +hæmorrhage had nevertheless occurred: let me be understood—after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and -precludes hæmorrhage; in both instances, the labour had been attended by +precludes hæmorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that -a contraction of the uterus, which would preclude hæmorrhage in the +a contraction of the uterus, which would preclude hæmorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, -that, in this case, the hæmorrhage depended not on a want of contraction +that, in this case, the hæmorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she<span class="pagenum"><a name="Page_344" id="Page_344">[Pg 344]</a></span> became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the @@ -14590,13 +14574,13 @@ cervix uteri, forming, as it were, a tight ring round it. The patient complains of a sense of dragging amounting to severe pain in the groins and lumbar region, and which compelling her to strain violently, often forces the uterus farther down, and sometimes induces complete inversion; -hæmorrhage more or less considerable accompanies it; the pain is more -acute in this than in the complete inversion, and the hæmorrhage more +hæmorrhage more or less considerable accompanies it; the pain is more +acute in this than in the complete inversion, and the hæmorrhage more violent; the patient suffers under an oppressive sense of sinking, with nausea or vomiting, cold clammy sweats, feeble fluttering or nearly extinct pulse, faintings or even convulsions.</p> -<p>In the <i>complete</i> form we have neither the hæmorrhage nor that frightful +<p>In the <i>complete</i> form we have neither the hæmorrhage nor that frightful train of symptoms produced by the strangulated condition of the inverted uterus; for now that it is fairly turned inside out, it is just, or nearly as capable of contracting as in its natural state, which it is prevented @@ -14638,7 +14622,7 @@ reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the -hæmorrhage at a period when every ounce of blood is of infinite +hæmorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent <i>judicious</i> treatment as a simply retained placenta will have a good effect in bringing on that regular and natural @@ -14652,10 +14636,10 @@ removed <i>before</i> attempting to reduce the fundus; as by so doing it will pass back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or -no danger from hæmorrhage, and where it is of the greatest importance to +no danger from hæmorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial -inversion, it is generally accompanied with hæmorrhage; and here, +inversion, it is generally accompanied with hæmorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed @@ -14697,7 +14681,7 @@ cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger space: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (<i>Sur les -Pertes de Sang</i>, § 218.) The hand, however, will be far preferable. We +Pertes de Sang</i>, § 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When @@ -14757,7 +14741,7 @@ advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the “pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse,” &c. will not only be relieved, but the -farther danger from hæmorrhage prevented.</p> +farther danger from hæmorrhage prevented.</p> <p>“The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire @@ -14774,7 +14758,7 @@ announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing -sensations.” (Dewees, <i>Compendious System of Midwifery</i>, § 1318.)</p> +sensations.” (Dewees, <i>Compendious System of Midwifery</i>, § 1318.)</p> <p><i>Chronic inversion.</i> Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have @@ -14803,7 +14787,7 @@ that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty.”</p> -<p>The periodical hæmorrhages, with profuse leucorrhœa during the +<p>The periodical hæmorrhages, with profuse leucorrhœa during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate @@ -14820,7 +14804,7 @@ inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour pretty high up in the vagina would prevent our ascertaining it, especially when there -is more or less hæmorrhage going on. In most cases, the history of the +is more or less hæmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis.</p> @@ -14849,7 +14833,7 @@ more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently.</p> <p><i>Extirpation of the uterus.</i> Where, however, the powers of the system are -rapidly breaking, from the profuse hæmorrhages at each menstrual period, +rapidly breaking, from the profuse hæmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or in other words, removing the uterus by ligature. Numerous cases are on record where @@ -14858,7 +14842,7 @@ suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case<span class="pagenum"><a name="Page_353" id="Page_353">[Pg 353]</a></span> recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation -is removed, the hæmorrhage and other discharges which had so greatly +is removed, the hæmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete.</p> @@ -14884,7 +14868,7 @@ formed by itself and the body of the uterus.</p> <p>Upon examination externally, we find the fundus pretty firmly contracted, but probably somewhat higher up the abdomen than usual; the vagina and os -uteri externum, or os tincæ, are usually found dilated, the passage +uteri externum, or os tincæ, are usually found dilated, the passage gradually tapering like a funnel to the os uteri internum, or upper end of the canal of the cervix.</p> @@ -14910,7 +14894,7 @@ and its forced dilatation<span class="pagenum"><a name="Page_355" id="Page_355"> trunk is only momentary, and because it has naturally more tendency to close than the other circles have, since it is that which constitutes the neck of the uterus in its natural state.” (Baudelocque, <i>Heath’s Trans.</i> -vol. ii. § 969.)</p> +vol. ii. § 969.)</p> <p>Dr. Douglas, of Dublin, also investigated this subject, and came to a similar conclusion: he considered that encysted or incarcerated placenta @@ -14926,7 +14910,7 @@ chamber engages only the cervix uteri and the vagina.” (<i>Medical Transactions of the Col. of Phys.</i> vol. vi. p. 393.)</p> <p>The late W. J. Schmitt of Vienna considered that the stricture was -produced by the os tincæ, or os uteri externum.</p> +produced by the os tincæ, or os uteri externum.</p> <p>From our own experience we would say that the seat of the stricture varies considerably in different cases; that in the simplest form it is nothing @@ -14955,7 +14939,7 @@ too much force in artificially delivering the child, by the introduction of the hand or instruments too cold, &c. The most frequent cause, however, is over anxiety to remove the <span class="pagenum"><a name="Page_356" id="Page_356">[Pg 356]</a></span>placenta; the cord is frequently pulled at, and at length the os uteri is excited to contract; in this case we -generally find the stricture at the os tincæ, which yields without much +generally find the stricture at the os tincæ, which yields without much difficulty, either by gentle friction with the hand over the fundus, and cautiously pulling the placenta in the axis of the superior aperture, or by introducing the hand and bringing it away.</p> @@ -14980,15 +14964,15 @@ and lighter colour of the part which has been adherent might, perhaps, justify such a conclusion. Cases have occurred where the inflammatory action has extended in the contrary direction (outwards,) producing mischief in the neighbouring parts, viz. abscess and injury of the pelvic -periosteum with subsequent pelvic exostosis. (<i>Neue Zeitschrift für +periosteum with subsequent pelvic exostosis. (<i>Neue Zeitschrift für Geburtskunde</i>, band v. heft 1.) We may also observe, that these adhesions of the placenta usually occur several times in the same individual.</p> <p><i>Prognosis and treatment.</i> The danger in these cases depends chiefly on -the presence or absence of hæmorrhage; in the latter case, we may wait +the presence or absence of hæmorrhage; in the latter case, we may wait safely, and give the uterus the opportunity of contracting upon the placenta, so as ultimately to dilate the stricture and expel it. In most -instances, where the os tincæ is the seat of the contraction, and the +instances, where the os tincæ is the seat of the contraction, and the placenta (as is usually the case here) already detached, a little patience, aided by gentle friction of the fundus, and carefully abstaining from all irritation of the os uteri, will be sufficient to attain this @@ -15067,7 +15051,7 @@ little or no inconvenience is experienced by the patient; the lochia, as we before observed, is sparing but natural, and ceases after the usual time, but not a trace of the placenta comes away. This fact has been repeatedly noticed, especially in later years; but the attention of -medical men was first called to the subject by Professor Naegelé, of +medical men was first called to the subject by Professor Naegelé, of Heidelberg, in 1828. In 1802, and again in 1811, cases of premature expulsion of the fœtus occurred to him where the membranes and placenta did not come away, and where no trace whatever of them appeared @@ -15108,12 +15092,12 @@ knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the fact beyond all doubt, he shows that cases of total adhesion are rarely if ever fatal; and that, where cases have terminated fatally, the placenta has only partially adhered, and the patient has been either destroyed by -hæmorrhage, or by the effects arising from the absorption of putrid +hæmorrhage, or by the effects arising from the absorption of putrid matter, or from injury of the uterus in attempting to remove the placenta. He considers that a placenta which is not fixed to the uterus by organic and intimate adhesions cannot be absorbed, though it may perhaps be retained for several days without danger, if there is contraction of the -uterus. (<i>Gazette Médicale de Paris</i>, July 8, 1840.) It may, however, be +uterus. (<i>Gazette Médicale de Paris</i>, July 8, 1840.) It may, however, be doubted whether this last observation be correct, as it is a well-established fact that cows which had been supposed with calf, and in which the symptoms of pregnancy had again subsided, have afterwards been @@ -15135,7 +15119,7 @@ has generally been observed, especially where the <i>whole</i> surface of the placenta has adhered, can easily be accounted for, the greater portion of the vessels which ordinarily furnish this discharge being closed up by the adherent mass: from the same reason we can explain why cases of total -attachment of the placenta are rarely or never attended with hæmorrhage.</p> +attachment of the placenta are rarely or never attended with hæmorrhage.</p> <p>Lastly, should any symptoms of fever or abdominal inflammation supervene, they must be treated according to the rules which we have given under @@ -15217,7 +15201,7 @@ energy and irritability during labour. On the other hand, where the menstrual periods produce so little suffering or derangement that, but for the appearance of the discharge itself, the patient has scarcely any means of determining their recurrence, the uterus betrays a similar want of -activity when labour comes on, which may therefore, <i>cæteris paribus</i>, be +activity when labour comes on, which may therefore, <i>cæteris paribus</i>, be expected to be slow and lingering.</p> <p>Mental affections, which we have already shown to be capable of retarding @@ -15283,7 +15267,7 @@ a complication of violent pains, wide pelvis, and small child.</p> <p><i>Effects of precipitate labour.</i> Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration -of the vagina, perineum, and hæmorrhage from inertia coming on in +of the vagina, perineum, and hæmorrhage from inertia coming on in consequence of the uterus being so suddenly<span class="pagenum"><a name="Page_364" id="Page_364">[Pg 364]</a></span> emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of @@ -15308,7 +15292,7 @@ suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a recumbent posture upon the floor: in this way it may receive a severe injury upon the head, -or the cord may be lacerated, and the child die from hæmorrhage before +or the cord may be lacerated, and the child die from hæmorrhage before assistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and vagina @@ -15357,7 +15341,7 @@ the cases which have come under our own notice.</p> pelvis, the pains are forcing the lower portion of the uterus down to, or through, the os externum, it will be necessary to support it carefully, until the os uteri is sufficiently dilated to let the head pass. A case of -this kind occurred to Professor Naegelé, of Heidelberg, where, during the +this kind occurred to Professor Naegelé, of Heidelberg, where, during the patient’s former labour, the pains had been so violent, and the uterus had been detruded to such an extent, that actually the lower half of it appeared between the labia: to prevent a similar accident occurring this @@ -15485,7 +15469,7 @@ membranes takes place at a moment when the patient is moving briskly on in some unfavourable posture, the cord will be very liable to prolapse. Nevertheless, cases are occasionally seen which arise without these predisposing circumstances.” (Boer, <i>von Geburten unter welchen die -Nabelschnur vorfällt</i>.)</p> +Nabelschnur vorfällt</i>.)</p> <p>The uterus is the chief means by which the cord is prevented from falling down between the presenting part of the child and the passages, from the @@ -15501,7 +15485,7 @@ over the whole head of the child. Thus, for instance, if we attempt to operate at an early stage, it feels more like a hard ring round the head, of about a finger’s breadth, and it may be felt to extend itself higher up, in proportion as the stimulus of the hand excites the activity of the -uterus.” (Michaelis, <i>Neue Zeiteschrift für Geburtskunde</i>, band iii. heft. +uterus.” (Michaelis, <i>Neue Zeiteschrift für Geburtskunde</i>, band iii. heft. 1.)</p> <p>Hence, therefore, whatever prevents the uterus from contracting with its @@ -15552,7 +15536,7 @@ have already alluded to.</p> <p>We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it -excited the attention of Professor Naegelé, junior. Levret, from the +excited the attention of Professor Naegelé, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the @@ -15564,7 +15548,7 @@ corresponded with the os uteri.</p> uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circumstances we ought to have every case of -partial placenta prævia accompanied with the cord presenting: still, +partial placenta prævia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus.</p> @@ -15577,11 +15561,11 @@ its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way.” -(<i>Die Geburtshülfliche Auscultation</i>, von Dr. H. F. Naegelé, p. 114.) The -two cases referred to by Professor Naegelé, jun., of prolapsus of the cord +(<i>Die Geburtshülfliche Auscultation</i>, von Dr. H. F. Naegelé, p. 114.) The +two cases referred to by Professor Naegelé, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circumstance the more remarkable. The fact was noticed by Giffard as early -as in 1728, in a case of flooding from partial placenta prævia; but he +as in 1728, in a case of flooding from partial placenta prævia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was “in part, if not wholly, separated from the uterus.”<a name='fna_137' id='fna_137' href='#f_137'><small>[137]</small></a></p> @@ -15591,7 +15575,7 @@ occurrence. Dr. Churchill, of Dublin, in a valuable paper, (<i>Edin. Med. and Surg. Journal</i>, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282¼.<a name='fna_138' id='fna_138' href='#f_138'><small>[138]</small></a> That prolapsus of the cord occurs -most frequently in foot presentations, as supposed by Professor Naegelé, +most frequently in foot presentations, as supposed by Professor Naegelé, senior, is disproved by the results of Mauriceau’s large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 @@ -15784,7 +15768,7 @@ Pregnancy and Auscultation</i>, p. 241.)</p> congestion.—Causes.—Symptoms.—Tetanic species.—Diagnosis of labour during convulsions.—Prophylactic treatment.—Treatment.—Bleeding.—Purgatives.—Apoplectic -species.—Anæmic convulsions.—Symptoms.—Treatment.—Hysterical +species.—Anæmic convulsions.—Symptoms.—Treatment.—Hysterical convulsions.—Symptoms.</i></p></div> @@ -15792,7 +15776,7 @@ convulsions.—Symptoms.</i></p></div> convulsions, not only of variable intensity, but differing considerably in point of character. We shall consider them under three separate heads, viz. epileptic convulsions with cerebral congestion; epileptic convulsions -from collapse or anæmia; and hysterical convulsions. Other species have +from collapse or anæmia; and hysterical convulsions. Other species have been enumerated by authors, but they are either varieties of, or intimately connected with, those of the first species.</p> @@ -15815,7 +15799,7 @@ connected with pregnancy or parturition, and which are preceded and attended with cerebral congestion, alone deserve, strictly speaking, the name of <i>Eclampsia parturientium</i> (which, in fact, signifies nothing more than the epilepsy of parturient females,) being peculiar to this -condition; whereas, the anæmic and hysterical convulsions may occur at any +condition; whereas, the anæmic and hysterical convulsions may occur at any other time quite independent of the pregnant or parturient state.</p> <p><span class="pagenum"><a name="Page_377" id="Page_377">[Pg 377]</a></span>The term “puerperal convulsions” is employed in a much more vague and @@ -15844,17 +15828,17 @@ attack the patient has “drowsiness, a sense of weight in the head, especially in stooping; beating and pain in the head; redness of the conjunctiva; numbness of the hands; flushing of the face, and twitching of its muscles; irregular and slow pulse; ringing in the ears, heat in the -scalp, transient but frequent attacks of vertigo, with muscæ volitantes, +scalp, transient but frequent attacks of vertigo, with muscæ volitantes, or temporary blindness; derangement of the auditory nerve; embarrassment of mind and speech; an unsteady gait; constipation and œdematous swellings.” (Ingleby, <i>op. cit.</i> p. 12.)</p> <p>As the attack approaches, the patient frequently complains of a peculiar -dragging pain and sense of oppression about the præcordia, which comes on +dragging pain and sense of oppression about the præcordia, which comes on and again abates at short intervals, and is attended with much restlessness and anxiety: this is followed by intense pain, which usually attacks the back of the head, and upon the accession of which the -præcordial affection apparently ceases; the pulse now becomes smaller and +præcordial affection apparently ceases; the pulse now becomes smaller and more contracted. If the convulsions do not make their appearance by this time, and the headach continues one or more hours, a slight degree of coma supervenes, the patient loses her consciousness more and more, and wanders @@ -15869,7 +15853,7 @@ looking to see the cause, we find the expression altered, the muscles of the face are twitching, the features beginning to be distorted, and the next moment she falls down in general convulsions.</p> -<p>Wigand (<i>Geburt des Menschen</i>, vol. i. § 102,) considers that the two +<p>Wigand (<i>Geburt des Menschen</i>, vol. i. § 102,) considers that the two symptoms which usher in the attack are, the frightful staring followed by rolling of the eyes, with sudden starts from right to left, and twisting of the head to the same side by the same sudden movements; as soon as the @@ -15964,12 +15948,12 @@ open, and the pain entirely ceases.” (<i>Posthumous Medical Writings</i>, i. p. 263.)</p> <p>By far the majority of cases of eclampsia parturientium occur in -primiparæ: thus in thirty cases which occurred to Dr. Collins, during his +primiparæ: thus in thirty cases which occurred to Dr. Collins, during his mastership at the Dublin Lying-in Hospital, “twenty-nine were in women with their first children, and the other single case was a second pregnancy, but in a woman who had suffered a similar attack with her first child.” In two instances, under our own notice, where the disease occurred -in multiparæ, the fits did not appear until <i>after</i> delivery; the patients +in multiparæ, the fits did not appear until <i>after</i> delivery; the patients were plethoric, and in one especially, the bowels were excessively deranged; in the other, the attack had much of the apoplectic character, and the coma did not at once abate until the fatal termination.</p> @@ -16073,7 +16057,7 @@ convulsed, whether there were lucid intervals between, or that the loss of understanding was permanent. The progress of labour in most of these cases seems even more rapid than in others, since we have often found the child between its mother’s thighs, though an instant before we could discover no -disposition for delivery.” (<i>Baudelocque</i>, trans. by Heath, § 1109.)</p> +disposition for delivery.” (<i>Baudelocque</i>, trans. by Heath, § 1109.)</p> <p><i>Diagnosis of labour during convulsions.</i> Where the patient is in a state of insensibility, we may infer the presence of labour by a variety of @@ -16113,7 +16097,7 @@ diminish its violence.</p> pregnancy, is particularly valuable in keeping off any disposition to these attacks: regular, and for her condition even tolerably active, exercise and strict attention to the bowels, should be required, -especially in primiparæ. If any distinct symptoms of cerebral congestion +especially in primiparæ. If any distinct symptoms of cerebral congestion make their appearance, such as flushed face, headach, or slight wandering; if, moreover, the pulse be slow and labouring, we must at once relieve the circulation by bleeding; and by an active dose of calomel and James’s @@ -16253,7 +16237,7 @@ reduce the power of the circulation we increase the disposition of the os uteri to dilate, and, as Baudelocque justly observes, “while we wait the favourable moment for operating, we should only employ those means which we could use after delivery, if the convulsions should continue.” (<i>Op. -cit.</i> § 1110.)</p> +cit.</i> § 1110.)</p> <p>By the time that the medicine has begun to operate, a considerable change will usually be observed in all the symptoms—the violence of the @@ -16299,7 +16283,7 @@ independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, but is no otherwise accessary to this end, than increasing by its efforts the determination of blood to the head.” (<i>Op. -cit.</i> § 1238.)</p> +cit.</i> § 1238.)</p> <p>The treatment will in no respect differ from that of the genuine puerperal convulsions, except that, as the danger is still greater, so, if possible, @@ -16308,8 +16292,8 @@ there is a convulsion, for there is merely loss of motion with insensibility. It is fortunately of rare occurrence, as the patient seldom recovers.</p> -<p><i>Anæmic convulsions.</i> The next form of epiplectic puerperal convulsions is -the anæmic form, where, in consequence of serious loss of blood or +<p><i>Anæmic convulsions.</i> The next form of epiplectic puerperal convulsions is +the anæmic form, where, in consequence of serious loss of blood or debility otherwise induced, the due balance of the nervous system has been disturbed, and irregular and convulsive actions have been the result.</p> @@ -16324,10 +16308,10 @@ prove stimulants and produce epilepsy.”</p> conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which, we suppose, always to depend upon causes weakening the energy of the brain.” “The first to be mentioned, -which I suppose to be of this kind, is hæmorrhage, whether spontaneous or -artificial. That the same hæmorrhage which produces syncope, often at the +which I suppose to be of this kind, is hæmorrhage, whether spontaneous or +artificial. That the same hæmorrhage which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and -observations it appears, that hæmorrhages <span class="pagenum"><a name="Page_388" id="Page_388">[Pg 388]</a></span>occurring to such a degree as +observations it appears, that hæmorrhages <span class="pagenum"><a name="Page_388" id="Page_388">[Pg 388]</a></span>occurring to such a degree as to prove mortal, seldom do so without first producing epilepsy.” (<i>Op. cit.</i>) It is a well-known fact, that when once a state of exhaustion or collapse has been carried beyond a certain point, the irritability of the @@ -16353,7 +16337,7 @@ features of the disease; the pale face, the glazy eye, the shrunken features and colourless lip, the cold moist skin, the heaving chest, the quick, weak, small, and irritable pulse, all betoken a condition of exhaustion and collapse. The history of the case will also show that the -patient has suffered from profuse hæmorrhage, or some other debilitating +patient has suffered from profuse hæmorrhage, or some other debilitating evacuation; and the intense pain on the summit of the head, verging into actual delirium, the rambling thoughts and confused mental associations, the restlessness or absolute insomnia, the tinnitus aurium, disposition to @@ -16374,7 +16358,7 @@ debility, as in cases of disorder of the general health, with sallowness and pallor, and a loaded tongue and breath.”</p> <p><i>Treatment.</i> Our treatment of these cases will not vary essentially from -that of exhaustion from hæmorrhage under the<span class="pagenum"><a name="Page_389" id="Page_389">[Pg 389]</a></span> ordinary circumstances; the +that of exhaustion from hæmorrhage under the<span class="pagenum"><a name="Page_389" id="Page_389">[Pg 389]</a></span> ordinary circumstances; the patient must be placed with her head low, and as soon as she is able to swallow, a little hot brandy and water, or ammonia, should be given to rouse the circulation to a sufficient degree of activity. If the uterus be @@ -16503,10 +16487,10 @@ may lie apparently stupid, she will nevertheless sometimes talk or indistinctly mutter. After the convulsion has passed over, she will often open her eyes and vacantly look about, and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head -in the clothes.” (Dewees’s <i>Compend. Syst. of Midwifery</i>, § 1240.)</p> +in the clothes.” (Dewees’s <i>Compend. Syst. of Midwifery</i>, § 1240.)</p> <p>When sufficiently recovered to be capable of swallowing, she should sip -some cold water, or what is still better, take a dose of spiritus ammoniæ +some cold water, or what is still better, take a dose of spiritus ammoniæ fœtidus in water; this soon produces copious eructations from the stomach, which are followed with much relief. Where there is a disposition to vomiting, and other evidences of a deranged stomach, it should be @@ -16528,9 +16512,9 @@ recovers from them almost immediately.</p> <p><span class="pagenum"><a name="Page_393" id="Page_393">[Pg 393]</a></span></p> <h2><a name="PART_V_CHAPTER_XII" id="PART_V_CHAPTER_XII"></a>CHAPTER XII.</h2> -<p class="title">PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.</p> +<p class="title">PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.</p> -<div class="note"><p class="hang"><i>History.—Dr. Rigby’s division of hæmorrhages before labour into accidental and +<div class="note"><p class="hang"><i>History.—Dr. Rigby’s division of hæmorrhages before labour into accidental and unavoidable.—Causes.—Symptoms.—Treatment.—Plug.—Turning.—Partial presentation of the placenta.—Treatment.</i></p></div> @@ -16538,28 +16522,28 @@ presentation of the placenta.—Treatment.</i></p></div> <p>There are few dangers connected with the practice of midwifery which are more deservedly dreaded, and which are wont to come more unexpectedly, both to the patient as well as to the practitioner, than that species of -hæmorrhage which occurs in cases where the placenta is implanted either +hæmorrhage which occurs in cases where the placenta is implanted either <i>centrally</i> or <i>partially</i> over the os uteri. Well has a celebrated teacher observed, that “there is no error in nature to be compared with this, for the very action which she uses to bring the child into the world -is that by which she destroys both it and its mother.” (Naegelé, <i>MS. +is that by which she destroys both it and its mother.” (Naegelé, <i>MS. Lectures</i>.) In other words, where there is this peculiar situation of the placenta it becomes gradually detached, either in proportion as the cervix expands during the latter months of pregnancy, or as the os uteri dilates with commencing labour, and is thus unavoidably attended with a profuse discharge of blood, which generally increases as the dilatation proceeds.</p> -<p>The peculiar feature of this species of hæmorrhage, necessarily +<p>The peculiar feature of this species of hæmorrhage, necessarily accompanying the commencement of every labour where the placenta is implanted over the os uteri, was first fully described in this country in 1775, by the late Dr. Rigby, in his classical <i>Essay on the Uterine -Hæmorrhage which precedes the Delivery of the full-grown Fœtus</i>, a work +Hæmorrhage which precedes the Delivery of the full-grown Fœtus</i>, a work which has been justly looked upon, both in England and the Continent, as the great source to which we are indebted for our practical knowledge in the management of these dangerous cases.</p> <p><i>History.</i> There is abundant evidence to prove the sudden attacks of -hæmorrhage during pregnancy, attended with circumstances of great danger +hæmorrhage during pregnancy, attended with circumstances of great danger to the life of the mother and her child, were known from the earliest times, and especially noticed by Hippocrates where he says, “that the after-burden should come forth after the child, for if it come first, the @@ -16575,7 +16559,7 @@ for having called our attention to the above passage. He has devoted his fifteenth chapter<a name='fna_140' id='fna_140' href='#f_140'><small>[140]</small></a> to the management of a case where the placenta presents, and shows that “the most certain and expedient method is to deliver the patient promptly, in order that she may not suffer from the -hæmorrhage which issues from the uncovered mouths of the uterine veins, to +hæmorrhage which issues from the uncovered mouths of the uterine veins, to which the placenta had been attached; that, on the other hand, the child being enclosed in the uterus, the orifice of which is plugged up by the placenta, and unable to breathe any more by the arteries of its mother, @@ -16583,11 +16567,11 @@ will be suffocated for want of assistance, and also enveloped in the blood which fills the uterus and escapes from the veins in it which are open.”</p> <p>The operation of turning, which had been newly practised by his teacher, -Ambrose Paré, and still farther brought into notice by himself, at that -time formed a great æra in midwifery, for it furnished practitioners with +Ambrose Paré, and still farther brought into notice by himself, at that +time formed a great æra in midwifery, for it furnished practitioners with a new and successful means of delivering the child in cases where urgent danger could only be avoided by hastening labour; hence, therefore, in all -cases of profuse hæmorrhage coming on before delivery, it was a general +cases of profuse hæmorrhage coming on before delivery, it was a general rule, if the case became at all dangerous, to turn the child.</p> <p>Guillemeau’s explanation of the nature of placental presentations was @@ -16617,14 +16601,14 @@ shock, when the cord was shortened from being twisted round the child.</p> to arise solely from its having been separated by some <i>accident</i> from the fundus, and fallen down to the os uteri.</p> -<p>Dr. Robert Lee, in his “Historical Account of Uterine Hæmorrhage in the +<p>Dr. Robert Lee, in his “Historical Account of Uterine Hæmorrhage in the latter Months of Pregnancy,” (<i>Edin. Med. and Surg. Journal</i>, April 1839,) has omitted all mention of this circumstance, and from the account which he has given of Mauriceau’s observations, would infallibly lead his readers to suppose that Mauriceau was fully acquainted with the real nature of these peculiar cases. Thus, he commences with saying, “The symptoms and treatment of cases of placental presentation are here -accurately described, and in all cases of hæmorrhage from this cause he +accurately described, and in all cases of hæmorrhage from this cause he recommends immediate delivery;” and again, he observes, “The rules for the treatment of these cases are laid down with the greatest precision. When the placenta was entirely separated, then only did he consider it as a @@ -16636,7 +16620,7 @@ majority of cases of placental presentation, he recognised the implantation of the placenta upon the os uteri. That such was very far from the case, we have already shown by quotations from various editions of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of -placenta prævia from Mauriceau, and has given a short summary of them. Out +placenta prævia from Mauriceau, and has given a short summary of them. Out of the thirteen cases in which Mauriceau has distinctly mentioned that the flooding had been caused by the entire separation of the placenta which presented, Dr. Lee has noticed it in only three; and in one of these he @@ -16649,20 +16633,20 @@ the uterus,” at all tend to show that he had any idea of the placenta being implanted upon the os uteri.</p> <p>By stating that “Mauriceau has also recorded the histories of thirty-seven -cases of uterine hæmorrhage in which the placenta did not present, but had +cases of uterine hæmorrhage in which the placenta did not present, but had adhered to the upper part of the uterus and been accidentally detached,” Dr. Lee has confirmed the erroneous inference that the implantation of the placenta upon the os uteri was known to this valuable author; whereas, we have proved by numerous quotations, that Mauriceau distinctly<span class="pagenum"><a name="Page_396" id="Page_396">[Pg 396]</a></span> supposed -that in <i>all</i> cases of hæmorrhage before labour, <i>whether the placenta was +that in <i>all</i> cases of hæmorrhage before labour, <i>whether the placenta was found presenting or not</i>, it had been originally attached “to the upper part of the uterus.”</p> <p>Paul Portal was the first, as far as we are acquainted, who describes the placenta as <i>adhering</i> to the os uteri. He has recorded eight cases, “in which,” as Dr. Rigby observes, “he was under the necessity of delivering -by art, on account of dangerous hæmorrhages, and in all of them he found -the placenta at the mouth of the womb.” (<i>Essay on Uterine Hæmorrhage</i>, p. +by art, on account of dangerous hæmorrhages, and in all of them he found +the placenta at the mouth of the womb.” (<i>Essay on Uterine Hæmorrhage</i>, p. 22, 6th ed.) In these he distinctly mentions the placenta adhering to the os uteri. In several of these he separated it from the os uteri and brought it away; and in seven he turned the child. In the other (Case 39,) @@ -16670,7 +16654,7 @@ the head burst its way through the placenta. In one case only (51,) does he attempt to make any practical inference whatever, having in all the others contented himself with merely stating the fact of the placenta adhering to the os uteri. In this instance, however, he has described the -real nature of the case, and pointed out the cause of the hæmorrhage. On +real nature of the case, and pointed out the cause of the hæmorrhage. On introducing his hand he “found the after-burden placed just before and quite across the whole inner orifice, which had actually been the occasion of the flux of blood; for by the opening of the orifice the said @@ -16680,7 +16664,7 @@ flooding, which sometimes is so excessive as proves fatal to the woman unless it be speedily prevented.” (<i>Portal’s Midwifery</i>, transl. p. 167.)</p> <p>There is no doubt, as Dr. Renton has very justly observed, “that Portal in -1672 (not 1683) knew as much on the subject of uterine hæmorrhage +1672 (not 1683) knew as much on the subject of uterine hæmorrhage occasioned by the displacement of the placenta from the os uteri, and the practice necessary for its suppression, as we do at the present time.” (<i>Edin. Med. and Surg. Journ.</i> July, 1837.) But we cannot coincide with @@ -16704,7 +16688,7 @@ because he mentions it as a cursory observation, without any farther notice or practical inference.</p> <p>The next author who has at all alluded to the real nature of placenta -prævia is Giffard, whose posthumous work was published in 1734. The value +prævia is Giffard, whose posthumous work was published in 1734. The value of his evidence on this subject is considerably modified by his having made no allusion to the implantation of the placenta upon the os uteri in the first ten cases of flooding, where he found the placenta presenting, @@ -16714,7 +16698,7 @@ fallen down to the os uteri. In cases 115, 116. and 224. he gives a perfectly correct explanation of the cause of flooding, but the opinion is expressed with such a degree of hesitation, and so cursorily, that we doubt much if it attracted more notice than the observations of Portal, -above alluded to, more especially as in the six cases of placenta prævia, +above alluded to, more especially as in the six cases of placenta prævia, which occur between the last two above-mentioned (viz. 120, 121. 158. 160. 185. and 209.,) he returns again to his former mode of describing them. We, therefore, regret that Dr. Renton has not mentioned this circumstance, @@ -16727,7 +16711,7 @@ given what is now recognised as the correct explanation, in only three out of nineteen cases, that we can explain why so little notice was taken of the subject at that time; why Dr. Smellie, when speaking of it, makes no allusion to Giffard; and why Dr. Rigby, in his <i>Essay on Uterine -Hæmorrhage</i>, was led to suppose that he was ignorant of the real nature of +Hæmorrhage</i>, was led to suppose that he was ignorant of the real nature of these cases:<span class="pagenum"><a name="Page_398" id="Page_398">[Pg 398]</a></span> certain it is that his opinion could scarcely be called a decided one.</p> @@ -16739,7 +16723,7 @@ woman is delivered; the discharge may, indeed, be intermitted by coagulums that stop up the passage, but when these are removed it returns with its former violence, and demands the same treatment that is recommended above.” His cases contain no observation beyond the recital that a -considerable hæmorrhage had occurred, the placenta had been found +considerable hæmorrhage had occurred, the placenta had been found presenting, and that he had turned the child. In his sixth case (Collect. 33, No. 2.) which is dated 1752, it is evident that he was ignorant of what had been said on the same subject by Giffard and Portal; for he @@ -16758,17 +16742,17 @@ the cases; nor in his directions about the management of floodings, are there any rules given relative to this situation of the placenta.</p> <p>Rœderer decidedly stands pre-eminent, as being the first author who -gave a distinct and complete description of this species of hæmorrhage; he +gave a distinct and complete description of this species of hæmorrhage; he points out the cause of it, and accurately describes its symptoms and mode of attack; he shows that the placenta may be entirely or partially -attached to the os uteri; that in the one case the hæmorrhage will be very +attached to the os uteri; that in the one case the hæmorrhage will be very profuse, and artificial assistance will be required; in the other it will be slighter, and in many cases it may be left to nature.<a name='fna_142' id='fna_142' href='#f_142'><small>[142]</small></a></p> <p><span class="pagenum"><a name="Page_399" id="Page_399">[Pg 399]</a></span>Levret cotemporaneously with the first edition of Rœderer’s work, published at Paris, a valuable paper on placental presentation, which, with the above-mentioned chapter of Rœderer, must be looked upon as the -first observations in which this form of hæmorrhage was made a distinct +first observations in which this form of hæmorrhage was made a distinct subject of consideration. Although Levret has in no wise claimed the merit of being the first who had noticed the fact of the placenta being implanted upon the os uteri, still there can be no doubt that to him and @@ -16776,9 +16760,9 @@ Rœderer we are indebted for having first investigated the subject and called the attention of the profession to its peculiar characters.</p> <p>Levret has reduced his observations under three heads, viz. that the -placenta is occasionally implanted over the os uteri, that hæmorrhage +placenta is occasionally implanted over the os uteri, that hæmorrhage under such circumstances is inevitable, and that the safest mode of -remedying this accident is the <i>accouchement forcé</i>. He has also added a +remedying this accident is the <i>accouchement forcé</i>. He has also added a few valuable remarks, but by far the greater part of the essay is occupied with theoretical arguments to prove that it is impossible for the placenta, which had been attached to the fundus, to sink down to the os @@ -16789,31 +16773,31 @@ merit being that of making it a subject of distinct consideration, and establishing it as a matter beyond doubt.</p> <p>Levret cannot, however, be looked upon as the first who considered that -the flooding, in cases of placenta prævia, was “inevitable,” although, +the flooding, in cases of placenta prævia, was “inevitable,” although, from his not having quoted Giffard, we willingly concede to him the merit of originality, as far as he himself was concerned: it was Giffard, -however, as far as we know, who first pointed out that hæmorrhage was the +however, as far as we know, who first pointed out that hæmorrhage was the necessary consequence of placental presentation, as is shown from what we have already quoted from him, although, to a certain extent, it was hinted at by Portal, in his fifty-first case. Levret’s memoir was afterwards reprinted in his large work, entitled <i>L’Art des Accouchemens</i>: the third edition, which appeared in 1766, was quoted by Dr. Rigby in the first -edition of his <i>Essay on Uterine Hæmorrhage</i>, 1775,<a name='fna_143' id='fna_143' href='#f_143'><small>[143]</small></a> in farther proof +edition of his <i>Essay on Uterine Hæmorrhage</i>, 1775,<a name='fna_143' id='fna_143' href='#f_143'><small>[143]</small></a> in farther proof of the placenta being implanted over the os uteri, and being the cause of -hæmorrhage.</p> +hæmorrhage.</p> <p>We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine -hæmorrhage which precedes the delivery of the full-grown fœtus has +hæmorrhage which precedes the delivery of the full-grown fœtus has stood the test of time, and will ever remain, not less remarkable for its practical value, than “for the perspicuity and simplicity of its style.” (Renton, <i>op. cit.</i>) To Dr. Rigby, without doubt, is due the merit of -having first <span class="pagenum"><a name="Page_400" id="Page_400">[Pg 400]</a></span>distinguished hæmorrhages, which occur before delivery, into +having first <span class="pagenum"><a name="Page_400" id="Page_400">[Pg 400]</a></span>distinguished hæmorrhages, which occur before delivery, into <i>accidental</i> and <i>unavoidable</i>, a division so truly practical and appropriate, as to have placed this subject in the clearest and simplest possible light. “He was,” as Dr. Collins has justly observed, “the first English author who fully established this most important practical -distinction in the treatment of uterine hæmorrhages, although Levret had +distinction in the treatment of uterine hæmorrhages, although Levret had many years before published a somewhat similar statement.” Dr. Rigby’s arrangement has been adopted by Dr. Merriman, Dewees, and every other modern author of any note; and the medical world have amply testified @@ -16830,27 +16814,27 @@ and M. Levret, while he contrived to make the profession believe that his doctrines were original, (Hamilton, <i>Practical Observations</i>, &c., 1836, vol. ii. p. 238;) and that “no fact of the slightest importance has since (Smellie) been discovered relating to the causes and treatment of uterine -hæmorrhage in the latter months of pregnancy.” (Dr. R. Lee, <i>Edin. Med. +hæmorrhage in the latter months of pregnancy.” (Dr. R. Lee, <i>Edin. Med. and Surg. Journ.</i>, 1839, vol. li. p. 389.) We, therefore, deem it only just to our readers, and also to the author, to lay before them his own account of what, at the time, he supposed to be a discovery, and how far he considered himself justified in laying claim to its originality.</p> -<p>“A case of hæmorrhage, in which I found the placenta attached to the os +<p>“A case of hæmorrhage, in which I found the placenta attached to the os uteri, occurred at a very early period of my practice; but not finding such a circumstance recorded in the lectures which I had attended, or taken notice of in the common elementary treatises on midwifery, I considered it at first merely as a casual and rare deviation from nature. In a few years, however, so many similar instances fell under my notice, as to convince me, that it was a circumstance necessary to be inquired -after in every case of hæmorrhage: and this conviction was confirmed by +after in every case of hæmorrhage: and this conviction was confirmed by the perusal of cases in midwifery; for I then found that the fact of the placenta being thus situated had been recorded by many writers, though in no instance which had then reached me, had any practical inferences been deduced from it. It appeared to me, indeed, most extraordinary that such a fact, known to so many celebrated practitioners, should not long before have led to its practical application, and in consequence to more fixed -principles in the treatment of hæmorrhages from the gravid uterus; and I +principles in the treatment of hæmorrhages from the gravid uterus; and I may, perhaps, be allowed to say, that I congratulated myself, young in years and practice as I was, in<span class="pagenum"><a name="Page_401" id="Page_401">[Pg 401]</a></span> being, probably, the first to suggest an important improvement in the treatment of one of the most perplexing and @@ -16891,7 +16875,7 @@ Was the practice in this country, at that time, at all influenced by Levret’s dissertation? or has it even since been translated into the English language? Was it, at that time, generally known that the attachment of the placenta to the os uteri was a frequent cause of -hæmorrhage? and were any directions for our conduct in these cases, +hæmorrhage? and were any directions for our conduct in these cases, founded on the knowledge of the fact, given by those who there lectured on the art of midwifery?</p> @@ -16899,7 +16883,7 @@ the art of midwifery?</p> originally attached to the os uteri, (and a single instance would establish this,) were scarcely sufficient to prove the frequency of its occurrence, from which alone arises the<span class="pagenum"><a name="Page_402" id="Page_402">[Pg 402]</a></span> necessity of practically -attending to it in every case of hæmorrhage. His observations (perhaps +attending to it in every case of hæmorrhage. His observations (perhaps even more creditable to him for being founded on such scanty materials) were derived from four cases only, and of these, but two were under his own immediate cognizance; whereas, in the first edition of this essay my @@ -16925,8 +16909,8 @@ periods, and the comparative rarity of placental presentations, will probably ever prevent our ascertaining the real cause.</p> <p><i>Symptoms.</i> The first symptom which warns us that the placenta is -presenting, is the sudden appearance of hæmorrhage, which is usually more -copious than ordinary hæmorrhage, and apparently comes on without any +presenting, is the sudden appearance of hæmorrhage, which is usually more +copious than ordinary hæmorrhage, and apparently comes on without any assignable reason: it is usually the more profuse the nearer the patient is to the full term of pregnancy, for not only now are the ruptured vessels larger, but the separation of the placenta is generally greater. @@ -16951,17 +16935,17 @@ shall feel the edge of the placenta projecting at one side of the os uteri, and the bladder of membranes, and probably the presenting part of the child at the other. Whereas, if the placenta be centrally attached, we shall find it attached to the whole circumference, except perhaps where -the separation is, from which the hæmorrhage proceeds. We shall +the separation is, from which the hæmorrhage proceeds. We shall distinguish the placenta by its spongy mass, by its soft irregular surface, and by the stringy feel which it communicates where it has been torn.</p> -<p>The character of the hæmorrhage is also different from that of common -hæmorrhage, inasmuch as it increases during a pain, and diminishes or -ceases during the intervals, whereas, in hæmorrhage under ordinary +<p>The character of the hæmorrhage is also different from that of common +hæmorrhage, inasmuch as it increases during a pain, and diminishes or +ceases during the intervals, whereas, in hæmorrhage under ordinary circumstances it is the reverse.</p> -<p>Where the hæmorrhage takes place at some distance of time from the full +<p>Where the hæmorrhage takes place at some distance of time from the full period of utero-gestation, it probably arises from the gradual development of the cervix during the latter months of pregnancy: where, on the other hand, it does not appear till just before labour, the separation of the @@ -16971,17 +16955,17 @@ attack would, in great measure, depend upon whether the placenta was centrally, or only partially, attached to the os uteri; that in the former case the placenta would be more liable to be separated by the gradual development of the inferior segment of the uterus; and that, therefore, -hæmorrhage would come on several weeks before the full term; whereas, if +hæmorrhage would come on several weeks before the full term; whereas, if only a portion of it cover the edge of the os uteri, the patient would probably go to the very end of pregnancy before any flooding appeared. Although this view is supported by the high authority of Professor -Naegelé, still we can scarcely agree with it, since not only do a +Naegelé, still we can scarcely agree with it, since not only do a considerable majority of recorded cases show that a patient with central presentation of the placenta may go to the full time without an attack of flooding, but also several of those which have come under our own observation lead to a similar conclusion.</p> -<p>The most alarming attacks of hæmorrhage are doubtless at the full term, +<p>The most alarming attacks of hæmorrhage are doubtless at the full term, when the os uteri is beginning to dilate from commencing uterine contractions, and the placenta is centrally attached over it: in these cases the discharge experiences little or no abatement beyond an @@ -16991,7 +16975,7 @@ separation of the placenta. Such cases, if left to themselves, would almost necessarily prove fatal. The first fainting fit or two would probably produce a temporary cessation of the discharge, and favour the formation of coagula in the upper part of the vagina; but with returning -contractions of the uterus, the hæmorrhage would be renewed with +contractions of the uterus, the hæmorrhage would be renewed with increased<span class="pagenum"><a name="Page_404" id="Page_404">[Pg 404]</a></span> violence, and quickly reduce the vital powers. In such cases the patient will probably die undelivered, or soon after the birth of a dead child. In some rare instances, the pains have been sufficiently @@ -17019,7 +17003,7 @@ Dr. Collins, where the placenta had been expelled many hours (probably about 18) before the birth of the child. “The membranes had ruptured, and the waters been discharged a fortnight previous to admission, from which time, until the evening before she was brought to the hospital, she had -more or less hæmorrhage. It was now ascertained that the placenta had been +more or less hæmorrhage. It was now ascertained that the placenta had been expelled the evening before her admission, and separated by the midwife in attendance. She left the hospital well on the thirteenth day.”<a name='fna_144' id='fna_144' href='#f_144'><small>[144]</small></a> (<i>Op. cit.</i> p. 103.) In all these cases the child has been born dead, and must @@ -17063,7 +17047,7 @@ will be astonished when I assure him that this case, which is so rare that I had only seen it twice in so many years, and that I had met with it but once out of so many thousand labours at our lying-in hospital, occurred to me in the last six months, <i>eight times</i>.” (<i>Collect. Soc. Med.</i> Havn. -1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his +1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his lectures, and states, that in some years placental presentation was so frequent that it seemed as if it were almost epidemic.</p> @@ -17077,27 +17061,27 @@ occurrence, that I am ready to believe that most, if not all, of those cases which require turning the child, are produced by this unfortunate situation of it.”</p> -<p>The period of pregnancy at which hæmorrhage may come on from placental +<p>The period of pregnancy at which hæmorrhage may come on from placental presentation, varies very considerably. Although, in by far the majority of these cases, it does not come on until the last four or six weeks, it now and then occurs at a much earlier period, viz. the sixth or even the fifth month, and sometimes even earlier. Where this is the case, it must -rather be<span class="pagenum"><a name="Page_406" id="Page_406">[Pg 406]</a></span> looked upon as one of “accidental” hæmorrhage or abortion, for +rather be<span class="pagenum"><a name="Page_406" id="Page_406">[Pg 406]</a></span> looked upon as one of “accidental” hæmorrhage or abortion, for it can scarcely be supposed that any changes about the os or cervix uteri could have been sufficient to have produced an “unavoidable” separation of the placenta at this time. Thus, for instance, in Dr. Rigby’s -seventy-fifth case, the first attack of hæmorrhage had appeared when the +seventy-fifth case, the first attack of hæmorrhage had appeared when the patient “was about three months gone with child;” and at that early period could hardly have been attributed to the peculiar situation of the -placenta, but to the more common causes of hæmorrhage connected with -abortion. In his forty-third case, the hæmorrhage, which came on about the +placenta, but to the more common causes of hæmorrhage connected with +abortion. In his forty-third case, the hæmorrhage, which came on about the twenty-sixth week, appears at first to have been purely “accidental,” although it was afterwards produced by “unavoidable” attachment of the -placenta. “We very seldom meet with unavoidable hæmorrhage before the +placenta. “We very seldom meet with unavoidable hæmorrhage before the sixth month of pregnancy; it is not until the cervix uteri begins to distend freely, and the changes that take place previous to the approach of labour commence, any suspicions are observed; consequently, it will be -in the last three months of utero-gestation that hæmorrhage of this nature +in the last three months of utero-gestation that hæmorrhage of this nature is found to occur.” (Collins, <i>op. cit.</i> p. 93.)</p> <p>The examination of a case where the placenta presents is not always easy; @@ -17114,7 +17098,7 @@ the purpose of turning the child.” (<i>Essay</i>, 6th ed. p. 35.)</p> <p><i>Treatment.</i> We have already stated that the earlier the period at which the flooding comes on, the less profuse it will be; the treatment, -therefore, where the hæmorrhage is inconsiderable, differs but little from +therefore, where the hæmorrhage is inconsiderable, differs but little from that in an ordinary case of abortion or miscarriage. The indications, in fact, are the same, viz. to stop the discharge, and allay any disposition to uterine contraction.</p> @@ -17123,7 +17107,7 @@ to uterine contraction.</p> possible with safety and tolerable comfort to herself. If the circulation be active, the pulse strong, with more or less heat of surface, it may even be desirable to reduce this by means of the lancet. “Under any kind -of active hæmorrhage, when the pulse is vigorous, the taking away blood +of active hæmorrhage, when the pulse is vigorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by the mere unloading of the vessels, and more especially in diminishing the velocity of blood within them.” (Dewees, <i>Compend.<span class="pagenum"><a name="Page_407" id="Page_407">[Pg 407]</a></span> Syst. of Midw.</i> p. @@ -17138,11 +17122,11 @@ opiate by the mouth. Her food must consist of little else than plain drinks, as tea, milk and water, &c., all of which must be taken cold; and she must preserve the most perfect quiet of body as well as mind. We cannot agree with Dr. Dewees in permitting “our patients, under treatment -for uterine hæmorrhage, to be five or six days without a discharge from +for uterine hæmorrhage, to be five or six days without a discharge from the bowels;” as a loaded state of the lower bowels cannot fail in our opinion to obstruct seriously the free return of the circulation from the pelvic viscera, and thus greatly increase the disposition to congestion -and hæmorrhage.</p> +and hæmorrhage.</p> <p>The longer the patient has still to go, the more desirable is it that we should, if possible, control the symptoms, and prevent them from @@ -17155,7 +17139,7 @@ practitioner and with safety to the mother; the child also will have so far advanced towards maturity as to give it a better chance of surviving the operation.</p> -<p>Wherever hæmorrhage has occurred during the last three months of +<p>Wherever hæmorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any assignable reason, we should earnestly warn the patient and her friends to summon the practitioner the moment there are any symptoms of its return; for if it be @@ -17163,7 +17147,7 @@ a case of placental presentation, it assuredly will return, and as certainly much more profusely than at first.</p> <p>Where the patient has gone nearly or quite to her full time, the first -attack is much more alarming; the hæmorrhage frequently appears with a +attack is much more alarming; the hæmorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quantity of blood is lost; thus a patient whom we had seen but a few hours previously in perfect health, was suddenly seized with profuse flooding as she was @@ -17193,7 +17177,7 @@ bleed largely and suddenly, the uterus itself must have attained to such a capacity as to admit the hand for artificial delivery.” (<i>Op. cit.</i> p. 48, 6th ed.) He farther observes, “that as the most material increase of the uterus does not take place until the end of the sixth month of pregnancy, -a hæmorrhage before that period will seldom require artificial delivery; +a hæmorrhage before that period will seldom require artificial delivery; and after that period, should it become necessary, that it is probable the hand may then be admitted for that purpose.” (<i>Ibid.</i> p. 51.)</p> @@ -17226,10 +17210,10 @@ artificially dilated, where the child was turned and delivered with perfect safety, and the uterus contracted into a hard ball; in fact, every thing seemed to have passed over favourably; a continued dribbling of blood has remained after labour, which resisted every attempt to check it; -friction upon the abdomen and other means for stopping hæmorrhage by +friction upon the abdomen and other means for stopping hæmorrhage by inducing firm contraction of the uterus were of no use, for the uterus was already hard and well contracted; the patient has gradually become -exhausted, and at last died; on examination after death, Professor Naegelé +exhausted, and at last died; on examination after death, Professor Naegelé has invariably found the os uteri more or less torn.</p> <p>“It must be acknowledged, indeed,” says Dr. Rigby, “that it may sometimes @@ -17247,7 +17231,7 @@ necessary, be more practicable and safe.” (<i>Op. cit.</i> p. 36.)</p> <p>We have already shown (see <span class="smcap">Turning</span>, p. 236.) that there is no means of rendering a rigid os uteri yielding and capable of admitting the hand equal to the relaxation produced by loss of blood: wherever the powers of -the system have already suffered from the effects of hæmorrhage, we may +the system have already suffered from the effects of hæmorrhage, we may feel almost certain that we shall find the os uteri capable of dilating, even if it be so little open as barely to admit the finger. Where the patient has become faint or fallen into actual syncope, the relaxation of @@ -17281,12 +17265,12 @@ above-mentioned, the hand must experience considerable difficulty in entering the os uteri, and yet the expulsion of the child cannot be safely trusted to the natural powers, it becomes necessary, as in certain cases of premature expulsion, to have recourse to such means as shall enable the -os uteri to go on dilating without the danger of farther hæmorrhage; in +os uteri to go on dilating without the danger of farther hæmorrhage; in other words, we must plug the vagina. “If, after the commencement of a flooding, we favour the formation of a coagulum by means of a plug, are we not aiding nature? It brings on labour much sooner, and the os uteri has time to dilate without farther loss of blood.” (Leroux, <i>Sur les Pertes de -Sang.</i> § 309.) By means of the plug, we enable the patient to go on with +Sang.</i> § 309.) By means of the plug, we enable the patient to go on with perfect security until the pains have produced a sufficient dilatation of the os uteri to admit the hand; after a time we may withdraw it, and if then not satisfied with the state of the os uteri, it must be again @@ -17302,7 +17286,7 @@ placenta and fœtus thrown off, and the flooding almost immediately controlled. The other means which we have constantly pointed out, should also be tried: they may aid the general intentions, and render the operation of the tampon more certain.” (Dewees, <i>Compend. Syst. of Midw.</i> -§ 1142.)</p> +§ 1142.)</p> <p>Although Dr. Rigby has given a short account of Leroux’s views respecting the use of the plug in these cases, we cannot but agree with Dr. Dewees, @@ -17312,17 +17296,17 @@ what Dr. Gooch, however, has stated in his <i>Account of some of the more important Diseases peculiar to Women</i>, there is every reason to suppose that Dr. Rigby was latterly in the frequent habit of using the plug,<span class="pagenum"><a name="Page_411" id="Page_411">[Pg 411]</a></span> and that he thought highly of it. The plug is not only useful in keeping the -hæmorrhage under due control until the os uteri be sufficiently dilated, +hæmorrhage under due control until the os uteri be sufficiently dilated, but may occasionally prove of the greatest value in cases of extreme exhaustion from loss of blood, where the patient is too much reduced to undergo the act of delivery, without running the risk of dying during the operation; the plug will enable us to wait with safety until the system has had time to rally its powers and be recruited by the administration of proper nourishment. “Mr. Grainger, of Birmingham, on visiting a poor woman -with placenta prævia, and apparently in a moribund condition, immediately +with placenta prævia, and apparently in a moribund condition, immediately filled the vagina and os uteri with linen cloths, and waited two days before he durst hazard delivery, which he accomplished with an auspicious -result.” (Ingleby, <i>on Uterine Hæmorrhage</i>, p. 155.)</p> +result.” (Ingleby, <i>on Uterine Hæmorrhage</i>, p. 155.)</p> <p><i>Turning.</i> The operation of turning the child will, in no wise, differ from that under more ordinary circumstances, and will require to be @@ -17389,19 +17373,19 @@ the child.</p> <p>“6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and -thus permit the child to die from hæmorrhage.</p> +thus permit the child to die from hæmorrhage.</p> <p>“7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control.</p> <p>“8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance -much time is lost that may be very important to the woman.” (<i>Op. cit.</i> § +much time is lost that may be very important to the woman.” (<i>Op. cit.</i> § 1153.)</p> <p>We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri: the less we separate the -placenta, the less also will be the hæmorrhage; and even this will be in +placenta, the less also will be the hæmorrhage; and even this will be in great measure controlled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case<span class="pagenum"><a name="Page_413" id="Page_413">[Pg 413]</a></span> @@ -17423,7 +17407,7 @@ will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of -hæmorrhage coming on after the child is delivered, for the contraction of +hæmorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circumstances. The placenta, @@ -17431,10 +17415,10 @@ which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was -effected without difficulty. In this instance, hæmorrhage returned after +effected without difficulty. In this instance, hæmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (<i>Med. Gaz.</i> Sep. 2, 1837.) The after treatment should be -conducted upon the same principles as in other cases of hæmorrhage.</p> +conducted upon the same principles as in other cases of hæmorrhage.</p> <p><i>Partial presentation of the placenta.</i> Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial @@ -17449,7 +17433,7 @@ some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar<span class="pagenum"><a name="Page_414" id="Page_414">[Pg 414]</a></span> reason we may -understand why the hæmorrhage is seldom so profuse in these cases as to be +understand why the hæmorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os @@ -17457,7 +17441,7 @@ uteri being prevented dilating by the close adhesion of the placenta—an opinion which is, moreover, approved of by Dr. Dewees as being “both ingenious and probable.” Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall -seldom find the hæmorrhage very profuse, until the os uteri has attained a +seldom find the hæmorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those @@ -17472,7 +17456,7 @@ degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be -sufficient to check the hæmorrhage; if not, by rupturing them we shall be +sufficient to check the hæmorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the @@ -17511,7 +17495,7 @@ considerable danger either to the mother or her child; but, for the most part, they are not of very common occurrence, those only which are of trifling import being met with most frequently. Even under the most dangerous forms of dystocia, as for instance, convulsions, and the -different forms of hæmorrhage, the danger, although great, is capable of +different forms of hæmorrhage, the danger, although great, is capable of being averted, from the mother at least, in the majority of instances by timely and skilful assistance; the means of treatment which art and experience have supplied us with, being generally capable of affording @@ -17579,7 +17563,7 @@ the symptoms during life.”</p> <p><span class="pagenum"><a name="Page_417" id="Page_417">[Pg 417]</a></span>“Pathological anatomy (says Dr. Stevens) is but one of the many ‘points of view in which we may consider the science of disease,’ and notwithstanding -all that has been said about ‘la médicine eclarireé par les ouvertures des +all that has been said about ‘la médicine eclarireé par les ouvertures des cadavres,’ I have a firm belief that morbid anatomy has done little good, particularly in the hands of those who do not understand its real value; for those who are constantly mistaking the effect for the cause, or @@ -17782,7 +17766,7 @@ make part of the lochia, which are less in quantity than they ought to be; but the patient has not any other sort of complaint for three or four days till the retained blood begins to putrefy. A fever then first makes its appearance, followed by a quick weak pulse, thirst, pain in the head, want -of sleep, sighing, load at the præcordia, restlessness, great weakness, +of sleep, sighing, load at the præcordia, restlessness, great weakness, dejection of spirits, either wildness or despair in the countenance, and the white of the eyes is often a little inflamed.” (<i>A Treatise on Childbed Fevers</i>, by Thos. Kirkland, M. D. p. 70.)</p> @@ -17923,10 +17907,10 @@ the perfection to be wished.” (<i>Op. cit.</i> p. 73.)</p> <p>Van Swieten compared the state of the inner surface of the uterus with that of a large wound,—“Something of a like nature seems to be affected in the womb, but in a slighter manner, because the injury is here -superficial, but on a broad surface.” (<i>Comment. on Boerhaave</i>, § 1329.) +superficial, but on a broad surface.” (<i>Comment. on Boerhaave</i>, § 1329.) He quotes also an interesting description from Moschion of the changes which are observed in the evacuations after delivery,—“<i>Primo sanguis, -secundo fæculentus et paucus, ultimo purulentus</i>.” “It hence appears,” he +secundo fæculentus et paucus, ultimo purulentus</i>.” “It hence appears,” he observes, “that that fever in lying-in women, which is called the milk fever, does not spring solely from the milk brought into the breasts, but also from the purifying of the womb by that gentle and superficial @@ -17946,7 +17930,7 @@ necessarily take place while this wound is healing. In this <span class="pagenum uterus presents an exact analogy to the surface of an amputated stump; and it is, therefore, not surprising, that the secondary evils of amputation should be so similar to those of the puerperal state.” (<i>Op. cit.</i> p. 75.) -Professor Schönlein also considers that the contagion of puerperal fever +Professor Schönlein also considers that the contagion of puerperal fever has the greatest similarity with hospital gangrene.</p> <p>The causes of puerperal disease which have been enumerated by Cruveilhier, @@ -18319,7 +18303,7 @@ produced on the circulation in order to bring it under such control as will moderate the state of inflammation. No two patients are alike in this respect; and it frequently happens, that where, from external appearances, we might have expected to find most strength, faintness is quickly -produced, and <i>vice versâ</i>: on the whole, we think that where the patient +produced, and <i>vice versâ</i>: on the whole, we think that where the patient has a small, quick, and oppressed pulse, we may expect she will require to lose a large quantity of blood, for in these cases the pulse rises in volume and strength as the bleeding proceeds; hence, as before observed, @@ -18393,7 +18377,7 @@ to inflammation of serous membranes: mercury not only tends to prevent the effusions of serum and coagulable lymph, but, where they have taken place, it is of great value in promoting their absorption. We agree with Dr. Locock, that calomel is by far the best form in which it can be used, -where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ, +where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ, which we have occasionally found useful in the gastro-bilious or enteric form to restore a depraved state of intestinal secretions, has failed us in the other forms where we wished to produce salivation. The purgative @@ -18429,7 +18413,7 @@ some instances, because the patient could not endure the intense smarting which it produced. We have occasionally covered the abdomen with camphorated mercurial ointment without previous blistering, and with good effect. The internal use of turpentine, circular friction upon the -abdomen, and enemata of Mist. Assafœtidæ, &c., which we have sometimes +abdomen, and enemata of Mist. Assafœtidæ, &c., which we have sometimes found useful in removing the tympanites of the adynamic puerperal fever, and which does not depend on an acute form of inflammation, are scarcely applicable in the present case.</p> @@ -18585,12 +18569,12 @@ pulse, or in preventing the disease from running into that state of tympanitic peritonitis, which is so fatal in its effects; and we are not only losing time by employing an inefficacious mode of treatment, but are exhausting the powers of the system, already more or less depressed. -“Large hæmorrhages,” as Dr. Ferguson correctly observes, “favour +“Large hæmorrhages,” as Dr. Ferguson correctly observes, “favour absorption,” (<i>op. cit.</i> p. 108;) and it would seem that by thus reducing the powers of the system, we diminish its capability of ridding itself by the natural outlets of the virus which has been carried into the circulation; nor do we see how this is to be assisted by bleeding. If a -state of actual hæmorrhage has been induced, bleeding, of course, must be +state of actual hæmorrhage has been induced, bleeding, of course, must be used with the greatest promptness; but in employing this remedy in the above-mentioned form of puerperal fever, although we relieve the inflammation for a time, the cause is not removed. It still continues to @@ -18705,7 +18689,7 @@ sorts of evils, and is unusually sensitive; complains inordinately of her sufferings in trying to suckle the child, and of the severity of her after-pains; not unfrequently she has severe headach, of that species which affects the top of the head, and which is generally considered to -arise from a state of debility and anæmia. In many cases the pain has +arise from a state of debility and anæmia. In many cases the pain has evidently been produced by the action of a griping purge. The pain is of the most intense character; indeed, in many cases, it is evidently too severe for the ordinary suffering from abdominal inflammation. So @@ -18768,7 +18752,7 @@ and bloodless.</p> <p><i>Treatment.</i> It is of the highest importance to distinguish these<span class="pagenum"><a name="Page_443" id="Page_443">[Pg 443]</a></span> affections from a state of inflammation; the treatment of the one will be precisely the reverse of the other. The lancet is as little indicated in -this case, as it is in puerperal convulsions from anæmia, and the effects +this case, as it is in puerperal convulsions from anæmia, and the effects produced will be scarcely less mischievous. The fatal cases which Dr. Gooch has recorded, show that it was not the disease so much as the treatment which destroyed the patients, and prove, as we have already @@ -18860,17 +18844,17 @@ the direct irritation of the unhealthy intestinal contents, upon the removal of which they at once disappear; although at the same time, if the source of irritation be not removed, we have no doubt but absorption will take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland -considers that retained fæces during a lying-in are capable of bringing on +considers that retained fæces during a lying-in are capable of bringing on symptoms which “may, properly enough, be called puerperal fever” (<i>op. cit.</i> p. 87;) and Dr. John Clarke, in enumerating the different causes -entertained by “writers of good reputation,” mentions, where fæces are +entertained by “writers of good reputation,” mentions, where fæces are detained in the intestines, “the thin putrid parts of which are supposed to be taken up into the blood.” (<i>Practical Essay on the Management of Pregnancy and Labour</i>, by J. Clarke, M. D., 1806, p. 53.)</p> <p>There is, however, no reason to confine the source of the putrilage, which infests the circulating current, in cases of gastro-bilious or intestinal -irritation, to unhealthy fæcal matter in the intestines; for in the +irritation, to unhealthy fæcal matter in the intestines; for in the experiment made by Professor Tiedemann, to which we have already alluded, viz. of injecting musk into the femoral vein of an animal, the poison seemed to concentrate itself upon the mucous membrane of the intestinal @@ -18888,7 +18872,7 @@ into the system.</p> labour as any of the other species, and frequently the symptoms are so trifling, at first, as scarcely to excite attention. There is an indistinct uneasiness about the abdomen; the tongue is never quite -natural, being either slightly furred with a few prominent papillæ, or +natural, being either slightly furred with a few prominent papillæ, or pale and flabby; the appetite is irregular, or fails considerably; the patient complains of weariness and lassitude; there is, perhaps, slight headach across the eyes and forehead; the face has a sallow tinge, and if @@ -18925,13 +18909,13 @@ offensive, and even pungent; whereas, in others, they seem to consist chiefly of dark unhealthy bile, mixed with water and mucus.</p> <p>This form of disease is frequently met with in patients who have been -weakened by hæmorrhage, and necessarily tends to aggravate the state of -anæmia which is present. She has the intense pain at the summit of the +weakened by hæmorrhage, and necessarily tends to aggravate the state of +anæmia which is present. She has the intense pain at the summit of the head, which characterizes this condition; she gets but little sleep, and that is disturbed by restless and uneasy dreams; she lies with the eyelids half closed, and the occasional twitchings of the muscles betray the irritable condition of the system; exhaustion quickly supervenes, and is -usually attended either with low delirium, or the anæmic form of puerperal +usually attended either with low delirium, or the anæmic form of puerperal mania.</p> <p><i>Appearances after death.</i> If the dysenteric affection has been very @@ -18966,13 +18950,13 @@ stomach, from its being converted into the bichloride. We also think that there will be less chance of vomiting, when the calomel is combined with the soda, than with an antimonial, as recommended by Dr. Locock; a common domestic enema of gruel and salt will assist the purgative, and bring away -much unhealthy fæculent matter. The medicines will generally require to be +much unhealthy fæculent matter. The medicines will generally require to be repeated in twenty-four hours, to insure the removal of the irritating cause from the bowels; the abdomen becomes softer and more free from uneasiness; the pulse rises in strength and fulness, but diminishes in rapidity, and the patient experiences general relief in her symptoms. She may now take an ammoniated saline, with tincture of hop or henbane during -the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and +the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and henbane at night, instead of the calomel, and a draught of rhubarb and magnesia with some aromatic confection the next morning, or of rhubarb and manna with sulphate of potash, rendered warm by a little spirit of nutmeg.</p> @@ -18982,7 +18966,7 @@ nature of the case is more liable to be mistaken; still, however, the evidences of gastric and enteric irritation are quite sufficient to guide the cautious and observant practitioner. The calomel here is not so desirable as where there is constipation; eight or ten grains of Hydrarg. -c. Cretâ will produce less irritation, and act as effectually: it will +c. Cretâ will produce less irritation, and act as effectually: it will require to be followed by the same treatment as above-mentioned, and to be repeated according to circumstances.</p> @@ -19014,9 +18998,9 @@ gorged circulation of the stomach, liver, and bowels, of the noxious and excrementitious matters which nature has brought to these emunctories, in order that they may be discharged from the system. It is in these cases where, although little or no food has been taken for some time, and -without any evidences of fæcal accumulation, we find the exhibition of +without any evidences of fæcal accumulation, we find the exhibition of certain purgatives, especially calomel, to be followed by such copious -fæculent evacuations, which we have every reason to believe have been +fæculent evacuations, which we have every reason to believe have been secreted by the liver and bowels under the action of this powerful remedy. The treatment recommended by Dr. Ferguson, is so in accordance with our own views, and so concisely expressed, that we may be allowed to quote it.</p> @@ -19031,7 +19015,7 @@ large dose of calomel, from ten to fifteen grains should be given. Small doses create purging, pain, and irritation, while the full dose produces one to six large pultaceous stools, after which the tongue is cleaned, rendered less red and more moist, and the pulse usually falls. These -stools, when examined, appear to contain the fæcal matter suspended in +stools, when examined, appear to contain the fæcal matter suspended in large quantities of mucus and greenish bile, as if the turgid capillaries of the irritated intestinal canal and liver had been freed from their load. In some instances, a repetition only of the same dose is required to @@ -19075,7 +19059,7 @@ membrane of the bowels, with occasional attacks of irritative fever arising from it. In these cases mercurials, except in mild and guarded doses, appear to aggravate the irritation of the mucous membrane, and increase the disposition of it to ulcerate: five grains of Hydrarg. cum -Cretâ and Dover’s powder may be given once, or at the utmost, twice, in +Cretâ and Dover’s powder may be given once, or at the utmost, twice, in the twenty-four hours; half a drachm of carbonate of ammonia neutralized by lemon juice, and rendered alkalescent by a little Spirit. Ammon. Arom., may be given in some aromatic water every three or four hours; injections @@ -19142,7 +19126,7 @@ surface of the body instead of being, as in others, dry and of pyrexial high heat, is here usually soft and clammy, and the heat not above the natural temperature; and not only is the skin cool with clammy exudation, but the muscles to the impression of the finger feel soft and flaccid, as -if deprived of their vis vitæ by the influence of contagion. Indeed, there +if deprived of their vis vitæ by the influence of contagion. Indeed, there is such prostration of muscular strength and depression of vital principle from the very outset of the attack, that I must suppose the contagion to act through the medium of the nervous system in a manner analogous to that @@ -19188,7 +19172,7 @@ even cheerful: a peculiar sickly odour exhales from the skin, and in many cases so distinctly, as to warn us the moment we enter the room of the patient’s condition. The dusky ashen hue of the skin becomes darker, the fingers are shrivelled, and the nails dark, or of a livid black as in -cholera; diarrhœa frequently attends, the fæces are unhealthy, and of +cholera; diarrhœa frequently attends, the fæces are unhealthy, and of the same peculiar odour just noticed; during the first stage the lochia are generally present, although of an unhealthy character; the milk also continues in the milder cases, but as the stage of collapse approaches @@ -19213,7 +19197,7 @@ the vitiated state of the blood appears to be the essential condition of their existence, quite independent of any inflammatory action; in fact, in this form, so rapid and overpowering are the effects of the poison which pervades the circulation, and so completely does it paralyze the whole -system, that there is neither time nor sufficient vis vitæ to make any +system, that there is neither time nor sufficient vis vitæ to make any effort at reaction. Hence, as Mr. Moore has correctly observed, “when the patient is rapidly destroyed by the violence of the disease, the morbid changes bear no proportion to the severity of the previous symptoms; a @@ -19232,15 +19216,15 @@ plague, we shall find a striking coincidence between the two diseases. This intrepid pathologist remarks, that “the state of general turgescence and dilatation of the venous system; the presence of inflammable gas in eight cases in the cellular tissue, in the veins of the head, feet, and -abdomen; the presence of petechiæ, both internally and externally; the +abdomen; the presence of petechiæ, both internally and externally; the general softening of the tissues; the enlargement, softening, and breaking down of the spleen; the petechial state of the mucous membrane of the stomach; the effusions of blood on the inner surface of that organ; the -passive hæmorrhages and boils, are symptoms which result from a change in +passive hæmorrhages and boils, are symptoms which result from a change in the condition of the blood. The symptoms connected with the state of the nervous system, viz. the rigours, headach, and confusion of mind, the quick and small pulse, the hurried respiration and vomiting, and also the -petechiæ, carbuncles, and buboes, are neither those of vascular nor +petechiæ, carbuncles, and buboes, are neither those of vascular nor nervous inflammation. The blood has never shown the buffy coat; it was found just as black in the arteries as in the veins, but in the former, in much smaller quantity; it always had the appearance of being dissolved.” @@ -19265,7 +19249,7 @@ appearances after death. Instead of being little else than a state of collapse from the very outset of the disease, under which, not a single attempt is made by the powers of the system to set up even the most feeble effort of reaction, a variety of symptoms attend its commencement and -progress, indicating that the vis vitæ has not altogether succumbed +progress, indicating that the vis vitæ has not altogether succumbed beneath the deadly effects of the malady. The very rigour itself, when violent, the headach and flushing of the face, if severe, are rather favourable than otherwise, and show that the system still possesses some @@ -19347,7 +19331,7 @@ Lying-in Hospital, in the early part of 1838, we met with several cases where the ovaries had entirely disappeared, their site being only discoverable by an oval thickening of the broad ligament, something like an empty cyst of peritoneum; this contained a small quantity of livid -pulpy débris of the ovary, and (on that side where conception had taken +pulpy débris of the ovary, and (on that side where conception had taken place) a remarkably well marked or rather exaggerated corpus luteum. The uterus is larger and its tissue much softer than under ordinary <span class="pagenum"><a name="Page_456" id="Page_456">[Pg 456]</a></span>peritonitis, so that, in many instances, the finger can be easily pushed @@ -19359,7 +19343,7 @@ find that fresh efforts are made to rid the circulation of the morbid matter with which it is infected. The patient is suddenly seized with severe pain, with heat, redness, and swelling of one of the large joints, presenting all the appearances of arthritic or rheumatic inflammation, and -also of certain muscles, especially the supinators of the arm, the glutæi, +also of certain muscles, especially the supinators of the arm, the glutæi, and gastrocnemii. The painful spot soon becomes hard, it is intensely tender, and in two or three days the feeling of fluctuation indicates the formation of an abscess, from which a large quantity of greenish coloured @@ -19416,7 +19400,7 @@ apartment, where she died shortly after. The two females who occupied the beds adjoining hers, while she remained in the large ward, were attacked with puerperal fever, and died.” (Collins, <i>op. cit.</i> p. 381.) During a typhus epidemic which prevailed a few years ago in the poor districts of -the metropolis, a prominent feature of which were petechiæ and a livid +the metropolis, a prominent feature of which were petechiæ and a livid rubeoloid eruption, precisely the same appearances were observed among the cases of adynamic puerperal fever at the General Lying-in Hospital.</p> @@ -19425,7 +19409,7 @@ epidemic, the child of every woman who had died of the disease perished also from erysipelas, so severe that it ran its course in a few hours. Dr. Gordon, of Aberdeen, remarks, that “with it and, at the same time, epidemic erysipelas began, progressed with equal pace, arrived at its -acmé, and terminated together.” He also says, that a very frequent crisis +acmé, and terminated together.” He also says, that a very frequent crisis of the disease was an external erysipelas. Mr. Hey remarks, that infectious fevers were common at the time; and he does not recollect ever having seen such malignant cases of erysipelas as then. Dr. Clark also @@ -19591,7 +19575,7 @@ scrupulous attention to cleanliness, and by frequently washing out the vagina and uterus with warm water.</p> <p>If diarrhœa has set in to an exhausting degree, the opiates must be -increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline +increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline draughts of citrate or acetate of ammonia, rendered alkaline in excess by Sp. Ammon. Arom. may be given from time to time; they appear not only to refresh the patient, but also to allay flatulence and vomiting, if @@ -19666,7 +19650,7 @@ characters.—Treatment.—Phlegmatia dolens in the unimpregnated state. <p><i>Nature of the disease.</i> Although we shall not be justified in stating -that the disease is one of the sequelæ of puerperal fever, inasmuch, as it +that the disease is one of the sequelæ of puerperal fever, inasmuch, as it is occasionally met with, entirely independent of labour and the puerperal state, still we must recognise a very close relation between these two diseases, especially between it and the uterine phlebitis, since, in a @@ -19995,7 +19979,7 @@ quinine, will be required; and now we may direct our attention to reduce the swelling of the limb; it may be gently rubbed with the compound camphor liniment for the purpose of stimulating the absorbents. Dr. Hull has given a useful formula for the same object:—“℞. Ung. -Adipis Suillæ, ℥jss; Camphoræ, ℨiij; quibus +Adipis Suillæ, ℥jss; Camphoræ, ℨiij; quibus liquefactis admisceantur Ol. Essent. Lavend. gtt xij; Tinct. Opii, ℨij. Fiat Linimentum, quotide ter quaterve utendum.” (<i>Op. cit.</i> p. 161.)</p> @@ -20033,7 +20017,7 @@ detailed. The patient came under his care, on account of shooting pains in the loins and hypogastric region, which was tender upon pressure; she had incontinence of urine, and a sanious discharge from the vagina.</p> -<p>On examination, instead of the os tincæ and cervix uteri, a large +<p>On examination, instead of the os tincæ and cervix uteri, a large irregular ulcerated excavation was found at the posterior end of the vagina. Shortly afterwards, increased uneasiness was experienced in the lower part of the abdomen, the right lower extremity swelled in its whole @@ -20041,7 +20025,7 @@ extent, with pain in the course of the femoral and iliac vessels, and all the other symptoms of phlegmatia dolens. The disease was treated by leeches and other antiphlogistic means, and the pain abated considerably; it, however, returned, and in about three weeks after, she died from a -violent attack of uterine hæmorrhage. On dissection, the fundus uteri was +violent attack of uterine hæmorrhage. On dissection, the fundus uteri was found somewhat enlarged and firm, the cervix had been destroyed by that kind of phagedenic ulceration, which is commonly called cancer of the uterus. The hypogastric vein was closed in consequence of previous @@ -20095,7 +20079,7 @@ congestion or inflammation.</p> <p>2. Where it arises from gastro-enteric irritation.</p> -<p>3. Where it is the result of general debility and anæmia.</p> +<p>3. Where it is the result of general debility and anæmia.</p> <p>The last two rather deserve the title of melancholia.</p> @@ -20334,9 +20318,9 @@ real character.</p> <p><i>Causes and symptoms.</i> This form of disordered mind is a disease of true debility, and is closely allied to delirium tremens, and convulsions -produced by anæmia. It can scarcely be said<span class="pagenum"><a name="Page_479" id="Page_479">[Pg 479]</a></span> to deserve either the terms +produced by anæmia. It can scarcely be said<span class="pagenum"><a name="Page_479" id="Page_479">[Pg 479]</a></span> to deserve either the terms “puerperal,” or “mania,” for we frequently see a very near approach to it -in females who are much weakened by hæmorrhage, either from menorrhagia, +in females who are much weakened by hæmorrhage, either from menorrhagia, malignant disease of the uterus, or abortion; and from being a disease which arises from great exhaustion, it rather deserves the name of melancholia, than of mania. In lying-in women, “there are two periods at @@ -20344,7 +20328,7 @@ which this is chiefly liable to occur; the one soon after delivery, when the body is sustaining the effects of labour, the other several months afterwards, when the body is sustaining the effects of nursing.” (Gooch, <i>op. cit.</i> p. 109.) In the one case, it is usually the result of profuse -hæmorrhage, in the other, it is produced by suckling her child when she is +hæmorrhage, in the other, it is produced by suckling her child when she is not strong enough for this purpose. “I have repeatedly seen the commencement of mental derangement in women who had recovered from their confinement and had been suckling several months. Nearly all these cases @@ -20361,7 +20345,7 @@ that it was wrong.” (Gooch, <i>op. cit.</i> p. 114.)</p> <p>This half-way state of mind between reason and derangement is frequently seen in women who have been exhausted by menorrhagia, leucorrhœa, &c., or who have been drained by nursing. We confess that we can see but little -difference in the effects of anæmia upon the brain and nervous system, +difference in the effects of anæmia upon the brain and nervous system, whether it be in the unimpregnated or puerperal state, beyond that, on account of the great changes which have taken place in the system by the process of labour, by the secretion of milk, &c., the system is probably @@ -20387,7 +20371,7 @@ children, because they had neither milk nor strength to enable them to nurse.” (<i>Op. cit.</i> p. 130.)</p> <p>A similar state of mind may be induced at an earlier period and more -suddenly, by the effects of a profuse hæmorrhage, by serious discharges, +suddenly, by the effects of a profuse hæmorrhage, by serious discharges, which occasionally take place shortly after labour, or even by mental depression; in fact, by whatever lowers the vital powers to a considerable extent. In these cases, the very history and appearance of the patient are @@ -20420,7 +20404,7 @@ assurance that the danger of fatal sinking is at all diminished.</p> <p>Disordered mind coming on some weeks after delivery from the effects of over-nursing, when the patient has been unable to afford the necessary supply to her child, is seldom attended with so much danger to life, as -where suddenly induced immediately after labour by hæmorrhage: the +where suddenly induced immediately after labour by hæmorrhage: the intermediate stage between<span class="pagenum"><a name="Page_481" id="Page_481">[Pg 481]</a></span> reason and derangement is more distinctly marked, and is of considerable duration; and the gradually increasing affection of the mind frequently warns even the patient herself to seek @@ -20459,9 +20443,9 @@ subsequent occasion.</p> support the powers of the patient, and to allay as far as possible the irritability of the brain and nervous system.</p> -<p>If the patient has been prostrated by hæmorrhage, not only a nutritious, +<p>If the patient has been prostrated by hæmorrhage, not only a nutritious, but even a cordial and stimulant diet will be necessary: the emulsion of -egg and brandy, which we have before recommended in anæmic puerperal +egg and brandy, which we have before recommended in anæmic puerperal convulsions, will here prove very useful; and it must be given in small but frequently repeated doses, until an improvement is observed in the pulse and in her general appearance. Under all circumstances, it will @@ -20487,7 +20471,7 @@ with perfect safety to a considerable extent.</p> <p>The bowels should be opened by the mildest laxatives, such as castor oil, rhubarb and manna, &c., medicines which will neither act violently, nor weaken by producing watery evacuations; and, once in every few days, it -will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, +will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, with extract of hop or gentian. To assist still farther in restoring her health and strength, she should take an infusion of a vegetable bitter with a mineral acid. As soon as her strength will permit, a change of @@ -20586,7 +20570,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 2em;">Comparative, of the, <a href="#Page_34">34</a>.</span><br /> <span style="margin-left: 1em;">Of the external organs of generation in the female, <a href="#Page_45">45</a>.</span><br /> <br /> -<i>Anæmic</i> puerperal convulsions, <a href="#Page_387">387</a>.<br /> +<i>Anæmic</i> puerperal convulsions, <a href="#Page_387">387</a>.<br /> <br /> <i>Anchylosis</i> of the fœtal joints, obstructing labour, <a href="#Page_284">284</a>.<br /> <br /> @@ -20643,7 +20627,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <i>Bronchial</i> Processes, description of the, <a href="#Page_71">71</a>.<br /> <br /> <br /><a name="caesarean" id="caesarean"></a> -<i>Cæsarean</i> Operation, <a href="#Page_243">243-278</a>.<br /> +<i>Cæsarean</i> Operation, <a href="#Page_243">243-278</a>.<br /> <span style="margin-left: 1em;">Indications for its performance, <a href="#Page_243">243</a>.</span><br /> <span style="margin-left: 1em;">Different modes of performing it, <a href="#Page_246">246</a>.</span><br /> <span style="margin-left: 1em;">History of the, <a href="#Page_248">248</a>.</span><br /> @@ -20652,7 +20636,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <br /> <i>Caput</i> succedaneum, in what it consists, <a href="#Page_165">165</a>.<br /> <br /> -<i>Carunculæ</i> myrtiformes, how produced, <a href="#Page_46">46</a>.<br /> +<i>Carunculæ</i> myrtiformes, how produced, <a href="#Page_46">46</a>.<br /> <br /> <i>Cerebral</i> tumours in the fœtus, obstructing labour, <a href="#Page_283">283</a>.<br /> <br /> @@ -20704,7 +20688,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 1em;">Prophylactic treatment of, <a href="#Page_383">383</a>.</span><br /> <span style="margin-left: 1em;">Treatment during the attack of, <a href="#Page_383">383</a>.</span><br /> <span style="margin-left: 1em;">Apopletic, <a href="#Page_387">387</a>.</span><br /> -<span style="margin-left: 1em;">Anæmic, <a href="#Page_387">387</a>.</span><br /> +<span style="margin-left: 1em;">Anæmic, <a href="#Page_387">387</a>.</span><br /> <span style="margin-left: 2em;">Symptoms of, <a href="#Page_388">388</a>.</span><br /> <span style="margin-left: 2em;">Treatment of, <a href="#Page_388">388</a>.</span><br /> <span style="margin-left: 1em;">Hysterical, <a href="#Page_390">390</a>.</span><br /> @@ -20796,7 +20780,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 2em;">Precipitate labour, <a href="#Page_361">361</a>.</span><br /> <span style="margin-left: 2em;">Prolapsus of the umbilical cord, <a href="#Page_368">368</a>.</span><br /> <span style="margin-left: 2em;">Puerperal convulsions, <a href="#Page_376">376</a>.</span><br /> -<span style="margin-left: 2em;">Placenta prævia, <a href="#Page_393">393</a>.</span><br /> +<span style="margin-left: 2em;">Placenta prævia, <a href="#Page_393">393</a>.</span><br /> <span style="margin-left: 2em;">Puerperal fevers, <a href="#Page_415">415</a>.</span><br /> <span style="margin-left: 2em;">Phlegmatia dolens, <a href="#Page_463">463</a>.</span><br /> <span style="margin-left: 2em;">Puerperal mania, <a href="#Page_473">473</a>.</span><br /> @@ -20880,7 +20864,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <i>Flatulence</i> during pregnancy, <a href="#Page_104">104</a>.<br /> <span style="margin-left: 1em;">Treatment of, <a href="#Page_104">104</a>.</span><br /> <br /> -<i>Flooding</i>, <a href="#Page_338">338</a>. See <a href="#haemorrhage"><i>Hæmorrhage</i></a>.<br /> +<i>Flooding</i>, <a href="#Page_338">338</a>. See <a href="#haemorrhage"><i>Hæmorrhage</i></a>.<br /> <br /><a name="foetus" id="foetus"></a> <i>Fœtus</i>, characters of a full-grown, <a href="#Page_75">75</a>.<br /> <span style="margin-left: 1em;">Nutrition of the, <a href="#Page_75">75</a>.</span><br /> @@ -20914,7 +20898,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <br /> <i>Gastro-bilious</i> puerperal fever, <a href="#Page_444">444</a>. See <a href="#fever"><i>Puerperal Fever</i></a>.<br /> <br /> -<i>Gastrotomy</i>, <a href="#Page_243">243</a>. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> +<i>Gastrotomy</i>, <a href="#Page_243">243</a>. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> <br /> <i>Generation</i>, internal organs of, described, <a href="#Page_22">22</a>.<br /> <span style="margin-left: 1em;">External organs of, <a href="#Page_45">45</a>.</span><br /> @@ -20924,7 +20908,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <i>Graafian</i> Vesicles, description of the, <a href="#Page_25">25</a>.<br /> <br /> <br /><a name="haemorrhage" id="haemorrhage"></a> -<i>Hæmorrhage</i>, uterine, after the birth of the child, <a href="#Page_338">338</a>.<br /> +<i>Hæmorrhage</i>, uterine, after the birth of the child, <a href="#Page_338">338</a>.<br /> <span style="margin-left: 1em;">Treatment of, <a href="#Page_339">339</a>.</span><br /> <span style="margin-left: 1em;">In placental presentation, <a href="#Page_399">399</a>.</span><br /> <span style="margin-left: 2em;">Treatment of, <a href="#Page_406">406</a>.</span><br /> @@ -20945,7 +20929,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <br /> <i>Hysterical</i> puerperal convulsions, <a href="#Page_390">390</a>. See <a href="#convulsions"><i>Convulsions</i></a>.<br /> <br /> -<i>Hysterotomy</i>, <a href="#Page_243">243</a>. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> +<i>Hysterotomy</i>, <a href="#Page_243">243</a>. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> <br /> <br /> <i>Inclination</i> of the pelvis, <a href="#Page_21">21</a>.<br /> @@ -21065,7 +21049,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 1em;">Operations of, <a href="#Page_216">216</a>.</span><br /> <span style="margin-left: 1em;">Forceps, <a href="#Page_216">216</a>.</span><br /> <span style="margin-left: 1em;">Turning, <a href="#Page_230">230</a>.</span><br /> -<span style="margin-left: 1em;">Cæsarian operation, <a href="#Page_243">243</a>.</span><br /> +<span style="margin-left: 1em;">Cæsarian operation, <a href="#Page_243">243</a>.</span><br /> <span style="margin-left: 1em;">Artificial premature labour, <a href="#Page_250">250</a>.</span><br /> <span style="margin-left: 1em;">Perforation, <a href="#Page_161">161</a>.</span><br /> <br /><a name="milk" id="milk"></a> @@ -21101,18 +21085,18 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <br /> <i>Nutrition</i> of the fœtus, <a href="#Page_75">75</a>. See <a href="#foetus"><i>Fœtus</i></a>.<br /> <br /> -<i>Nymphæ</i>, anatomical description of the, <a href="#Page_47">47</a>.<br /> +<i>Nymphæ</i>, anatomical description of the, <a href="#Page_47">47</a>.<br /> <span style="margin-left: 1em;">Varicose and œdematous swellings of the, <a href="#Page_317">317</a>.</span><br /> <br /> <i>Nipples</i>, excoriated, <a href="#Page_193">193</a>.<br /> <span style="margin-left: 1em;">Treatment of, <a href="#Page_194">194</a>.</span><br /> <br /> <br /> -<i>Œdematous</i> swellings of the labia and nymphæ, <a href="#Page_317">317</a>.<br /> +<i>Œdematous</i> swellings of the labia and nymphæ, <a href="#Page_317">317</a>.<br /> <span class="pagenum"><a name="Page_488" id="Page_488">[Pg 488]</a></span><br /> <i>Operations</i> in midwifery. See <a href="#midwifery"><i>Midwifery</i></a>.<br /> <br /> -<i>Operation</i>, Cæsarian. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> +<i>Operation</i>, Cæsarian. See <a href="#caesarean"><i>Cæsarian Operation</i></a>.<br /> <span style="margin-left: 1em;">For Inducing premature labour, <a href="#Page_253">253</a>.</span><br /> <br /> <i>Organs</i> of generation, internal, in the female, <a href="#Page_22">22</a>.<br /> @@ -21245,7 +21229,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 1em;">Expulsion of the, <a href="#Page_167">167</a>. See <a href="#labour"><i>Labour</i></a>.</span><br /> <span style="margin-left: 1em;">Management of the, <a href="#Page_186">186</a>.</span><br /> <span style="margin-left: 1em;">In twin cases, <a href="#Page_187">187</a>.</span><br /> -<span style="margin-left: 1em;">Prævia, <a href="#Page_393">393</a>.</span><br /> +<span style="margin-left: 1em;">Prævia, <a href="#Page_393">393</a>.</span><br /> <span style="margin-left: 2em;">History of, <a href="#Page_393">393</a>.</span><br /> <span style="margin-left: 2em;">Symptoms of, <a href="#Page_402">402</a>.</span><br /> <span style="margin-left: 3em;">Comparative frequency of, in different years, <a href="#Page_405">405</a>.</span><br /> @@ -21263,7 +21247,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <br /> <i>Plethora</i>, effects of, on uterine contraction, <a href="#Page_327">327</a>.<br /> <br /><a name="plug" id="plug"></a> -<i>Plug</i>, utility of the, in restraining hæmorrhage, <a href="#Page_410">410</a>.<br /> +<i>Plug</i>, utility of the, in restraining hæmorrhage, <a href="#Page_410">410</a>.<br /> <span style="margin-left: 1em;">Best means of applying, <a href="#Page_152">152</a>.</span><br /> <br /> <i>Position</i> of the patient during labour, <a href="#Page_176">176</a>.<br /> @@ -21322,7 +21306,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <span style="margin-left: 1em;">Of the arm with the head, <a href="#Page_273">273</a>.</span><br /> <span style="margin-left: 1em;">Of the hand and feet, <a href="#Page_273">273</a>.</span><br /> <span style="margin-left: 1em;">Of the head and feet, <a href="#Page_274">274</a>.</span><br /> -<span style="margin-left: 1em;">Of the placenta, <a href="#Page_393">393</a>. See <a href="#placenta"><i>Placenta Prævia</i></a>.</span><br /> +<span style="margin-left: 1em;">Of the placenta, <a href="#Page_393">393</a>. See <a href="#placenta"><i>Placenta Prævia</i></a>.</span><br /> <br /> <i>Prolapsus</i> of the umbilical cord, <a href="#Page_368">368</a>.<br /> <br /> @@ -21505,7 +21489,7 @@ the effect of intercourse.” (Gooch, <i>op. cit.</i> p. 158.)</p> <i>Vagina</i>, contracted, obstructing labour, <a href="#Page_314">314</a>.<br /> <span style="margin-left: 1em;">Cicatrices in the, <a href="#Page_315">315</a>.</span><br /> <br /> -<i>Varicose</i> swellings of the labia and nymphæ, <a href="#Page_317">317</a>.<br /> +<i>Varicose</i> swellings of the labia and nymphæ, <a href="#Page_317">317</a>.<br /> <br /> <i>Ventral</i> Pregnancy, <a href="#Page_119">119</a>. See <a href="#extra"><i>Extra-uterine Pregnancy</i></a>.<br /> <br /> @@ -21629,7 +21613,7 @@ Completely Revised, with Numerous Additions and Improvements,<br /> <small>CONTAINING</small></p> <p class="note">A concise account of the various Subjects and Terms, with a vocabulary of -Synonymes in different languages, and formulæ for various officinal and +Synonymes in different languages, and formulæ for various officinal and empirical preparations, &c.</p> <p class="center">IN ONE ROYAL 8vo. VOLUME.</p> @@ -21752,7 +21736,7 @@ very considerably to the value of his work, but has shown an extent of reading which, we confess, we were not prepared by his former edition to expect. He has also availed himself of the additional materials supplied by the works that have been published in the interval, -especially those of Müller and Burdach. So that as a collection of +especially those of Müller and Burdach. So that as a collection of details on human physiology alone, we do not think that it is surpassed by any work in our language: and we can recommend it to students in this country (England) as containing much with which they @@ -21816,7 +21800,7 @@ Hygiene. By Robley Dunglison, M. D. &c., &c. In 1 vol. 8vo.</p> <p class="center">THE CYCLOPEDIA OF<br /> <span class="huge">PRACTICAL MEDICINE AND SURGERY,</span></p> -<div class="note"><p class="hang"><i>Or Essays on ASTHMA, APHTHÆ, ASPHYXIA, APOPLEXY, ARSENIC, ATROPA, AIR, +<div class="note"><p class="hang"><i>Or Essays on ASTHMA, APHTHÆ, ASPHYXIA, APOPLEXY, ARSENIC, ATROPA, AIR, ABORTION, ANGINA-PECTORIS, and other Subjects Embraced in the Articles from A to Azote, prepared for the Cyclopedia of Practical Medicine by</i></p></div> @@ -21997,7 +21981,7 @@ with more ample information.</p> published objections to the doctrine have been regarded as too cogent to be permitted to pass unheeded. It will be seen on farther examination in the interval of many years, which has elapsed since the -publication of the sixth edition of the Encyclopædia, has not induced +publication of the sixth edition of the Encyclopædia, has not induced him to modify his sentiments on this head. On the contrary, he appears to be as satisfied at this time, of the fallacy of the positions of the Phrenologist, as he was at any former period.”</p> @@ -22202,7 +22186,7 @@ modo ex testibus in uterum, sive ipsa ova, sive ovis contenta materia transmittatur, ut alibi ex professo ostendam, si quando dabitur partium genitalium analogiam exponere, et errorem illum tollere quo mulierum genitalia genitalibus virorum analoga creduntur.” (<i>Nicolai Stenonis -Elementorum Myologiæ Specimen, &c.</i> Amst. 8vo. p. 145.)</p> +Elementorum Myologiæ Specimen, &c.</i> Amst. 8vo. p. 145.)</p> <p><a name='f_3' id='f_3' href='#fna_3'>[3]</a> “Ova in omni animalium genere reperiri confidenter asserimus, quandoquidem ea non tantum in avibus, piscibus tam oviparis quam @@ -22244,7 +22228,7 @@ M. D.</p> <p><a name='f_14' id='f_14' href='#fna_14'>[14]</a> The axis of the brim of the pelvis runs in such a direction, that if a line were drawn from its centre, it would pass upwards and forwards through the umbilicus: the gravid uterus has its axis rarely or never -inclined less than this, and usually much more, especially in multiparæ in +inclined less than this, and usually much more, especially in multiparæ in whom the fundus is occasionally inclined so strongly forwards as to receive the name of pendulous belly.</p> @@ -22280,7 +22264,7 @@ first brought under his notice, will be enabled to enter with more ease and advantage upon the consideration of those which are obscure and difficult.</p> -<p><a name='f_18' id='f_18' href='#fna_18'>[18]</a> Siebold’s Journal für Geburtshülfe, vol. xiv. heft. 3. 1835.</p> +<p><a name='f_18' id='f_18' href='#fna_18'>[18]</a> Siebold’s Journal für Geburtshülfe, vol. xiv. heft. 3. 1835.</p> <p><a name='f_19' id='f_19' href='#fna_19'>[19]</a> On the Signs and Symptoms of Pregnancy, p. 133.: by W. F. Montgomery, M. D. In a note to the above quotation, the learned author very properly @@ -22335,8 +22319,8 @@ the first change which he has observed.</p> <p><a name='f_25' id='f_25' href='#fna_25'>[25]</a> Allen Thomson on the Development of the Vascular System in the Fœtus of Vertebrated Animal. (<i>Edin. New Philosop. Journ.</i> Oct. 1830.)</p> -<p><a name='f_26' id='f_26' href='#fna_26'>[26]</a> Pander. Beiträge zur Entwickelungs-gesechichte des Hünchens im Eie. -Würzburg, 1817.</p> +<p><a name='f_26' id='f_26' href='#fna_26'>[26]</a> Pander. Beiträge zur Entwickelungs-gesechichte des Hünchens im Eie. +Würzburg, 1817.</p> <p><a name='f_27' id='f_27' href='#fna_27'>[27]</a> In making these observations upon the formation of the ductus arteriosus, we must request our readers to consider this as still an @@ -22375,39 +22359,39 @@ whilst it is small, discharge the overplus by the vessels which open into the vagina during the first months.”</p> <p><a name='f_32' id='f_32' href='#fna_32'>[32]</a> The menstrual blood is more pale and sparing: it usually comes from -the hæmorrhoidal vessels of the vagina, or at most, from those of the -cervix uteri. (Levret, <i>Art des Accouchemens</i>, § 233.)</p> +the hæmorrhoidal vessels of the vagina, or at most, from those of the +cervix uteri. (Levret, <i>Art des Accouchemens</i>, § 233.)</p> <p><a name='f_33' id='f_33' href='#fna_33'>[33]</a> Should the vessels of the cervix uteri take upon them the secretion of the menses, this discharge can thus continue through pregnancy. (Carus, <i>Lehrbuch der Gynakologie</i>, bd. ii. p. 67.)</p> -<p><a name='f_34' id='f_34' href='#fna_34'>[34]</a> L’Art d’Accouchemens, § 369. (note;) also Deventer, Novum Lumen +<p><a name='f_34' id='f_34' href='#fna_34'>[34]</a> L’Art d’Accouchemens, § 369. (note;) also Deventer, Novum Lumen Obstet. chap. xv.; Perfect’s Cases of Midwifery, vol. ii. p. 71. [Meurer, American Journ. Med. Sc., April 1841, p. 494.]</p> <p><a name='f_35' id='f_35' href='#fna_35'>[35]</a> This fact was observed so long ago as by Aristotle, also by Schenk, as quoted by Mauriceau, lib. i. chap. 1. Mauriceau himself mentions having seen several cases, one of which forms the subject of his 393d -observation. “Le 8 Juin, 1685. J’ai vu une jeune femme agée seulement de -seize ans et demi, marié depuis un an qui était grosse de cinq mois ou -environ, quoiqu’elle n’eut jamais eu ses menstrues, à ce qu’elle me dit -aussi bien que son marie, qui ne pouvait pas se persuader qu’elle cût pû -devenir grosse, n’ayant pas encore eu ce premier signe de fécondité; +observation. “Le 8 Juin, 1685. J’ai vu une jeune femme agée seulement de +seize ans et demi, marié depuis un an qui était grosse de cinq mois ou +environ, quoiqu’elle n’eut jamais eu ses menstrues, à ce qu’elle me dit +aussi bien que son marie, qui ne pouvait pas se persuader qu’elle cût pû +devenir grosse, n’ayant pas encore eu ce premier signe de fécondité; m’alleguant, pour soutenir son opinion, qu’on ne voyait jamais de fruit -d’un arbre qui n’eut été précédé de sa fleur. Mais je lui dis qu’il était +d’un arbre qui n’eut été précédé de sa fleur. Mais je lui dis qu’il était certain, comme il reconnut bien par sa propre experience en voyant accoucher sa femme d’un enfant vivant quatre mois ensuite, que les jeunes -femmes pouvaient bien quelquefois devenir grosses, ainsi qu’il était -arrivé à sa femme, sans avoir jamais eu leur menstrues, si elles usaint du -coit dans le temps méme quelles étaient sur le point d’avoir effectivement +femmes pouvaient bien quelquefois devenir grosses, ainsi qu’il était +arrivé à sa femme, sans avoir jamais eu leur menstrues, si elles usaint du +coit dans le temps méme quelles étaient sur le point d’avoir effectivement cette evacuation naturelle pour le premier fois.”</p> <p><a name='f_36' id='f_36' href='#fna_36'>[36]</a> Rœderer, Elm. Art. Obst. p. 46. The original is a masterly specimen of description, not less remarkable for its singular comprehensiveness than the beauty of the style. “Menstruorum suppressionem -mammarum tumour insequitur, quocirca mammæ crescunt, replentur, dolent -interdum, indurescunt; venæ earum cœruleo colore conspicuæ redduntur; +mammarum tumour insequitur, quocirca mammæ crescunt, replentur, dolent +interdum, indurescunt; venæ earum cœruleo colore conspicuæ redduntur; crassescit papilla, inflata videtur, color ejusdem fit obscurior; simili colore distinguitur discus ambiens qui in latitudinem majorem expanditur, parvisque eminentiis quasi totidem papillulis tegitur.”</p> @@ -22426,21 +22410,21 @@ variety of shades not unlike a large bruise of some days’ standing. Dr. Montgomery mentions a case where the areola was almost black, and upwards of three inches in diameter. A similar case occurred not long since.</p> -<p><a name='f_39' id='f_39' href='#fna_39'>[39]</a> Bibliothèque Universalle, t. ix. p. 248; also in the Isis for 1819, +<p><a name='f_39' id='f_39' href='#fna_39'>[39]</a> Bibliothèque Universalle, t. ix. p. 248; also in the Isis for 1819, part iv. p. 542.</p> -<p><a name='f_40' id='f_40' href='#fna_40'>[40]</a> “Mémoir sur l’Auscultation appliquée à l’étude de la Grossesse, ou -Recherches sur deux nouveaux Signes propres à faire reconnaïtre plusieurs -Circonstances de l’Etat de Gestation; lu à l’Academie Royale de Médecine -dans la Séance Générale du 26 December, 1821. Par J. A. Lejumeau de +<p><a name='f_40' id='f_40' href='#fna_40'>[40]</a> “Mémoir sur l’Auscultation appliquée à l’étude de la Grossesse, ou +Recherches sur deux nouveaux Signes propres à faire reconnaïtre plusieurs +Circonstances de l’Etat de Gestation; lu à l’Academie Royale de Médecine +dans la Séance Générale du 26 December, 1821. Par J. A. Lejumeau de Kergaradec.”</p> <p><a name='f_41' id='f_41' href='#fna_41'>[41]</a> Dr. Evory Kennedy, Observations on Obstetric Auscultation, &c. 1833.</p> -<p><a name='f_42' id='f_42' href='#fna_42'>[42]</a> H. F. Naegelé, Die Geburtshülfliche Auscultation, 1838; also Dr. +<p><a name='f_42' id='f_42' href='#fna_42'>[42]</a> H. F. Naegelé, Die Geburtshülfliche Auscultation, 1838; also Dr. Corrigan, Lancet.</p> -<p><a name='f_43' id='f_43' href='#fna_43'>[43]</a> Die Geburtshülfliche Exploration, von Dr. A. P. Hohl.</p> +<p><a name='f_43' id='f_43' href='#fna_43'>[43]</a> Die Geburtshülfliche Exploration, von Dr. A. P. Hohl.</p> <p><a name='f_44' id='f_44' href='#fna_44'>[44]</a> This sign of pregnancy has very recently excited some attention, and the researches of M. Tanchou of Paris, (see <i>American Journ. Med. Sc.</i> @@ -22493,19 +22477,19 @@ into a mass of mouldiness.</p> from four to nine months, four in women who had not quickened, and who considered themselves as labouring under disease of the womb, and the remaining four in patients who had been under treatment for casual -complaints—one for sciatica at the Hôtel Dieu, another for ascites in the -city, a third for an ulcer in the neck at La Pitié, and the last had been +complaints—one for sciatica at the Hôtel Dieu, another for ascites in the +city, a third for an ulcer in the neck at La Pitié, and the last had been cauterized twice a week for a pretended disease of the uterus. In none of these cases had the existence of pregnancy been suspected, although in every one of them the fact was soon placed beyond doubt.—<span class="smcap">Editor.</span></p> -<p><a name='f_45' id='f_45' href='#fna_45'>[45]</a> Baudelocque wrote an account of it to Professor Naegelé of +<p><a name='f_45' id='f_45' href='#fna_45'>[45]</a> Baudelocque wrote an account of it to Professor Naegelé of Heidelberg, from whom we received the particulars.</p> <p><a name='f_46' id='f_46' href='#fna_46'>[46]</a> See Treatise on the Diseases of Females, 6th ed. p. 46. Ed.</p> <p><a name='f_47' id='f_47' href='#fna_47'>[47]</a> Ovum deforme, in quo partes embryonis et secundarum distingui vix -possunt, molam vocabimus. (Rœderer, <i>Elementa Artis Obstetricæ</i>, § +possunt, molam vocabimus. (Rœderer, <i>Elementa Artis Obstetricæ</i>, § 738.)</p> <p><a name='f_48' id='f_48' href='#fna_48'>[48]</a> Dr. J. Y. Simpson on the Diseases of the Placenta. (<i>Edin. Med. and @@ -22519,7 +22503,7 @@ Motte.</i>)</p> <p>“Every mole is a blighted ovum which has been the product of conception. We are not justified in classing under the head of moles every mass which is produced and lodged within the uterus.” (Froriep’s <i>Handbuch der -Geburtshülfe</i>, § 180.)</p> +Geburtshülfe</i>, § 180.)</p> <p><a name='f_50' id='f_50' href='#fna_50'>[50]</a> Our friend, Dr. Nebel, of Heidelberg, has a preparation of a fœtus which was retained for fifty-four years in the abdomen. This is the @@ -22531,7 +22515,7 @@ edition, where the notes contain very ample references.)</p> care for inflammation of the cervix uteri. There was that general enlargement of the uterus which attends this condition; and, on endeavouring to lift a heavy weight, she was seized with violent pain in -the pelvis, great difficulty in passing fæces and urine, and, on +the pelvis, great difficulty in passing fæces and urine, and, on examination, the uterus was found retroverted. The bowels were well opened with castor oil, and in a day or two it recovered its natural position.</p> @@ -22583,12 +22567,12 @@ Montgomery M. D. p. 253.</p> <p><a name='f_60' id='f_60' href='#fna_60'>[60]</a> Dewees, Compendious System of Midwifery, sect. 408. A similar case is recorded by Dr. Montgomery.</p> -<p><a name='f_61' id='f_61' href='#fna_61'>[61]</a> “Qui inter septimi et noni mensis, à prima conceptione, finem -contingit partus, <i>præmaturus</i> vocatur: <i>abortus</i> vero quando ante dictum +<p><a name='f_61' id='f_61' href='#fna_61'>[61]</a> “Qui inter septimi et noni mensis, à prima conceptione, finem +contingit partus, <i>præmaturus</i> vocatur: <i>abortus</i> vero quando ante dictum tempus embryo excidit; id quod circa tertium graviditatis mensem ut -plurimum accidit. Vitalem esse præmaturum fœtum observatio nos docet, +plurimum accidit. Vitalem esse præmaturum fœtum observatio nos docet, embryonem autem non manere superstitem constat.” (Rœderer, <i>Elem. Artis -Obst.</i> cap. xxiii. § 716.)</p> +Obst.</i> cap. xxiii. § 716.)</p> <p><a name='f_62' id='f_62' href='#fna_62'>[62]</a> During the great influenza epidemic, abortions were remarkably frequent.</p> @@ -22608,18 +22592,18 @@ after the ovum has been broken and its contents expelled. A portion of the involucrum sometimes insinuates itself into the neck of the uterus, and prevents the degree of contraction necessary to interrupt farther bleeding. This accident most frequently attends the earlier abortions. As -hæmorrhage is maintained by the cause just named it suggests the propriety +hæmorrhage is maintained by the cause just named it suggests the propriety of never breaking the ovum; especially before the fourth month. When the flooding is maintained by this cause, it will not cease but upon the event of its removal. This condition of the placenta and neck of the uterus is easily ascertained by an examination; it will readily be felt to be embraced by the neck of the uterus; and though a portion may protrude a -little distance below the os tincæ, it cannot be extracted by the fingers; +little distance below the os tincæ, it cannot be extracted by the fingers; for the os uteri or cavity of the uterus will not be sufficiently large to permit the fingers to pass into it, that this mass may be removed; the crotchet should then be substituted; the mode of using it is as follows:—The fore-finger of the right hand is placed within or at the -edge of the os tincæ; with the left we conduct the hooked extremity along +edge of the os tincæ; with the left we conduct the hooked extremity along this finger, until it is within the uterus; it is gently carried up to the fundus, and then slowly drawn downwards, which makes its curved point fix in the placenta; when thus engaged, it is gradually withdrawn, and the @@ -22631,7 +22615,7 @@ the discharge instantly ceased. See Art. “<span class="smcap">Abortion</sp experience is induced to believe” that “in cases in which we cannot command the removal of the placenta by the fingers—that is, when this mass continues to occupy the uterine cavity, or but very little protruded -through the os tincæ,” the administration of ergot, will often supercede +through the os tincæ,” the administration of ergot, will often supercede the necessity of the crotchet. <i>Treatise on the Diseases of Females.</i> Sixth Edition, p. 351.—<span class="smcap">Ed.</span></p> @@ -22795,43 +22779,43 @@ chapters on the Forceps in his <i>System of Midwifery</i>. Ed.]</p> 187.</p> <p><a name='f_85' id='f_85' href='#fna_85'>[85]</a> Another circumstance is humanely insisted on by Madame la Chapelle -with much propriety: “Je ne manque jamais de fair voir le forceps à la -femme, et de lui expliquer à-peu près son usage, et sa façon d’agir. Il -n’en est aucune que cette démonstration ne tranquillise, et j’en rencontre -souvent qui à leur deuxieme accouchement sollicitent l’application du -forceps qu’elles ont vu mettre en usage pour les débarasser du premier.” +with much propriety: “Je ne manque jamais de fair voir le forceps à la +femme, et de lui expliquer à -peu près son usage, et sa façon d’agir. Il +n’en est aucune que cette démonstration ne tranquillise, et j’en rencontre +souvent qui à leur deuxieme accouchement sollicitent l’application du +forceps qu’elles ont vu mettre en usage pour les débarasser du premier.” (<i>Pratique des Accouhemens</i>, p. 64.)</p> <p><a name='f_86' id='f_86' href='#fna_86'>[86]</a> Madame la Chapelle confirms this mode of introducing the forceps: “Pour moi, je l’introduis constamment sur le ligament sacro-sciatique.” (<i>Pratique des Accouchemens</i>, p. 66.)</p> -<p><a name='f_87' id='f_87' href='#fna_87'>[87]</a> “Quand une fois la tête est hors les parties osseuses, elle ne -retrograde plus, je les dêsarticule (the blades) avec la clef placée entre -elles en forme de lévier; je les extrais en les inclinant graduellement, -car souvent l’extraction un peu brusquée d’une branche produit l’expulsion -de la tête.” (<i>La Chapelle.</i>)</p> +<p><a name='f_87' id='f_87' href='#fna_87'>[87]</a> “Quand une fois la tête est hors les parties osseuses, elle ne +retrograde plus, je les dêsarticule (the blades) avec la clef placée entre +elles en forme de lévier; je les extrais en les inclinant graduellement, +car souvent l’extraction un peu brusquée d’une branche produit l’expulsion +de la tête.” (<i>La Chapelle.</i>)</p> -<p><a name='f_88' id='f_88' href='#fna_88'>[88]</a> “Mon avis est que la choix n’est point <i>nécessaire</i> quand l’uterus +<p><a name='f_88' id='f_88' href='#fna_88'>[88]</a> “Mon avis est que la choix n’est point <i>nécessaire</i> quand l’uterus est encore rempli d’eau, et que la position est douteuse. En pareil cas je -conseillerais même plutôt de faire usage de la main droite, quoique, pour +conseillerais même plutôt de faire usage de la main droite, quoique, pour mon compte, l’habitude m’ait rendu l’usage aussi familiar que celui de l’autre.” (Mad. la Chapelle, <i>Prat. des Accouch.</i> p. 88.)</p> -<p><a name='f_89' id='f_89' href='#fna_89'>[89]</a> “Une chose très importante à observer quand on se trouve contraint -par la perte de sang à en venir à l’opération, et que les eaux ne sont -point encore ouvertes, c’est de couler la main tantôt à droit, tantôt à +<p><a name='f_89' id='f_89' href='#fna_89'>[89]</a> “Une chose très importante à observer quand on se trouve contraint +par la perte de sang à en venir à l’opération, et que les eaux ne sont +point encore ouvertes, c’est de couler la main tantôt à droit, tantôt à gauche le plus haut et le plus doucement qu’il est possible de long les -membranes qui contiennent les eaux sans les rompre, jusqu’ à ce qu’ on ait -trouvé les pieds de l’enfant pour s’en saisir. Car s’il arrive qu’elles se -rompent avant qu’on ait pris cette précaution, pendant qu’on les cherche, -les eaux s’écoulent, les sang se perd, a la matrice se referme en partie, -et l’opération devient par-là plus difficile et plus dangereuse.” +membranes qui contiennent les eaux sans les rompre, jusqu’ à ce qu’ on ait +trouvé les pieds de l’enfant pour s’en saisir. Car s’il arrive qu’elles se +rompent avant qu’on ait pris cette précaution, pendant qu’on les cherche, +les eaux s’écoulent, les sang se perd, a la matrice se referme en partie, +et l’opération devient par-là plus difficile et plus dangereuse.” (<i>Pratique des Accouchemens</i>, p. 277.)</p> -<p><a name='f_90' id='f_90' href='#fna_90'>[90]</a> Traité des Accouchemens, 1770. § 691. “Pour moi, j’ai toujours au -contraire trouvé un grand advantage à insinuer la main jusqu’aux pieds de -l’enfant, et à n’ouvrir les membranes qu’en saisissant ces derniers.” (<i>La +<p><a name='f_90' id='f_90' href='#fna_90'>[90]</a> Traité des Accouchemens, 1770. § 691. “Pour moi, j’ai toujours au +contraire trouvé un grand advantage à insinuer la main jusqu’aux pieds de +l’enfant, et à n’ouvrir les membranes qu’en saisissant ces derniers.” (<i>La Chapelle</i> p. 90.)</p> <p><a name='f_91' id='f_91' href='#fna_91'>[91]</a> “We must by no means burst the bag of liquor amnii until the hand has @@ -22841,21 +22825,21 @@ withdraw the hand until we have fairly gained the feet and brought them down; for otherwise the waters escape, the uterus contracts, and the rest of the operation is more difficult.” (<i>Boer</i>, vol. iii. p. 17. note.)</p> -<p><a name='f_92' id='f_92' href='#fna_92'>[92]</a> “Je suis loin de prétendre, avec Puzos, que la traction sur un seul -pied ait les avantages récis.” (<i>La Chapelle</i>, p. 93.)</p> +<p><a name='f_92' id='f_92' href='#fna_92'>[92]</a> “Je suis loin de prétendre, avec Puzos, que la traction sur un seul +pied ait les avantages récis.” (<i>La Chapelle</i>, p. 93.)</p> <p><a name='f_93' id='f_93' href='#fna_93'>[93]</a> “Dans tous ces accouchemens je laisse le plus souvent agir la nature, -et je le fais avec bien plus de sécurité quand je sçais que la femme a -accouché précédemment et fort aisément d’enfans volumineux, quand je +et je le fais avec bien plus de sécurité quand je sçais que la femme a +accouché précédemment et fort aisément d’enfans volumineux, quand je reconnois son bassin pour avoir toutes les dimensions requises, quand les -contractions de la matrice sont bonnes.” &c. (<i>Traité des Accouchemens</i>, § +contractions de la matrice sont bonnes.” &c. (<i>Traité des Accouchemens</i>, § 674.)</p> -<p><a name='f_94' id='f_94' href='#fna_94'>[94]</a> Ueber die künstliche Wendung auf den Steiss, in the Heidelberg Klin. +<p><a name='f_94' id='f_94' href='#fna_94'>[94]</a> Ueber die künstliche Wendung auf den Steiss, in the Heidelberg Klin. Annalen, vol. ii. part i. p. 142.</p> -<p><a name='f_95' id='f_95' href='#fna_95'>[95]</a> Traité des Hernies, contenant une ample Déclaration, &c., par Pierre -Franco de Turriers en Provence, demeurant à presént à Orange: à Lyon, +<p><a name='f_95' id='f_95' href='#fna_95'>[95]</a> Traité des Hernies, contenant une ample Déclaration, &c., par Pierre +Franco de Turriers en Provence, demeurant à presént à Orange: à Lyon, 1561.</p> <p><a name='f_96' id='f_96' href='#fna_96'>[96]</a> See <span class="smcap">Dystocia from Malposition of the Child</span>. [The student who desires @@ -22866,7 +22850,7 @@ to investigate this subject farther, may consult Dr. Churchill’s successfully, for mother and children. See <i>American Journal</i>, for May 1838.—<span class="smcap">Ed.</span>]</p> -<p><a name='f_98' id='f_98' href='#fna_98'>[98]</a> [Dr. Churchill has collected the statistics of 409 cases of Cæsarean +<p><a name='f_98' id='f_98' href='#fna_98'>[98]</a> [Dr. Churchill has collected the statistics of 409 cases of Cæsarean section, of which number, 228 mothers were saved; and 181 lost, or about 1 in 2¼: and out of 224 children, 160 were saved, and 64 lost—or about 1 in 3½.</p> @@ -22882,7 +22866,7 @@ result to the child is given, 138 were saved, and 49 lost; or nearly 1 in 4. <i>Researches on Operative Midwifery.</i> By F. Churchill, M. D., Dublin, 1841. Editor.]</p> -<p><a name='f_99' id='f_99' href='#fna_99'>[99]</a> [The propriety of an early resort to the Cæsarean section, in cases +<p><a name='f_99' id='f_99' href='#fna_99'>[99]</a> [The propriety of an early resort to the Cæsarean section, in cases where it is necessary, has been very properly insisted upon; but the circumstances which render it necessary, are not always readily determined. M. Castel states, that in a case at the <i>hospice de @@ -22890,7 +22874,7 @@ perfectionnement</i>, in which the operation was determined on, some delay became necessary in order to find accommodation for the crowd of students who collected to witness it, and before this could be effected the woman was delivered naturally. M. Gimelle says, that at the hospital of M. -Dubois, a small woman, who had five times submitted to the Cæsarean +Dubois, a small woman, who had five times submitted to the Cæsarean section, was delivered naturally the sixth time. <i>Am. Journ. Med. Sc.</i> Aug. 1838. Ed.]</p> @@ -22908,9 +22892,9 @@ Brownlow Street, and colleague of Dr. W. Hunter.</p> <p><a name='f_103' id='f_103' href='#fna_103'>[103]</a> Barlow, Medical Facts and Observations, vol. viii. Although we are in great measure indebted to Dr. Denman for having brought this operation into general notice, it is to the late Professor May, the father-in-law of -Professor Naegelé, that the merit is due for having first pointed out the +Professor Naegelé, that the merit is due for having first pointed out the advantage of exciting uterine contraction before rupturing the membranes. -(<i>Programma de Necessitate Partûs quandoque præmature, vel solo +(<i>Programma de Necessitate Partûs quandoque præmature, vel solo Instrumentorum adjutorio promovendi.</i> Heidelberg, 1799.)</p> <p><a name='f_104' id='f_104' href='#fna_104'>[104]</a> [The student who desires to investigate this subject farther, is @@ -22939,22 +22923,22 @@ cases, or 1 in 1,205⅔.</p> 1,944⅓. Of 251 cases, in which the result to the mother is given, the mortality was 52, or about 1 in 5. (<i>Op. Cit.</i>) Editor.]</p> -<p><a name='f_107' id='f_107' href='#fna_107'>[107]</a> The above arrangement is that which is given by Professor Naegelé, -in his <i>Lehrbuch der Geburtschülfe</i>.</p> +<p><a name='f_107' id='f_107' href='#fna_107'>[107]</a> The above arrangement is that which is given by Professor Naegelé, +in his <i>Lehrbuch der Geburtschülfe</i>.</p> <p><a name='f_108' id='f_108' href='#fna_108'>[108]</a> <i>Pratique des Accouchemens</i>, p. 21. “Je puis assurer n’avoir jamais -rencontré aucune position du col, ni du tronc proprement dit.” (p. 19.)</p> +rencontré aucune position du col, ni du tronc proprement dit.” (p. 19.)</p> <p><a name='f_109' id='f_109' href='#fna_109'>[109]</a> Merriman’s Synopsis of difficult Parturition, last edition, p. 69. The elongated form of the protruded bag of membranes is, however, by no means a constant occurrence, as cases frequently occur where nothing of the kind has appeared.</p> -<p><a name='f_110' id='f_110' href='#fna_110'>[110]</a> Boer’s <i>Naturliche Geburtshülfe</i>, b. iii. p. 64. A case of actual +<p><a name='f_110' id='f_110' href='#fna_110'>[110]</a> Boer’s <i>Naturliche Geburtshülfe</i>, b. iii. p. 64. A case of actual evolution has also been described by Mr. Barlow, p. 399.</p> <p><a name='f_111' id='f_111' href='#fna_111'>[111]</a> Med. Chir. Trans., case by Dr. Smith, of Maidstone. See also an -interesting case by Professor Naegelé, in the British and Foreign Medical +interesting case by Professor Naegelé, in the British and Foreign Medical Review, where the uterus was ruptured by sudden violence, part of the child was delivered per vaginam, the rest by an abscess through the abdominal parietes. No. x. April, 1838.</p> @@ -22975,7 +22959,7 @@ Journ. Med. Sc.</i>, May 1840, p. 236.—<span class="smcap">Ed.</span>]</p> sort in his lectures: he distinctly “heard the head crack, and a large quantity of fluid came away.”</p> -<p><a name='f_116' id='f_116' href='#fna_116'>[116]</a> Observationes Anatomicæ, 52. A similar case has been recorded by Dr. +<p><a name='f_116' id='f_116' href='#fna_116'>[116]</a> Observationes Anatomicæ, 52. A similar case has been recorded by Dr. Wrangel, in the Archiv. der Gesellschaft der Correspondirenden Aerzte zu St. Petersburg.</p> @@ -22993,12 +22977,12 @@ sutures into the cranial cavity, the tumour had the appearance of a hydrocephalus.</p> <p><a name='f_117' id='f_117' href='#fna_117'>[117]</a> Quoted by Dr. Lee in the Med. Gazette, Dec. 25, 1830, from the -Journ. Gén. de Méd. tom. xliii. xlv.</p> +Journ. Gén. de Méd. tom. xliii. xlv.</p> <p><a name='f_118' id='f_118' href='#fna_118'>[118]</a> Merriman’s Synopsis, p. 216.; also Dr. J. Y. Simpson’s fifth case of fatal peritonitis, in Edin. Med. and Surg. Journ. No. cxxxvii. The patient had suffered under four different attacks of venereal disease. Some -interesting cases have been published in the Neue Zeitschrift für +interesting cases have been published in the Neue Zeitschrift für Geburtskunde, band vii. heft 1. by Dr. Bunsen of Frankfort and Dr. Kyll of Cologne. In almost every case of great accumulation of liquor amnii, the child was dead, hydrocephalic, or with ascites and in many the placenta @@ -23009,14 +22993,14 @@ in 500 cases. In 127 of these, the cord was 18 inches long, in 77 cases 24 inches, and in 45 cases 20 inches long. The extremes were 12 and 54 inches. <i>Op. Cit.</i>—<span class="smcap">Ed.</span>]</p> -<p><a name='f_120' id='f_120' href='#fna_120'>[120]</a> In a case of this sort Mauriceau says, “Ce nœud étoit extrémement -serré: mais cela ne s’etoit fait seulement que dans la sortie de l’enfant; -car s’il eût été long-temps serré de la sorte dans le ventre de la mère, -l’enfant auroit certainement peri; à cause que le mouvement du sang que -lui étoit nécessaire, auroit été entièrement intercepté dans ce cordon. -J’ai encore accouché depuis ce temps la, sept autres femmes, dont les -enfans qui étoient tous vivans, avoient pareillement le cordon noüé d’un -semblable nœud qui s’étoit fait de la même manière, par +<p><a name='f_120' id='f_120' href='#fna_120'>[120]</a> In a case of this sort Mauriceau says, “Ce nœud étoit extrémement +serré: mais cela ne s’etoit fait seulement que dans la sortie de l’enfant; +car s’il eût été long-temps serré de la sorte dans le ventre de la mère, +l’enfant auroit certainement peri; à cause que le mouvement du sang que +lui étoit nécessaire, auroit été entièrement intercepté dans ce cordon. +J’ai encore accouché depuis ce temps la, sept autres femmes, dont les +enfans qui étoient tous vivans, avoient pareillement le cordon noüé d’un +semblable nœud qui s’étoit fait de la même manière, par l’extraordinaire longueur de leur cordon.” (<i>Obs.</i> 133.)</p> <p><a name='f_121' id='f_121' href='#fna_121'>[121]</a> [Dr. Zollickoffer, of Middleburg, Md., relates two cases, in each of @@ -23034,13 +23018,13 @@ through which the whole body of the fœtus passed, and afterwards, by its motion and weight, had drawn the knot, already formed, into such a degree of tightness, that the umbilical vessels were entirely compressed; for when the knot was loosened out, all that part of the navel string -which was taken into the knot was quite flattened.” (Vol. xiii. § 1306.)</p> +which was taken into the knot was quite flattened.” (Vol. xiii. § 1306.)</p> <p><a name='f_123' id='f_123' href='#fna_123'>[123]</a> One of the most remarkable cases of extreme pelvic deformity from -mollities ossium is described by Professor Naegelé in his Erfahrungen und +mollities ossium is described by Professor Naegelé in his Erfahrungen und Abhandlungen. The patient was the mother of six living children when she was attacked with the disease: the seventh, after great difficulty, was -born dead, and the eighth was delivered by the Cæsarean operation, which +born dead, and the eighth was delivered by the Cæsarean operation, which proved fatal. The spine was pressed so downwards, that the third lumbar vertebra was opposite to the superior edge of the symphysis pubis; the distance of the left ramus of the pubes from the fourth lumbar vertebra @@ -23064,7 +23048,7 @@ Embryotomy was again performed. She had become much more deformed and helpless, but in three years afterwards she was again pregnant. “She now appeared to be little more than an unwieldy lump of living flesh.” The antero-posterior diameter was now only 1¼ inch, becoming gradually -narrower at each side. The Cæsarean operation was performed with a fatal +narrower at each side. The Cæsarean operation was performed with a fatal result. On examination after death, the rami of the ischium were found “little more than half an inch asunder.”</p> @@ -23085,10 +23069,10 @@ alone; where from 4 to 3 or 2¾ inches, delivery may take place by the efforts of nature, or assisted by the crotchet, or lever; from 2¾ to 2½ inches, it requires artificial premature delivery; from 2½ to 1½ inches, embryulcia; and from 1½ inch to the lowest possible -degree of distortion, the Cæsarean operation.</p> +degree of distortion, the Cæsarean operation.</p> <p><a name='f_127' id='f_127' href='#fna_127'>[127]</a> For many of the above observations we are indebted to an admirable -article upon the subject by our friend, Professor Naegelé, jun., in the +article upon the subject by our friend, Professor Naegelé, jun., in the <i>Medicenischen Annalen</i>, band ii. heft 2.</p> <p><a name='f_128' id='f_128' href='#fna_128'>[128]</a> Dr. Merriman has detailed two interesting cases, which were @@ -23103,7 +23087,7 @@ Medicine, by our friend Mr. Ingleby, of Birmingham; a practical work of great value.</p> <p><a name='f_130' id='f_130' href='#fna_130'>[130]</a> [The following very singular case of tumour of the pelvis is -recorded by Professor <span class="smcap">D’Outrepont</span>, of Würtzburg.</p> +recorded by Professor <span class="smcap">D’Outrepont</span>, of Würtzburg.</p> <p>A woman, twenty-six years old and well made, gave birth when twenty-five years of age to her first child without difficulty. Towards the end of her @@ -23129,7 +23113,7 @@ slightly compressible. When labour commenced, the professor called a consultation in which it was determined that unless a great change had taken place in the character of the tumour, an attempt should be made to remove it, or to cut away the bone if that should be found to be -implicated, and as a last resource, to perform the Cæsarean section.</p> +implicated, and as a last resource, to perform the Cæsarean section.</p> <p>On an examination being made, the right foot of the child was found to present, the cord was prolapsed, and did not pulsate. The tumour, however, @@ -23219,13 +23203,13 @@ upon a dilatation of the os uteri a separation has always followed, and hence a flooding naturally ensues.”</p> <p><a name='f_142' id='f_142' href='#fna_142'>[142]</a> The second edition of Rœderer’s admirable <i>Elementa Artis -Obstetriciæ</i>, which was published by his distinguished successor, +Obstetriciæ</i>, which was published by his distinguished successor, Wrisberg, in 1766, three years after his death, is that which is chiefly known, although it never had an extensive circulation in this country. The means of communication with the Continent at that time were very different to what they are at present; and although none can regret more than ourselves that Rœderer’s work should have passed unnoticed in Dr. -Rigby’s <i>Essay on Uterine Hæmorrhage</i>, still we feel assured that the +Rigby’s <i>Essay on Uterine Hæmorrhage</i>, still we feel assured that the liberal portion of the medical world, whether in this or other countries, will not attribute this omission to a disingenuous suppression of his name, but rather to the more probable circumstances that, residing in a @@ -23257,360 +23241,6 @@ same work, vol. v. p. 46.—<span class="smcap">Editor.</span>]</p> <p> </p> <p> </p> -<hr class="full" /> -<p>***END OF THE PROJECT GUTENBERG EBOOK A SYSTEM OF MIDWIFERY***</p> -<p>******* This file should be named 40654-h.txt or 40654-h.zip *******</p> -<p>This and all associated files of various formats will be found in:<br /> -<a href="http://www.gutenberg.org/dirs/4/0/6/5/40654">http://www.gutenberg.org/4/0/6/5/40654</a></p> -<p> -Updated editions will replace the previous one--the old editions -will be renamed.</p> - -<p> -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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