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H AND-BOOK
OF
PRACTICAL MIDwifeRy,
INCLUDING FULL INSTRUCTION FOR THE
H O M CEO PATHIC TREAT'M ENT
OF THE
DISORDERS OF PREGNANCY,
AND THE
f :
ACCIDENTS AND DISEASES INCIDENT TO LABOR AND THE
PUERPERAL STATE,
BY
J. H. MARSDEN, A.M., M.D.
Elomo 8wm ; humani nihil a me alienum puto.
BOERICKE & TAFEL,
NEW YORK : PHILADELPHIA :
145 GRAND STREET. - 635 ARCH STREET.
1879.

Copyright, 1879, by V. H. Marsden, A.M., M.D.
PRESS OF GLOBE PRINTING. HOUSE, PHILADELPHIA.
PRE FA C E.
THE design of this work is to furnish the student
and young practitioner, within as narrow limits as pos-
sible, all necessary instruction in practical midwifery.
The object of this benign art is, or at least should be,
to save life, maternal and infantile, and to reduce suf-
fering to its lowest possible minimum. Any method
which will best accomplish these purposes, is the best
method, no matter by whom devised.
In order to secure sufficient space fully to discuss
all subjects of practical importance, and yet restrict the
size of the book within very moderate bounds, the
author has omitted some preliminary topics usually
embraced in a treatise on midwifery. He has taken
for granted that the student has already become famil-
iar with anatomy and physiology, through the study
of works specially upon these subjects, including a
minute description of the reproductive organs, and the
theories of conception, embryonic development and
foetal growth. Having no peculiar views of his own
upon these subjects, he thinks it as well to send his
pupils for instruction to those who have made them a
special study. Here they may learn at least the theo-
ries of to-day; but it is more than doubtful, whether
we shall ever be able fully to analyze the operations of
creative power. By this disposal a large amount of
space is economized, and the student is not subjected
to the unnecessary expense of purchasing what he may
be presumed already to possess in other books. The
truth is, practical midwifery is in a great measure, if
not wholly, independent of any theory of conception
or embryology.
It is not claimed that the following work is abso-
iv. PREFACE,
lutely original. To make it so, it would have been
necessary to reject the fruits gathered by all the labor-
ers of past ages in this important field, and who, it may
be asked, would be willing to incur such a fearful re-
sponsibility, or who possessed of such unbounded self-
conceit, as to suppose himself competent after casting
all these away, to supply their place from his own in-
dependent resources. At the same time it is hoped
the book may be found to contain as large a proportion
of original matter as is usually met with in treatises
upon the same subject. But whether this adds to the
excellence or detracts from the value of the work, the
author does not consider himself the proper umpire to
decide. The reader must judge for himself. Let all
that claims originality go for what it is worth—noth-
ing more is asked.
The portions of the book taken from the general
stores of knowledge upon the subject, which have been
long accumulating, are such as the author has found
from his personal experience to be really valuable, or
such as approved themselves to his common sense.
Quotations are for the most part credited to their
authors. When we draw, however, upon our common
stock of knowledge, it is often impossible to determine
what is originally our own, or what we have gotten by
the way from some other source. It is, too, a remark-
able fact, that the same fortunate thought often occurs
to men about the same time who are distant from, and
entirely independent of each other. Important truths
are revealed to the world in the fulness of time, when
mankind is more or less prepared for their reception;
but their introduction and promulgation are seldom
entrusted to a single individual, however gifted he
may be.
PREFACE. V
In using the results of other men's labors, the author
cherishes the belief, that he has wished to render to
every man his due, and if to the reader any thing
appear seemingly at variance with such. avowal, it is
hoped he will charitably attribute it to oversight,
rather than to dishonorable intention.
In regard to the therapeutics of the work, the au-
thor would simply remark that he has not adopted the
method seemingly pursued by some, of writing out the
pathogenesis of a drug as given in the books—for in-
stance Belladonna—and then Sagely adding, “if these
symptoms occur give Belladonna.” On the contrary,
he has stated the treatment which in his past experi-
ence he has generally found successful in the particular
case in question; then reference is probably made to
remedies recommended upon what he esteems good
authority, and this is perhaps followed by a list con-
sidered worthy of examination and comparison with
existing symptoms. It is thought best that the young
practitioner should, in a careful and unbiassed manner,
examine the symptoms of the case before him as they
actually exist, and having got a correct and precise
view of these, then consult, if necessary, his materia
medica, and fit the drug to the symptoms, not the
symptoms to the drug.
Perhaps some in turning over the pages of this book
will be disappointed and surprised at the absence of all
pictorial illustrations. The author is aware of the im-
portance attached by many to this method of teaching
midwifery. He begs leave to say, however, that hav-
ing himself had long experience as an instructor in
schools and colleges, he feels that he has a right to
claim an independent opinion in matters pertaining to
the art of teaching. It is his confirmed belief that in
vi PREFACE.
teaching midwifery, the wood-cuts and plates given as
illustrations, rather tend to create erroneous views than
to furnish an elucidation of the subject. The student,
therefore, when he comes to the bed-side is not unfre-
quently under the necessity of unlearning what he has
erroneously learned from books. An exact knowledge
of anatomy, aided by an imagination of ordinary power,
will enable him correctly to comprehend all that can
be fully comprehended, until he has an opportunity of
confirming or correcting his views at the bedside of the
parturient woman.
In treating of the mechanism of labor the author has
enunciated and endeavored to illustrate what seemed
to him the fundamental law governing the process of
parturition. Content with doing this, he has left to
those fond of such investigation, to determine the
special modifications of force and resistance concerned
in effecting individual results.
Finally, the kind indulgence of the reader is humbly
solicited, not upon the ground that pressing business
and cares had prevented due attention to the prepara-
tions of this work; for if there had been such insur-
mountable hindrance to its proper execution, it ought
never to have been undertaken ; but rather upon the
ground that all human performances are necessarily
imperfect, through the very imperfection of human
nature itself. Such is the author's estimate of the im-
portance of his subject, that after having for many
years done all within his power in its behalf, he feels
bound to subscribe himself an “unprofitable servant.”
THE AUTHOR.
York SULPHUR SPRINGs, PA.
January, 1879.
C O N T E N T S.
PAGE
DIAGNOSIS OF PREGNANCY, . ę e º te e d 1
DISORDERS OF PREGNANCY, e º - º & º & 12
ABORTION AND PREMATURE DELIVERY, . º º º 31
LABOR, . * e & cº g e e tº e t e º 41
MECHANISM OF LABOR, . • - e º º tº º 48
MANAGEMENT OF LABOR, . © © * § fe & º 58
MANAGEMENT OF THE CHILD, e e e º º tº 81
MANAGEMENT OF THE LYING-IN WOMAN AFTER CHILD-
BIRTH, . * º º º ë • º e § e tº 90
DEVIATIONS FROM NORMAL LABOR, . - - º tº 101
Retarded Labor, . º tº e © º ſº e & © 101
Abnormal Labor, arising from deformed pelvis of the mother, 115
Deviations from Normal Labor, having their origin in some pecu-
liar Condition of the Child, . º o º te e o 122
Deviations from Normal Labor, arising from unfavorable presenta-
tions of the Foetus, e • e º e º o e 135
a. Presentation of the Face, º º tº e tº e o 135
b. Presentation of the Back and Side, . º tº º e 143
c. Presentation of the Breech, Knees and Feet, . º • º 145
Deviated Presentations of the head, . g º e º we 153
ACCIDENTS AND DISEASES INCIDENT TO LABOR AND THE
PUERPERAL STATE, e e º - te g º º 160
Prolapse of the Cord, tº e º ſº - - º º 160
Adherent Placenta, tº e e te º - e º º 163
Haemorrhage, . * . te w e g e - º e 166
a. Ante-partum, Accidental Haemorrhage, . e e - º 167
viii
CONTENTS.
b. Placenta Praevia or unavoidable Haemorrhage, .
c. Post-Partum Haemorrhage,
d. Post-Partum secondary Haemorrhage,
Laceration of the Perineum,
Toxaemic Puerperal Disease,
Puerperal Convulsions,
False or spurious Peritonitis,
Mastitis or Inflammation of the Mammary Glands,
OBSTETRIC OPERATIONS,
Forceps,
Version,
a. Cephalic Version,
b. Podalic Version,
Craniotomy,
Cephalotripsy,
Induction of Premature Labor,
Caesarean section, .
ANAESTHESLA IN LABOR,
SYNOPSIS OF THERAPEUTICS,
PAGE
169
175
187
194
201
220
236
238
248
248
266
266
269
276
279
286
291
296
308
PRACTICAL MIDWIFERY.
CHAPTER I.
DIAGNOSIS OF PREGNANCY.
As one of the first duties which the obstetrician is likely to
be called upon to perform, is the treatment of the disorders
incident to pregnancy, it is highly important he should be
able to diagnose that condition with the greatest possible cer-
tainty. We say with the greatest possible certainty, for we
believe it is admitted upon all hands, that in the early 'stages
at least, absolute certainty in all cases is unattainable. Much
research has been expended in the effort to discover some one
infallible sign or symptom which, whensoever found to exist,
might decide the question beyond a doubt. As yet, however,
the attempt has been unsuccessful. It is rather through a
concurrence of symptoms, than through any single one, that
we are enabled to arrive at a considerable degree of certainty.
I speak here of the early stage, for as pregnancy advances, it
becomes more and more manifest, until it leaves us room for
scarcely a doubt of its existence.
One of the first and perhaps most constant signs of preg-
nancy, is the cessation of the catamenial flow. Where this
function has been heretofore regularly performed and suddenly
ceases, is absent at the time of its expected recurrence, with-
out any other assignable cause, it may be strongly suspected
(1)
2 PRACTICAL MIDWIFERY.
in the case of married women, and of those of whose chastity
we may entertain doubts that conception has taken place.
Generally the menses fail to appear at the period next after a
fruitful copulation. But this is not always the case. Some-
times the evacuation will recur, scarcely modified, for one or
two periods after the beginning of pregnancy. Cases too are
not wanting wherein the catamenial function (or something
resembling it) has been performed without interruption,
throughout the entire term of gestation. This however is
very rare. *
But there are, we must bear in mind, other causes besides
conception which occasionally interrupt the regular recur-
rence of the catamenia. Exposure, for instance, to wet or
cold during the flow, especially if the woman at the time be in
a warm or perspiring condition, is very apt to interrupt it sud-
denly and prevent its return at one or more subsequent periods.
So well are females acquainted with this, that young girls
wishing to conceal their illicit pregnancy, will often account
to the physician for the absence of their monthly periods, by
asserting that they had taken cold, had got wet feet, etc.
Diseases too, which greatly debilitate the system, diminish
the quantity and impoverish the quality of the blood, lead
eventually to a partial or total suppression of the menses.
Such are chlorosis, phthisis pulmonalis and the different forms
of anemia.
There are certain cases too, in which we cannot avail our-
selves of this sign of pregnancy, valuable as it may be. For
instance it sometimes happens that women who have already
borne children, again become pregnant before the reappearance
of the external sign of ovulation. Others conceive, it is said,
who have never menstruated at all. I once attended a woman
in confinement whose word I had no reason to question, who
told me she had but once menstruated in her life, and that
was shortly before her marriage, although she was at the time
to which I refer, the mother of several children. Perfect re-
lates the case of a young woman who presented all the signs of
pregnancy, who had before that period never menstruated at
all, but her courses then appeared and continued at the regular
DIAGNOSIS OF PREGNANCY. 3
epochs throughout gestation. (Cases of Midwifery, Vol. ii., p.
71) Deventer, Baudelocque and Chambon, furnish cases of
women who were “regular” only during gestation. In some
of these very rare cases the appearance of the catamenia was
regarded as satisfactory evidence that conception had taken
place. Such instances as the above are however so rare as not
to detract very materially from the value of menstrual sup-
pression as a sign of pregnancy.
The so-called “morning sickness” is another important sign
often occurring at an early stage of gestation. It is not how-
ever a uniform attendant upon that condition. Some patients
entirely escape it, even some who have been much harassed by
it during one pregnancy, do not experience it in a subsequent
one. Dr. Clay, of Manchester, asserts that it sometimes occurs
in the early stage of ovarian tumors. The nausea of preg-
nancy is peculiar and easily distinguishable from that arising
from ordinary causes. It usually manifests itself when the
patient first rises in the morning, increases in severity till it
results in efforts to throw up, sometimes very severe and dis-
tressing. As the stomach is then generally empty, nothing is
ejected but the Secretions of that organ and of the upper por-
tion of the alimentary tract, occasionally mixed with bile.
The distressing sickness has been compared to that occasioned
by tobacco smoke in the first attempts to use segars. Morning
sickness is very variable both in the length of its daily parox-
ysms, and in its persistence in the course of gestation. In
some cases it lasts but a few minutes after its onset, in others
it continues through the most part or even the whole of the
day, while some enjoy no exemption from it except during
their sleeping hours, and even then are occasionally awaked by
excessive nausea. In most instances it entirely ceases to re-
cur at or a little before the middle of gestation, while some
patients continue to be harassed up to its very close.
Cotemporaneous with the vomiting of pregnancy may often
be observed a peculiar aspect of the countenance, which, when
present, I have thought of much value in our diagnosis. Per-
haps it occurs more frequently in young women of fair com-
plexion and nervous temperament. There is an unusual trans-
4 PRACTICAL MIDWIFERY.
parency of the skin, the eyes appear hollow, and are sur-
rounded with a dark or livid circle. The features are sharp
and attenuated, and the face and indeed the whole frame
seems somewhat emaciated. The general expression of the
countenance is sad and languishing. These appearances are
probably produced by the womb monopolizing the process of
nutrition to build it up and fit it for the requirements of the
growing foetus.
Among the earlier signs of pregnancy may be mentioned,
although of rather rare occurrence, profuse Sahivation. “I
have known cases of this kind” says Dr. Meadows, “where
the quantity of fluid which poured from the mouth might be
measured almost by pints in the twenty-four hours.” No in-
dications of inflammation of the mouth or gums appear upon
examination in such cases. It is, as Dr. Montgomery remarks,
“easily distinguished from the ptyalism induced by mercury,
by the absence of sponginess and Soreness of the gums, and of
the peculiar fetor.” Of course other signs of pregnancy being
present, and the history of the case when accessible, will assist
us in this differential diagnosis.
Among the first signs, some authors enumerate “slight flat-
ness of the hypogastric region” and depression of the umbilical
cicatrix. Also certain changes in the uterus and vagina. The
os and cervix become soft and spongy; the transverse, lip-like
fissure is changed into a more circular form, and the tempera-
ture of the vagina is somewhat higher than normal.
Toward the close of the second month after conception, cer-
tain sensations are experienced in the mammary glands and
nipples, attracting the attention of the woman. She has a
feeling of fullness and throbbing in the substance of the
former, they increase in size, and have a peculiar knotty
glandular feel. The areola surrounding the nipples enlarges
in its diameter and assumes a darker hue, the difference being
greater in women of dark complexion. In the virgin state it
should be observed that the color of the nipple and areola
differs but little from that of the surrounding skin, being of a
light pink-like tint. Dr. Clay also maintains that the areola
of the nipple enlarges and becomes darker in cases of ovarian
tumor.
DI AGNOSIS OF PREGNANCY. 5
Connected with enlargement of the breasts, especially in
young women where the change is rapid, little smooth bright
lines are observed in the skin, resembling such as are found
upon the abdomen after considerable distension in that region
has taken place.
The tissue around the nipple becomes elevated, soft and
puffy, and this is considered by Dr. Montgomery as among
the most valuable signs of existing pregnancy. It is said that
Mr. John Hunter, in the case of a young girl, the subject of a
post-mortem examination, asserted positively from this sign
alone that a foetus was contained in the womb, which was
found to be the case, although the hymen was said to be still
entire. The follicular glands or sebaceous follicles, fifteen or
twenty in number around the nipple, become much developed
and elevated, so as to be very conspicuous. These changes in
the nipples and areola are certainly very strong evidence of
pregnancy, and I believe are generally so considered. In-
stances are on record however, at least in regard to most of
them, that they have been known to be produced by other
causes and therefore, singly, cannot be regarded as positive
proof of existing utero-gestation.
As pregnancy advances, other signs manifest themselves in
the condition of the womb, size and shape of the abdomen,
etc. Even at an early stage of gestation and before the woman
experiences any unusual sensations indicative of her condition,
if an examination be made “per vaginam,” the womb will be
felt somewhat increased in size and weight. The whole of the
lower part of the body gradually enlarges, and towards the
close of the third or beginning of the fourth month, a hard
rounded tumor will be found rising slightly above the os pubis
in front. This is the fundus of the womb which gradually in-
creases in size, and rises higher and higher until that organ at
full term seems to occupy the whole abdominal cavity. This
gradual enlargement of the womb is a very valuable sign. It
is however sometimes simulated by the existence of uterine
growths, ovarian cysts and solid tumors, ascites, etc. Diag-
nostic distinctions between these and pregnancy is not always
easy. Uterine tumors are usually associated with a bad condi-
6 PRACTICAL MIDWIFERY.
tion of the health, often with severe floodings. Those of the
ovary in like manner, are generally accompanied by bad health
and emaciation. The enlargement moreover in the case of
the latter if noticed in the beginning, is usually found low in
the hypogastric region and to one side of the median line, cor-
responding with the site of the right or left ovary. Ovarian
cysts however, sometimes do not attract the attention of the
patient till they occupy a central position, and then she usu-
ally insists that they have been there from the beginning.
Ascites is not only associated with a sallow, sickly complexion
and actual bad health, but generally dropsical effusions will be
found in the feet and lower extremities. Fluctuation in the
abdomen more or less distinct, can also mostly be detected. In
the case of pregnaney on the contrary, by the time the uterine
tumor becomes noticeable, the woman usually enjoys excellent
health. The morning sickness, if it had theretofore been trou-
blesome, has mostly by this time passed away. The pale ema-
ciated appearance which may have signaled the early stage,
gives place to what the French call “en bon point,” the aspect
of robust, rugged health. The history of these different con-
ditions will also furnish much aid in forming a correct diag-
nosis. Upon this, however, I need not dilate, the reflecting
student will easily conceive how different this would be in the
several conditions just referred to. It is of vast importance
however, to distinguish the diseased conditions of which we
have spoken from pregnancy. Errors have led to the most
serious results, as for instance, the tapping of the pregnant
woman under the delusion that she was suffering from dropsy,
to her great hazard and sometimes even with fatal conse-
quences to herself and unborn offspring.
Dr. Braxton Hicks has recently called the attention of the
profession to a diagnostic sign of pregnancy, not before speci-
ally noticed in that point of view. He maintains, that as soon
as the womb is large enough to be felt, if the hand be applied
over it, without any friction or pressure, that organ will be
felt to harden or contract every five or ten minutes, sometimes
oftener, rarely at longer intervals. Dr. Tyler Smith had
noticed this phenomenon, but ascribed it to peristaltic action,
DIAGNOSIS OF PREGNANCY. 7
and perhaps failed to appreciate its availability as a symptom
of utero-gestation, and a means of enabling us to distinguish
that condition from uterine enlargements from tumors or
other causes. If Dr. Hicks be correct as to the constancy of
these contractions, and their persistence throughout the whole
course of pregnancy, from their first occurrence, they should
certainly be regarded as of great value in diagnosis.
Dr. Playfair tells us that since reading Dr. Hicks’ paper, he
has “paid considerable attention to this sign,” which he has
never failed to detect, even in the retro-flexed gravid uterus
contained entirely in the pelvic cavity. “If the hand” says
he, “be kept steadily on the uterus, its alternate hardening
and relaxation can be appreciated with the greatest ease. The
advantage which this sign has over the foetal movements, is
that it is constant, that it is not liable to be simulated by any-
thing else, and that it is independent of the life of the child,
being equally appreciable when the uterus contains a degener-
ated ovum or dead foetus.” (Playfair's Midwifery, pp. 134–35.
A very important sign of pregnancy is derived from the
operation called “passive movement,” or, as the French term it,
ballottement. A very good idea of this may be obtained by
supposing a solid substance enclosed in a bladder filled with
water, and of such specific gravity as to sink to the bottom,
but this not much exceeding that of the fluid in which it is
immersed. Let the bladder be held up with one hand and
with a finger of the other let a quick impulse be given to the
solid body in an upward direction. The sensation will be con-
veyed to the finger of something departing from it, and in a
moment falling back upon it again. Now the pregnant womb
corresponds to the apparatus we have supposed. It contains a
sac called the amnion ; this sac is filled with a fluid called the
waters or amniotic fluid. Within this the foetus floats freely,
representing the solid body we have just supposed. Now if a
sudden impulse be given to this body by the finger through
the walls of the womb in an upward direction, the same sensa-
tion will be experienced of something departing and then fall-
ing back again.
The operation is performed in the following manner: the
8 PRACTICAL MIDWIFERY.
woman standing erect upon her feet as the preferable position,
the index finger of the left hand is introduced into the vagina
and carried up till it impinges upon the womb, either before or
behind the cervix; better behind if the finger of the left hand
be employed. In either case, there is only the thin wall of
the womb between the point of the finger and the ovum,
whereas, if the finger impinged upon the cervix, the thickness
of the intervening tissues would be considerably greater. The
palmar aspect of the finger being thus applied to the womb, a
sudden stroke is given to the latter, from below upward and
from behind forward, and then the finger maintained in its po-
sition. It is important that the direction of the force should
be somewhat forward and not directly upward, for the axis of
the womb generally corresponds to that of the upper strait,
and if the foetus be impelled in this direction it will have a
much freer movement, and consequently the impulse of its re-
turn will be much more plainly perceptible than if impelled
directly upward, in which direction its movement would be
very limited. At the moment the impulse is given, a sensation
of something departing is perceived, and if the finger be re-
tained in situ, it will perceive the mobile body falling back
upon it. The operation may be performed while the woman
is in the recumbent posture, but not so advantageously, as we
have not then so much the aid of gravitation.
This sign is generally considered available about the fifth
month. Before that period the foetus is mostly too small,
and perhaps the uterine walls too thick, to admit of the opera-
tion being successfully performed. When available, it affords
the strongest evidence of pregnancy, as no other known con-
dition gives rise to the same phenomenon. But failure in a
single trial is not to be regarded as positive evidence of the
non-existence of pregnancy. Our search is not always success-
ful in the fifth month, the small size of the child enabling it
easily to change position, so that one day it may be found and
perhaps the next elude the most diligent search.
Avicenna, who was born in the year 980, studied and de-
scribed the peculiar characteristics of the urine of pregnant
women. More recently and after the observations of the author
DIAGNOSIS OF PREGINANCY. 9
just named had passed out of notice, the subject awakened a
new interest and was studied with greater precision by Nauche,
Eguisier and Tanchon in France, Letheby and Stark in Eng-
land, and in the United States by Dr. Elisha K. Kane of Phila-
delphia.
The experiments of these gentlemen demonstrate, that if the
urine of a pregnant woman be left to stand in a wine glass ex-
posed to the atmosphere, in a few hours a deposit of cloudy
flakes settles upon the sides of the glass, the urine in conse-
quence becoming more limpid. In the course of two or three
days, the urine again becomes more intensely clouded, and soon
after a pellicle forms upon the surface. About the third or
fourth day after its formation portions separate, and are preci-
pitated so that by the fifth or sixth day it has mostly disap-
peared. This pellicle has been denominated Kyesteine, from
the Greek word kuesis gestation. It is said to be seldom no-
ticed before the second month of utero-gestation and to be most
noticeable between the third and seventh month. It has been
thought by some to be peculiar to pregnancy, and therefore
when seen, conclusive proof of its existence. This, however,
has been disputed by others, who insist that a similar, if not an
identical state of the urine is sometimes found in that of per-
sons laboring under certain diseases, such as phthisis, articular
diseases, etc. Dr. Kane, whose observations have been perhaps
the most extensive as well as precise, has also noticed this ap-
pearance in the urine of women giving suck. “In forty-four
out of ninety-four cases of suckling women, he observed Kye-
steine presenting all its characteristics.” But the proportion
of pregnant women manifesting this peculiarity of the urine
was still much greater, namely four out of five.
It would appear therefore that when Kyesteine is found in
the urine of a woman in good health and not giving suck, it
is strong presumptive evidence that she is pregnant. Taken
in connection with other coexisting symptoms tending to es-
tablish the same point, it may assist us much in forming a cor-
rect diagnosis.
As utero-gestation advances, other signs are developed, while
some of those already enumerated are intensified. The ab-
10 PRACTICAL MIDWIFERY.
dominal tumor from month to month increases in size, and the
fundus of the womb ascends higher and higher, giving rise
finally to difficulty of respiration and sometimes interfering
with the process of digestion. About the middle of the fifth
month, sooner or later, according to circumstances, the move-
ments of the foetus are felt by the mother. This generally in
the minds of women themselves is considered as indubitable
proof of their pregnancy, and yet even in this they have some-
times been mistaken. Other internal movements or delusive
sensations have been taken for the motions of a child, when
the sequel showed that none could have been present. When
the woman first perceives the “quickening,” as it is called, she
considers her term half expired and she mostly reckons the
time of her expected confinement from that period. This
reckoning, however, often proves fallacious. Many circum-
stances conspire to make the time of quickening different in
different cases. Something for instance will depend upon the
vigor of the child, and something upon the acute sensibilities
of the mother. But however deceptive the first sensations the
woman may experience, which she refers to the motions of a
child within her womb, she can scarcely be mistaken in the
latter months of utero-gestation. These movements become so
strong as to be in some cases actually painful and give rise to
a peculiar feeling of sickness. This symptom of pregnancy,
when fully developed, can scarcely lead to a mistake, as there is
no known cause capable of producing it in its intensity, except
a living child.
The sounds of the foetal heart may now under favorable cir-
cumstances be heard by the aid of the stethoscope. To succeed
in this, the woman should lie upon a bed of sufficient height, so
as not to require the operator to stoop too much; otherwise the
congestion of the head caused by stooping, will seriously in-
terfere with accurate hearing. The instrument should be
placed at once in front, below, and a little to the left side; for
here the pulsations are most commonly heard. If we do not
thus attain our object, it is well to inquire of the woman
where she usually feels the foetal movements. If she can in-
form us of this, we may expect to detect the pulsations upon
tº DIAGNOSIS OF PREGNANCY. 11
the opposite side; for the child’s members which execute the
movements are folded upon the front of its body, and the sen-
sations of the woman therefore determine to which side of her
abdomen the front of the child, for the time being at least, is
turned. The back of the foetus through which the sounds of
the heart are most readily heard, is of course turned in the
opposite direction, designating the region to which the stetho-
scope is to be applied. We need scarcely say that the sounds
of the foetal heart afford important evidence of pregnancy, as
there is nothing else for which they can be mistaken. The
quickness of the pulsations will distinguish them from those
of any of the maternal arteries, if such could be heard.
We have thus given some of the most obvious and reliable
symptoms of pregnancy. If we meet with a coincidence of all
or even several of the more important of these, we can enter-
tain no reasonable doubt of the nature of the case before us.
It must be remembered, however, that unmarried females who
are anxious to conceal their condition, generally misrepresent;
in short we can place no reliance whatever upon their state-
ments. In examining such, we should depend principally
upon symptoms which they cannot misrepresent or conceal, or
over which they have no control. For instance, if they even
admit that the catamenia is suppressed, they account for it by
stating that they had got their feet wet or taken cold, and per-
haps can give even the day and peculiar circumstances when
the accident happened. In the very large proportion of cases
where there is cessation of the monthly periods of young girls,
without any corresponding derangement of health, there is
illicit pregnancy, although the denoument may never declare
it before the world. In such cases, however, we are not to be
rash in our conclusions. We may do great injustice to a
worthy young woman by even thinking her guilty of unchas-
tity, although we should communicate our suspicion to no one
else. The female character once Sullied, seldom wholly re-
gains its pristine lustre. Besides there are exceptional cases,
such as those of young girls at School who often are deprived
of proper exercise while their minds are wholly devoted to
their tasks. But if this state of things be long continued, it
T2 PRACTICAL MIDWIFERY.
seldom fails to engender ill health, which in its turn tends to
prolong the amenorrhoea.
As it was not our intention in this place to delineate the
whole course of utero-gestation through its various stages,
from its beginning to its end, but simply to furnish the means
of its diagnosis, it is unnecessary we should go on to speak of
the various phenomena developed as it approaches its close.
Some of these will more properly engage our attention under
other divisions of this work.
CHAPTER II.
DISORDERS OF PREGNANCY.
It is the duty of the physician, so far as in his power, to re-
lieve the sufferings of the pregnant woman as they arise
during the course of utero-gestation. It is not sufficient to
exhort her to patience with the assurance that by and by all
will again be right. Her sufferings, though strictly speaking
they may not be those of disease, are yet real, and none the
less demand relief. It is a satisfaction to know that homoeo-
pathy has resources in controlling the disorders of pregnancy,
much more efficient than those possessed by the old school of
medicine, while they are at the same time, when properly
used, wholly innocuous, and therefore much better suited to
the delicate condition of the patient.
MENSTRUAL SUPPRESSION.—The physician is not often con-
sulted on account of the menstrual suppression, which takes
place in the great majority of cases immediately after concep-
tion. With married women this is usually referred to the
true cause. But often unmarried girls, who have become
pregnant by illicit intercourse, apply to the physician for re-
lief from this abnormal state, partly for the sake of concealing
DISORDERS OF PREGINANCY. 13
for the time their real condition, and it is to be feared some-
times with the hope that the medicine given may produce
abortion. The homoeopathic physician, even though he should
form an incorrect diagnosis, is not likely to be so unfortunate
in his treatment as to unintentionally bring about this result.
But it is highly important, even to him, to be upon his guard,
and where any of the usual concomitant signs of pregnancy
can be detected, to abstain from medication altogether. Where
amenorrhoea is the consequence of pregnancy, all medical treat-
ment must be unavailing and worse than useless. It is a
natural consequence of utero-gestation which will find relief
soon after the termination of that condition, and not till then.
The surplus blood, which in the non-pregnant state was wont
to pass off by regular monthly evacuations, is now employed
for a specific object, namely, for the increase in size of the
uterus necessary to prepare it for its new function, and the
growth of the foetus contained within its cavity. According
to a recent theory of menstruation, the periodical change in
the interior surface of the womb, fitting it to become the re-
ceptacle of the impregnated ovum, usually accompanied by
effusion of blood, and termed nidification, no longer takes
place, because no longer required. The distension in this
organ caused by the rapid afflux of blood thereto, is sometimes
accompanied by feelings of considerable discomfort to the pa-
tient, such as a sensation of weight in the uterine region, ten-
sion, frequent desire to urinate, weakness of the limbs, anxiety,
palpitation of the heart, accompanied sometimes by change of
temper, depression of spirits, etc. Nux wom. may prove a use-
ful remedy for these symptoms. Puls., if the woman be of a
lymphatic temperament, pale complexion and of a gentle timid
character. Bellad., where there are signs of congestion to the
head. Act. rac. and Digit., where palpitations of the heart
are troublesome; for the latter symptom perhaps also Arsenite
of Copper, 4th decimal.
MORNING SICKNESS, or the vomiting of pregnancy, although
very common and often causing great discomfort, is in many
cases borne by the patient as an unavoidable and irremediable
suffering pertaining to her condition. This in part arises from
14 PRACTICAL MIDWIFERY.
the very partial success usually attendant upon the ordinary
treatment of this affection. Sometimes, however, this ailment
becomes so distressing, and even threatening, that the sufferer
anxiously seeks relief. The practitioner should, therefore, be
prepared to treat such cases successfully, as may usually be
done by means of homoeopathic remedies. Nux wom. will
often be found to correspond with the symptoms of these cases
and consequently prove curative. When the nausea and vom-
iting are not confined to the first hours after rising, but are
rather continual, the food taken into the stomach is ejected,
bile or mucus mixed with bile is thrown up by repeated retch-
ings, Ipecac. is indicated. Sepia is supposed to be suited to
the vomiting of milky mucus. Dr. Cowley tells me he finds
it in the 1st dec. trit. a very efficient remedy. Arsen. corre-
sponds to those cases where vomiting occurs immediately
after eating or drinking, and which are attended by great
prostration. Puls. where vomiting comes on in the night ac-
companied by depraved appetite, desire for acid substances,
beer, wine, etc.; diarrhoea alternating with constipation.
Kreosote is another useful remedy, the characteristic symp-
toms for which my experience does not enable me to give, but
perhaps some guide may be found for its successful applica-
tion in its symptomatology. The late Prof. C. D. Meigs spoke
highly of minute doses of Sulphate of Soda, and Dr. Simpson
claims to have used successfully the Oxalate of Cerium. I re-
member a case of uncommon severity which occurred in my
practice, for the relief of which I used Nux wom., Ipecac.,
Oxalate of Cerium, and perhaps some other remedies, with
very partial, if any success. I afterwards gave Arsenite of
Copper, 3d dec., with almost immediate benefit and very
shortly complete relief. This case was characterized by con-
stant and severe nausea, the rejection of all food and drink al-
most immediately after it was swallowed, great emaciation
and prostration of strength, the patient was obliged constantly
to maintain the recumbent posture, great depression of spirits,
disinclination to all motion or effort, quick and feeble pulse,
occasional pain of a spasmodic character in the region of the
womb, and at one time after some little indiscretion in diet,
DISORDERS OF PREGNANCY. 15
frequent and painful dysenteric discharges from the bowels,
with tenesmus, although about midwinter. Amelioration
followed the employment of the Arsenite by the second day,
and the amendment was almost uninterrupted till complete
recovery had taken place. The patient passed the remaining
months of utero-gestation in comparative comfort, had a
normal labor at full term, giving birth to a well developed
female child of good size, and she made an excellent recovery.
The persistent vomiting of pregnancy, termed by Cazeaux
“irrepressible vomiting,” is perhaps sometimes dependent upon
a neurosis or extreme irritability of the sympathetic system of
nerves, and if this surmise be correct, I would entertain high
hopes of the frequent utility of the Arsenite of Copper for its
removal. When vomiting is accompanied by indigestion, the
undigested food being ejected, Pepsin may relieve. The lin-
ing membrane of the gizzard of the common fowl, dried and
triturated, has been highly praised. Actea racemosa has been
favorably spoken of by some as a remedy for this distressing
affection. I have tried this medicine in a few cases, but so far
as I can remember, not with flattering results. From its ad-
mitted influence however, over the womb, it is worthy of a
careful study in this relation.
When the vomiting is accompanied by salivation, or by the
so-called “bilious symptoms,” such as coated tongue, constipa-.
tion, etc., Merc. Sol. should be tried. Also Podophyllin and
perhaps Leptandrin may be worthy of notice.
Dr. Grailey Hewitt has lately advanced the theory that the
vomiting of pregnancy is not unfrequently caused by antiver-
sion or retroversion of the womb, or even by flexions of that
organ. He defends this theory with much good sense and co-
gency of argument. While there is probably at this time an
undue tendency to refer serious derangements of health to
trivial deviations from the normal position of the womb, it is
not improbable that any deviation from its natural position,
sufficient to produce irritation in that organ may cause, or at
least increase morning sickness. In cases therefore which ob-
stinately resist medical treatment, it is proper we should make
a careful examination, and correct any displacements we may
16 PRACTICAL MIDWIFERY.
find existing. Although not partial to the use of pessaries,
especially in cases of the impregnated uterus, we think it
would be well after the womb is straitened or reposited, to
apply one to retain it in its normal condition. We are too
little addicted to the use of the instrument to be very authori.
tative in giving advice as to the proper selection. That called
the “inflated ring pessary * is reported as having been success-
fully used, and Dr. Hale, an excellent authority, recommends
Thomas's, Hewitt's, and Jackson's.
It is probable, as we may assume that the vomiting of preg-
nancy arises generally, if not always, from an irritation of the
womb in the extremely susceptible condition in which it is
then found, that the efficacy of the pessary mainly depends
upon the counter-irritation which is set up by its presence.
The reflex action previously expended upon the stomach, may
be, as it were, recalled and turned upon the points of contact
of the pessary.
That the irritation of the womb giving rise to vomiting is
not, at least always, caused by versions and flexions of that
organ, seems to be sustained by the fact, that vomiting usually
ceases when abortion, spontaneous or artificial, takes place, un- .
less we must assume, that upon that occurrence the womb at
once regains its normal condition. This circumstance, we
think points to the contained ovum as the “Fonset origo’’ of
the evil. It may be that flexions, in the early stage of preg-
nancy, are more common than we have supposed.
When all measures fail to arrest the vomiting, and the
patient is manifestly in danger of losing her life from its per-
sistence, we are usually advised to produce abortion as a last
resort—a measure, however, which I am happy to Say I have
never been obliged to adopt.
CHOREA.—This affection is supposed to occur most frequently
in first pregnancies, and in young women of delicate health
and irritable nervous system. It probably happens most gen-
erally in the early stages of gestation, before the womb has, so
to speak, become reconciled to the new process going on within
it. The same remedies are applicable here, that are useful in
the disease occurring in the non-pregnant woman. In this
DISORDERS OF PREGINANCY. 17
case, however, the uterus may be regarded as the seat of the
malady—the centre whence the irritation emanates. Hence
we will probably find Actea racemosa our best remedy. I
have at least found it very efficacious. The first decimal di-
lution given at such intervals as the urgency of the case may
seem to demand, will doubtless in many instances procure re-
lief. Valerianate of Zinc and Sulphate of Zinc are also very
worthy of consideration.
CONSTIPATION, arises partly from the sedentary habits of
many women during pregnancy, but oftener perhaps from
pressure, caused by the increasing size of the uterus, interfer-
ing with the peristaltic action of the bowels, and a diversion
of nervous influence from the latter to the womb. This de-
rangement may be greatly alleviated by suitable hygienie
measures. Gentle exercise in the open air, admixture of fruit
largely with the food of the patient, the use of bran bread, etc.,
will be found serviceable.
The patient should procure a good gum-elastic syringe and
be instructed in the use of it. When the bowels cannot be
evacuated without much straining, which by the way might
produce haemorrhage and abortion, she should administer to
herself an injection of tepid water, and if ineffectual at first,
repeat it in the course of an hour till a free evacuation is pro-
cured. If an enema of simple warm water do not answer the
purpose, a little castile soap may be added. It has been re-
commended to drink a glass of pure, fresh water on rising each
morning, which may prove useful. The utmost regularity
should be observed in attending to the calls of nature, and in
visiting the water closet at a stated time even though no
urgency requires her to go.
The remedies most likely to be useful, if the foregoing meas-
ures do not succeed, are Nux wom., taken at bed time, Sulphur,
if Nux vom. fail to give relief, taken also in the evening, or
Nux vom. may be taken at night and Sulphur in the morning,
by way of alternation. Bryonia, in obstinate cases taken more
frequently, say a dose every two hours through the day, will
sometimes prove efficacious. Temporary relief may be pro-
2
18 PRACTICAL MIDWIFERY.
cured by taking a few grains of inspissated ox gall, especially
when the patient is troubled with flatulency.
DIARRHOEA is not an unfrequent attendant upon pregnancy.
It may occur at any time in its course, and when conjoined
with much irritation and pain it should be arrested as speedily
as possible, otherwise it may lead to abortion through exten-
sion of the irritation of the lower bowel to the womb. The
treatment of the diarrhoea of pregnant women does not differ
from that of ordinary cases, for which the reader will do well
to consult Dr. Bell’s excellent treatise.” It wery frequently
happens that a moderate and almost painless diarrhoea is ex-
perienced very near the occurrence of labor. This need not be
regarded with any apprehension, as it is a wise provision by
which the rectum is emptied of its often indurated contents,
and thereby greater space provided for the passage of the head
of the child.
PAIN IN THE BACK, LOINS, etc., are very frequently com-
plained of by pregnant women. Those of the back may be
sometimes owing to exertion or fatigue, in the effort to support
the erect position owing to the weight of the distended womb
in front. Nux vom. is likely to prove useful in this case.
Rhus and Arnica should also be thought of.
Pains of the loins and abdomen however, are perhaps gen-
erally of a neuralgic character. They may arise from mechani-
cal pressure caused by the enlarged uterus, or from an affection
of the pelvic nerves, sympathetic with the excited condition of
that organ. If the former, we would expect relief from
Arnica internally given and externally applied; if the latter,
which is probably by far the most frequent, we must look for
our remedies amongst that class of medicines which afford re-
lief in neuralgias of the nerves of that region. Aconite will
often be found useful and Cupr. ars. perhaps more frequently
so, especially if the pains be of a spasmodic or crampy char-
acter. Morphia, in small doses will probably often prove effi-
cient, as I know from experience it is one of our best remedies
in neuroses of the nerves of the chest, abdomen and pelvis.
* “Dysentery, Diarrhoea,” etc.
DISORDERS OF PREGINANCY. 19
The pains occurring in the abdominal and uterine region not
long before confinement, I have seen sometimes greatly allevi-
ated or entirely removed by the alternate use of Cypripedium
pubescens and Caulophyllum. I have little doubt that Arsen-
ite of Copper will answer a good purpose under similar circum-
stances, although up to the present writing I have not had an
opportunity of trying it. It is important these pains should
be relieved, as I have long been of the opinion that their per-
sistence renders subsequent labor tedious.
ISCHURIA or pain and difficulty in voiding the urine is a fre-
Quent attendant upon pregnancy. According to Croserio,
when there is frequent desire to evacuate the bladder, attended
with great pain in urinating, tenesmus vesicae without the
color of the urine being changed, Nux vom. is a specific. If
the urine escapes involuntarily, Camphor is to be preferred.
In cases of extreme vesical tenesmus, especially if associated
with tenesmus of the rectum and evacuation of mucus, I would
again advise Arsenite of Copper. In some of these urinary
difficulties, especially urethritis or irritation of the urethra,
Equisetum hyemale is specific. º
Where the dysuria is owing to retroversion or anteversion
of the womb, this organ should, at the earliest moment pos-
sible, be restored to its normal position. When it is not too
forcibly jammed in the pelvis this object may be effected in
the following manner. The urine should be first evacuated
by the catheter, and the rectum emptied, if loaded, by means
of an enema. The patient is placed upon her left side or back,
or made to assume the knee and elbow position. We suppose
the latter to be the most advantageous. The fingers, well
oiled, are carried up within the vagina until the fundus is
reached and its position, whether backward or forward, ascer-
tained. It is then gently and very gradually pushed up. Dr.
Playfair advises the introduction of a gum elastic bag high
up into the vagina, to be distended with water by means of a
syringe. He contends that the gradual, continued pressure
thus produced is safer and more effective than that more sud-
denly and forcibly applied by means of the fingers. The water
in the bag is to be occasionally let out, in order to give the
20 PRACTICAL MIDWIFERY.
patient an opportunity to urinate, but is to be immediately
refilled. To inflate the bag with air would probably answer
better as being more elastic than water, and the only additional
danger, the bursting of the bag, could, with care, be avoided.
When these measures do not succeed, the author just referred
to, recommends to fully anaesthetize the patient for the purpose
of relaxation of the tissues; and to secure greater freedom in
manipulation. She is to be placed upon the left side near the
edge of the bed, while two fingers of one hand (the left, if
trained, doubtless the most convenient) or the whole hand, if
practicable, are introduced into the rectum, with which the
fundus, in case of retroversion, is pushed up, while, with one
or two fingers of the other hand in the vagina, the cervix is
pulled down. In case of anteversion we suppose he would
have us reverse the process.
Retroversion of the womb may depend upon the increasing
weight of that organ in the early stage of pregnancy while it
is yet contained within the pelvis, perhaps abnormally large.
But according to the view of Dr. Tyler Smith, which seems to
be corroborated by more recent observations, in a very large
proportion of cases it depends on pregnancy having occurred
in a uterus already retroverted or retroflexed.
As we have here had occasion to refer to the use of the
catheter, before proceeding, we will give the necessary direc-
tions for the successful use of that instrument. And first as
to the choice of the most suitable one. There are the metallic
catheter, the flexible gum elastic, and what is called the
British, which is a tube of textile fabric covered with varnish.
The latter is the best for all ordinary purposes. Indeed in
cases of uterine displacement the urethra is sometimes so
elongated by the bladder being pushed up, that the interior of
that viscus cannot be reached by the ordinary metallic instru-
ment.
The patient is to be placed upon her back near the edge of
the bed. With the forefinger of the left hand well oiled, the
operator parts the labia and ascertains the centre of the pubic
bone or pubic arch. Carrying up the finger a little further,
just within the bone, a slight elevation will be felt. This
DISORDERS OF PREGINANCY. 21
marks the meatus urinarius or entrance to the urethra, or pas-
Sage to the bladder. Retaining his finger in this position, he
now directs the point of the catheter, also well oiled, along its
palmar surface until it impinges upon the meatus. The instru-
ment being held at an angle of about forty-five degrees to the
horizon and gently carried forward in that direction, drops, as
it were, into the bladder. No violence should ever be used,
for, if properly directed, the instrument passes so readily as
scarcely to be felt. When the quantity of urine contained in
the bladder has nearly passed off, gentle pressure with the
hand over that organ will contribute to its more complete
evacuation. In desperate cases, where the catheter cannot be
passed, and where the evacuation of the urine is absolutely
necessary, it may be drawn off by puncturing the bladder one
or two inches above the pubis with the fine needle of an
aspirator.
SLEEPLESSNESS.—The pregnant woman is sometimes annoyed
with sleeplessness, which proves a source of great discomfort,
as well as a cause of impairment of health. She, in conse-
quence, becomes nervous and miserable. Where there is no
symptom co-existing with this wakefulness, requiring another
medicine, a dose of Coffea, on retiring, will often afford relief.
A case that once fell under my observation, and in which
Coffea was of little service, seemed to yield completely to Nux
vom. This case was that of a young lady far advanced in
gestation with her second child. In the case of nervous women
the Bromides may be of service; think also of Cypripedium
and other calmative remedies.
HAEMORRIMAGE, in some of its forms, not unfrequently demands
our interference. Although in the vast majority of cases the
catamenia ceases immediately after conception, this, as we have
already said, is not uniformly so. Sometimes there is a dis-
charge of blood at the regular epochs, or nearly So, for two,
three or more periods. This, if slight or very moderate, and
not accompanied by bearing-down pain, need generally create
no uneasiness, especially so, if it be known to be the habit of
the patient. But if very copious and attended by labor-like
pains, there is every reason to apprehend approaching abortion.
22 PRACTICAL MIDWIFERY.
Prompt treatment in such cases is imperatively demanded, and
unless the ovum is partially extruded or the os uteri so far
dilated as to admit the point of the finger, it may be suc-
cessful.
Should we find the patient flooding and at the same time
suffering from violent bearing-down pains, as if all within
must be forced out, Bell. is the remedy, and, if timely
administered, will no doubt often arrest the haemorrhage and
prevent abortion.
We remember a case in point which occurred some years
ago, where we found the symptoms indicating the above named
remedy strongly marked and where miscarriage appeared to
be imminent. Bell. was administered without, so far as we
can remember, any other medicine or even the employment of
any adjuvant. The result was most satisfactory, not only the
pains and haemorrhage ceasing, but gestation proceeded satis-
factorily to full term, and terminated in a fortunate labor and
the birth of a well developed female child.
When there is excessive flooding, Viburn. opul. and Viburn.
prun. are excellent remedies, and, if given in time, will often
prevent abortion.
When the haemorrhage occurs at the regular catamenial
epoch, in the form of menorrhagia, Apoc. can. will no doubt
often be found effective. Again, where a patient has once
experienced slight haemorrhages at monthly intervals, increas-
ing in severity until they have resulted in abortion, it is well,
upon the appearance of what may be the beginning of a similar
series, to give Sabina until the haemorrhage has ceased, and to
anticipate its recurrence by the administration of the same
medicine at the next and subsequent periods, until the usual
time of abortion be past. I remember a case in which, I sup-
posed, I averted this accident by the management just indi-
cated.
Sabina and Ergot are, strangely enough, mentioned by Dr.
Meadows as preventives of abortion. After speaking of Asaf.
as a uterine tonic, he remarks: “There are other drugs also
which undoubtedly possess this property in a very high degree
—Ergot, for instance, and Savin. With the latter I have
DISORDERS OF PREGINANCY. 23
had no experience, but with the former I have seen decidedly
good results. The dose should be small, as, of course, we do
not wish to produce any uterine contraction.” This goes, very
strikingly, to show how near a man’s mind may sometimes
come to the grasping of a great truth and, after all, wholly
miss it.
These remedies he supposes to act as uterine tonics, an expla-
nation utterly vague and unsatisfactory. He seems to have
made no inference from the fact that Sabina is often used to
produce abortion, the very accident he would employ it, in
small doses, to prevent and that Ergot in large doses, by the
violent contractions it produces, rapidly expels the contents of
the gravid uterus. The singular phenomenon in these agents
of blowing both hot and cold, is to be explained upon the
assumption that in large doses they are stimulant, in small
doses, tonic. The great principle foreshadowed by their appar-
ently contradictory action is wholly overlooked.
In the treatment of threatening haemorrhages taking place
in the course of gestation, it is all-important that the patient
should at once assume the recumbent posture and maintain
the utmost quietude, both of body and mind. She should, if
possible, be placed in a cool, well-aired room, and have upon
her person and her bed just sufficient clothing, and no more,
than is necessary to prevent chilliness and discomfort.
We have here spoken of the treatment of haemorrhage during
pregnancy and that necessary to prevent abortion. Abortion
itself and the resulting haemorrhage will engage our attention
in a future chapter of this work.
PRURITUS, or itching of the external genital parts, is often a
source of extreme annoyance to pregnant women. The inclina-
tion to scratch is often irresistible, and in very sensitive sub-
jects the irritation of the general system from the local affection
is sometimes so great as to threaten convulsions. The causes
of this ailment are not always very apparent, and probably
differ somewhat in different cases. Sometimes it is, perhaps,
attributable to the depraved secretions of the mucous mem-
brane lining the labia and vagina; at others it seems to depend
upon aphthous disease of that tissue. In some cases, finally,
it may arise from want of proper cleanliness.
24 PRACTICAL MIDWIFERY.
In the treatment of this affection absolute rest should be
enjoined upon the patient, as the friction produced by walking
about always tends to aggravate it. The most perfect cleanli-
ness should also be observed. The remedies recommended for
its successful treatment are Conium, Kreasote, Bryon., Arsen.,
Rhus, Pulsat., Silic., Sulphur, Lycop., Graphit. and Sepia—a
goodly number, certainly. We have usually depended upon
external applications for the removal of this trouble. Amongst
these we have most successfully used a solution of the bi-borate
of soda (Borax). This solution we have prepared extempora-
neously, and without regard to any exact degree of strength,
as this seems not essential to success, only let it not be too
strong—say two drams to eight fluid ounces of distilled or rain
water. Let the parts be first thoroughly washed with warm
water and wiped dry. The above solution may then be applied
by means of a cloth. The application should be repeated twice
or oftener in the course of the day. A solution of the bi-sul-
phite of soda has also acted well in our hands. Some have
strongly advised a very weak solution of the bi-chloride of mer-
cury. Of this preparation I believe I can say nothing from
personal experience. S. Tarnier, the annotator of Cazeaux's
Midwifery, says he has succeeded in the more obstinate cases
of the affection with a solution of thirty-one grains of the bi-
chloride to sixteen and a half ounces of distilled water. Hav-
ing first thoroughly cleansed and dried the parts, he advises a
small sponge saturated with the fluid to be rapidly passed over
the entire itching surface. “A smart burning sensation is the
first effect of the application, which is alleviated by a few min-
utes’ washing with cold water. Subsequent applications are
less and less painful, and the cure is generally rapid.”
CRAMPS. — Some women during pregnancy are greatly
troubled with cramps by night in the calves of the legs; an ex-
ceedingly painful affection. According to Croserio, a dose of
Verat. 30, at bed-time, succeeds admirably in relieving them.
In nervous women he advises Nux vom. and Coffea. Cupr.
met. is, according to my experience, the great remedy for
cramps—a dose of the 2d or 3d dec., taken at bed-time, will
usually procure immunity for the night, and persevered in
DISORDERS OF PREGINANCY. 25
for some time, will generally break up the habit of regularly
recurring nocturnal cramps. I have used with success some of
the salts of copper, as the acetate. The arsenite of copper has
also proved efficacious in my hands in arresting the nightly
paroxysms.
CEDEMA, not an unfrequent attendant upon pregnancy, will
be fully treated of in the chapter upon Puerperal convulsions.
HAEMORRHOIDS.–The loaded state of the bowels common to
pregnancy, in conjunction with pressure by the gravid uterus,
often gives rise to very troublesome haemorrhoids. For the re-
lief of these we may resort to Hamm. virg., internally given
and externally applied. Dr. Fordyce Barker strongly recom-
mends Aloes, and as it is strictly homoeopathic to this affection,
we ought not to refuse giving it a trial. I have used it with
excellent results in cases of hemorrhoids following parturition.
Dr. Barker claims to have made the discovery from a fortunate
experience of his own. Having treated a lady for constipation
with aloetic pills, she was rejoiced to find herself cured of piles,
from which the doctor had not known that she had been
suffering.
AEsc. hipp., so valuable a remedy in ordinary hamorrhoids,
will likely also prove serviceable here. In the case of women
liable to this affection, it would be well to forestall its occur-
rence, by giving the remedy regularly toward the close of ges-
tation. The same advice may be given with regard to Collin-
sonin 1st dec., when there is obstinate constipation.
It must be observed, however, that we are not so likely to
succeed in entirely relieving haemorrhoids occurring before labor
as after it, or Under ordinary circumstances. The cause of the
trouble, in the former case, is still present and acting, and we
cannot, for the time being, avail ourselves of the precept “tolle
causam.”
As pregnancy affords no certain immunity from ordinary or
prevailing diseases, women during gestation may suffer from
any of these. In case of an attack, special care should be taken
to procure relief for the patient as soon as possible, lest abortion
or premature delivery should result, which would, in many in-
stances, greatly augment her danger. The treatment of such
26 PRACTICAL MIDWIFERY.
cases differs in no important respects from that of the same
diseases occurring in other subjects. In this we have greatly
the advantage over our allopathic gompetitors, whose violent
remedies are, for the most part, wholly unsuited to the delicate
condition of such patients, and it is to be feared, especially
when unskillfully applied, not unfrequently attended with dis-
astrous results. How common it is for pregnant women so
treated to abort and afterwards die. This is a frequent occur-
rence in the case of continued fevers, acute exanthemata, etc.
The early, prompt and careful treatment of our patients, un-
der the above circumstances, is important not only upon their
own account, but also that of their unborn offspring. There is
danger on the one hand of premature birth, and on the other,
that if the mother be not speedily and wholly restored to
health, her offspring, even if carried to term, may bear the im-
press through life, in an enfeebled constitution, arising from
mal-nutrition during its intra-uterine life.
Dr. Hale, in a small, but very interesting work lately pub-
lished (Treatment of General and Special Disorders and Acci-
dents of Pregnancy), gives the following list of remedies as
specially applicable, viz.: Arnic., AEsc., Aletris, Bromides,
Cauloph., Calc. car., Cimicif., Collin., Digit., Ferrum,
Eupat. purp., Gelsem., Gossyp., Helon., Ignat., Nux wom.,
Pulsat., Secale, Scutel., Trill., Senec., Sep. ristil.., Vibur. and
Ver. vir.
We would advise the student to study thoroughly the patho-
geneses of these drugs, most of which will be found satisfacto-
rily given in Dr. Hale's New Remedies.
Before closing my remarks upon the treatment of the disor-
ders of pregnancy, I may as well speak of a subject in this rela-
tion, as more properly belonging here than elsewhere—a sub-
ject which has not, as yet, shared professional interest and at-
tention at all commensurate with its importance.
Every practitioner of experience will have met with young
women who carry their products of conception until all the or-
gans of the foetus are fully formed, but which, from some cause
or other, blights and dies, and is therefore necessarily extruded
at a premature birth. Sometimes when the foetus is born, it
DISORDERS OF PREGNANCY. 27
has the appearance of recent death—at others, there are unmis-
takable signs of decomposition having set in some time previ-
ously. Some women repeatedly meet with this misfortune un-
til they no longer conceive at all, and become thenceforth
sterile.
Again there are women who carry their offspring to full
term and bring them forth at maturity, but in a feeble, sickly
condition, soon to become a prey to some one of the numerous
diseases of infancy, not unfrequently, perhaps, one of a cerebral
character, such as tubercular meningitis.
It becomes, therefore, a question of importance, whether or
not these unfortunate results may be in whole or in part pre-
vented, by a judicious treatment of the parent during preg-
nancy, and of the foetus itself through the parent. Such an at-
tempt would have a large scope, embracing not only cases such
as we have just now referred to, but all cases of hereditary ten-
dency to disease. This is, therefore, a subject worthy of the
profoundest research, for these, apparently hereditary tenden-
cies, seem at this moment to threaten the extinction of the hu-
Iſla, Il I’8 Cé.
One of the most obvious indications, if we wish to secure the
full and healthy development of the child, is to promote the
highest degree of ‘health in the mother during gestation.
“Like produces like,” is a general truth, well known even to
the skilful breeder of stock, so that a primary object with him
is, to maintain the best possible health and condition in his
dams whilst they carry their young. The first thing, therefore,
is to attend specially to the health of the pregnant woman, not
only by enjoining upon her the strictest hygienic regulations,
but by treating promptly all the disorders of her condition as
just pointed out, and especially any actual diseases, should such
occur. But this is not all. There are probably agents which
have the power, from the first moments of foetal life, to modify
nutrition in the embryo, and so to control it throughout the
growth of the latter, as to result in a fully developed and
healthy child at the normal term of birth. If this view be cor-
rect, the medicine, given to the mother, acts through her or-
ganism, upon the growing foetus within her womb.
28 PRACTICAL MIDWIFERY.
Mrs. N., a young woman of moderate health, subject to dys-
memorrhoea, and some leucorrhoeal flow during a part of the
inter-menstrual period, was some considerable time married
before conception took place. I was called upon to attend her
in labor at what she supposed to be about the termination of
the eighth month. She was delivered of an emaciated child,
below the usual size, and presenting the appearance of having
been dead for some time.
The same lady again became pregnant and fell in labor
about the close of the seventh month. The child presented by
the breech, and was extruded with so much rapidity that the
attendance of no one could be secured till after it was born.
It was alive at birth, very small and lived but a few hours.
I proposed to this lady, should she again become pregnant
to treat her during gestation with the hope of a better result.
It was not long till I had the opportunity, for she notified me
almost at the earliest moment she suspected her condition. I
gave her Calc. carb. and Sil., alternate weeks, one powder
daily—occasionally suspending medicine for one or two weeks.
This treatment was continued till perhaps within two months
of the close of utero-gestation. At full term she gave birth to
a fully developed and beautiful female child, of good size and
apparently having enjoyed good health up to the time of birth.
This child was however unfortunately lost at birth. I had
some four weeks previous detected a breech presentation or
rather what would inevitably be such, unless the foetus should
change position. I warned the patient most urgently to send
for me in time as I resided several miles distant. Unfortu-
nately she neglected this injunction, and when I arrived, after
the greatest exertions on my part, I found the child had been
born for some time and hopelessly dead through delay of the
after-coming head. The best methods were perseveringly used
for resuscitation, but without effect.
In the summer of 1875 I was requested by a lady then stay-
ing at the York Springs Hotel, to see her little girl. She was
a young woman, highly intelligent, the wife of a lawyer, and
niece of one of the most eminent jurists of our State. This
child, her second, was probably about eighteen months old.
DISORDERS OF PREGNANCY. 29
She told me her first born had died at an early age of what
was supposed to be tubercular meningitis, and the present one,
perhaps during most of her life, had shown a similar tendency,
disposed to be fretful, waked up suddenly from sleep in appa-
rent alarm, very nervous and easily excited, and I discovered
some erythematous eruption on different parts, although the
weather was not excessively warm. I treated the child with
considerable improvement during the stay of the family. Be-
fore she left I proposed to the lady that if she would notify me
of the commencement of utero-gestation, if such should again
happen to her, I would endeavor to prevent this unfortunate
tendency in her offspring. Early the following winter the hus-
band wrote to me, and the lady was treated as above. I since
met with her at the Katalysine Springs of Gettysburg when
she told me her child had been born as she supposed at the
commencement of the ninth month, had appeared then, and
continued to be, very healthy. She moreover stated her labor
had been a remarkably easy one.
In the autumn or early winter of 1874 I attended Mrs. W.,
also a young woman in a premature labor, which was at least
the third of that kind she had experienced. I had not seen
her in the previous ones. After tedious suffering a foetus of
small size was extruded considerably advanced in decomposi-
tion. The placenta was firmly held in the os uteri which ob-
stinately resisted all attempts to insinuate the fingers. All the
parts were very imperfectly dilated. I succeeded in removing
only a portion of the after-birth. I left Ergot to be taken
in small repeated doses, and under its influence, after consid-
erable suffering, the remainder was extruded during the suc-
ceeding night. The patient evidently suffered from septi-
caemic poisoning in consequence of having retained a dead
foetus, for some time in a putrid condition. For this I gave
Ars. a., and continued it for many days. Under this treat-
ment she regained much better health than she had enjoyed in
the intervals of her former confinements. She again became
pregnant about the beginning of the present year (1878), and
was treated nearly throughout the whole course of utero-ges-
tation with Calc. and Sil., and other remedies, pro re nata.
30 PRACTICAL MIDWIFERY.
During the autumn she gave birth at full term, to a remark-
ably healthy, vigorous boy, in all respects well developed and
of large size. She made an excellent recovery and the child
thrives.
Perhaps the agency of Calc. and Sil. may be questioned
in this latter case, and the fortunate result rather attributed to
the improved condition of the mother's health. But admitting
this, it is still a case in point. In all probability this patient’s
health had suffered after her former miscarriages, through sep-
ticaemic poisoning, and no proper attention being paid to this,
she conceived again when not in condition to nourish properly
and bring to healthy maturity the product of conception. But
when as above, the blood poison was effectually counteracted
by the persevering use of Ars. and her health restored to its
normal standard, she was then prepared to impart healthy
growth to her offspring. .
From repeated trials however, I am pretty fully convinced
that Calc. and Sil. have a decided effect upon the nutrition
of the foetus in utero. To explain the precise process by which
this is accomplished, would be as difficult as to explain the
phenomena of life and growth generally. Healthy nutrition is
probably uniform in its action, and uniform in its result,
namely a well developed and healthy organism—or in other
words an organism capable of performing its functions in a
harmonious manner. On the contrary any aberration from
normal, healthy nutrition tends to the production of an organ-
ism inharmonious in its action, the result of which is ill health
more or less pronounced, according to the greater or less diver-
gence from the normal standard.
When there is a tendency to malnutrition in the foetus,
whether from defective health or idiosyncrasy of the mother,
or any other cause, if we can introduce into the foetal circula-
tion, through that of the parent, an agent capable of making
an impression upon the vitality of the child, similar to that of
the disturbing cause already in action, we probably for the
time bring to a standstill the mal-nutrient process, and so
divert nutrition from its abnormal course that it may regain
and thenceforward pursue a normal one.
ABORTION AND PREMATURE DELIVERY. 31
If the numerous congenital dyscrasias which now seem to
threaten the extinction of the human race, at least human
health and well being, be ever annihilated or even diminished,
we think it will be through some such process as the judicious
treatment of the pregnant woman and the foetus within her
womb even from its embryo state.
We are far from thinking Calc. and Sil., the only agents
available for this purpose. Doubtless there are others that
stand ready to play their parts as soon as their powers are
known, and only await our more perfect knowledge to be sent
upon their errands of good will to our race. A wide field of
exploration is here open, and laurels grow upon every side to
wreathe the brow of the successful explorer. What we want
is patient and profound research, accurate observation, and
logical deduction from the facts ascertained, irrespective of
any preconceived whim or cherished theory.
CHAPTER III.
ABORTION AND PREMATURE DELIVERY.
In the preceding chapter we have spoken of the treatment
of haemorrhage during gestation, when likely to lead to abor-
tion, and also of that of uterine contractions, tending to the
same result. It is here our design to indicate the best means
of managing the case where that accident cannot be prevented
or has actually occurred. There are instances wherein no
remedial or preventive measures will avert the catastrophe,
and there are others again where this might have been effected,
but, from the absence of medical aid—we are summoned to the
patient after abortion has taken place.
In the term abortion we will include all those cases wherein
the contents of the gravid uterus are expelled before the
32 PRACTICAL MIDWIFERY.
viability of the foetus. The foetus is usually incapable of
maintaining an independent existence before the end of the
sixth or beginning of the seventh month of utero-gestation.
The exceptions to this rule are so rare as not to affect its
general correctness. Indeed few survive, born long before the
completion of the seventh month.
The causes producing abortion may be arranged in two
classes, viz.:
1. Those which act directly upon the womb and induce the
expulsion of its contents.
2. Those which occasion the death of the foetus, and thus
lead to its extrusion as a foreign body.
In regard to susceptibility to the influence of the former,
there is a vast difference in women. Those of extreme irrita-
bility of the nervous system, are by far the most liable to the
accident from this class of causes. Among these we may
reckon diseases affecting the womb, such as tumors within its
cavity or its walls, ulceration of the cervix, rigidity of its
fibres resisting the distension necessary to the accommodation
of the growing foetus contained within it. Strong and sudden
mental emotions, irritation of nerves, although not in imme-
diate proximity to the uterus, as that of the trifacial, by the
extraction of a tooth, those of the lower bowel, by the exist-
ence of ascarides, by accumulated faeces, violent purgation, or
dysentery, may all give rise to abortion, by exciting contrac-
tions of the womb. The same, perhaps, may be said of con-
gestion of that organ, through excessive Sexual excitement.
In short, whatever by reflex action powerfully excites the
uterus, as injuries to organs or parts in sympathy with it,
whether accidental or operative, may give rise to abortion. It
may be remarked that impending abortion, through this class
of causes, is often amenable to treatment, if our aid be invoked
in due time; at least we should not despair of success, but per-
severe in our efforts until dilatation of the os, or the partial
extrusion of the ovum, demonstrates that longer continuance
is useless.
The causes of the second class, which, directly or indirectly,
destroy the life of the foetus, are also very numerous. Among
ABORTION AND PREMATURE DELIVERY. 33
them may be reckoned falls, detaching more or less extensively
the placenta, blows upon the abdomen, haemorrhage from what-
ever cause, acute, and especially eruptive diseases of the mother,
idiopathic morbid conditions of the foetus itself, either in acute
or chronic form, arising, it may be, from taint inherited from
one or both parents. When the life of the foetus is destroyed,
its early extrusion from the uterine cavity is mostly inevitable;
indeed, a consummation rather to be desired, than prevented.
So long as foetal life is intact, the functions of the healthy
womb are in perfect consonance with the development of the
ovum contained within it. But the moment that the life of
the foetus ceases, the ovum becomes a foreign body, and as
such produces an abnormal irritation in the nerves supplying
the organ, which before felt only a healthy stimulation from
its presence.
The extrusion of the foetus usually takes place within a few
days after its death. But this is not always the case. It may
be retained until near or fully up to the usual term of gesta-
tion. In the case of twins, we have sometimes found that one
had ceased to live, apparently at an early period of its intra-
uterine life, while the other had continued to develop, and
was born alive, at or near the usual time. Such was the case
of an unmarried girl I once attended in labor, who had con-
cealed her condition up to the last moment, and even denied it
when agonizing under the throes of child-birth. When she
first permitted me to examine her, I found a small foetus block-
ing up the passage. This I removed, and from its very dimi-
nutive size and other indications, I believed it had died a con-
siderable time before. Another head presented, which proved
to be that of a child which had attained nearly to the ordinary
intra-uterine growth, and which was born alive, but died in
convulsions within a few hours. If I might believe the young
woman, who had always heretofore borne a good character,
her pregnancy was the result of a single coitus, and she had
carried these twins to the close of the eighth month. I re-
member another case of premature labor, where the skin of
the foetus broke and peeled, simply by passing the mother's
parts, and thus gave evidence of somewhat advanced decom-
3
34 PRACTICAL MIDWIFERY.
position. There are cases on record where the product of con-
ception has come away by shreds in a very putrid state. It is
therefore desirable that the contents of the womb should be
evacuated shortly after foetal life becomes extinct. By the
retention of the ovum there is always risk to the mother's
health, and, perhaps, even life, through septicæmia; although,
through the wise provisions of a kind Providence, this cer-
tainly happens less frequently than one would apprehend, and
this, probably, because there is no surface in condition freely
to absorb the poison.
Abortion occurs by far the most frequently within the first
three months of pregnancy. It is therefore impossible to
determine with certainty, whether the ovum still retains its
vitality or not. If, however, we are called in time, it is our
duty, leaving this out of view, to use all means in our power
to prevent so serious an accident. If we confine ourselves
to the employment of strict homoeopathic measures, and even
the use of adjuvants not inconsistent therewith, we shall do
no harm. If extrusion be necessary, nature will very generally,
in despite of our efforts, complete her process for the safety of
the patient, and leave to us the humbler task of attending to
the after-treatment, which, by the way, is all-important. As
we have already said, it is of this we principally designed to
speak in the present chapter.
In order to instruct the student in the nature of the duties
which will usually devolve upon him in such cases, I will de-
tail the treatment of one, which may be regarded as typical:
I was summoned early in the morning to see a young woman,
wife of a laborer, who lived some miles distant. The messen-
ger, either through stupidity or want of proper information,
led me to believe that the patient had had a miscarriage some
two or three days before, and was now suffering from some
drawback in her convalescence. It was not till on my way
that I learned that she was flooding alarmingly and was almost
lifeless. When I reached the place I found her pale as a corpse
surface cold, pulse scarcely, if at all, to be felt, almost speech-
less, haemorrhage still going on. Learning a few of the particu-
lars, it appeared that on the previous afternoon she had been
ABORTION AND PREMATURE DELIVERY. 35
walking across a field near to her house, when she had inad-
vertently stepped into a gulley, which had given her a very se-
were shock, attended with considerable alarm. The effect had,
however, apparently passed off, and she had retired to bed in
the evening as usual. In the night she awoke with severe
bearing down pains, accompanied by profuse haemorrhage,
which increased in violence and continued up till the time I
saw her. What should I then do? Should I sit down by the
bedside, and quietly interrogate the patient as to her subjective
symptoms, so as to ascertain the indicated remedy? But she
was unable to answer my questions satisfactorily, if at all.
The objective symptoms were such as I have detailed, and
would scarcely lead me at first trial to select a medičine upon
which I might confidently rely at such a critical moment. In-
stead of this, however, I called forthwith for a bowl of warm
water, a clean towel, a piece of soap, and a little lard without
salt. I hastily but thoroughly washed my hands, cleansing
them from all impurities they might have contracted, smeared
the left one with the lard, thereby softening the surface and
lubricating it, the more easily to pass through a narrow chan-
nel. I had the woman turned upon her left side, and properly
supported by other women who were present. If too weak to
be turned she might retain her position upon the back—I pre-
fer the left side. I then cautiously and tenderly introduced
the index and middle fingers into the vagina, and carried up
their points to the mouth of the womb. This, with all my
care, caused a good deal of pain, for the walls of the vagina are
not so dilatable in a case of abortion as in labor at full term.
I, however, insinuated the fingers slowly, and the vagina grad-
ually yielded to the distending force. When the points of the
fingers reached the os uteri, I felt the ovum projecting—partly
extruded, but still firmly embraced and held by the os. It was
not sufficiently extruded, however, to allow me to take hold of
it with the points of the two fingers brought together as the
blades of a forceps. I, therefore, at first acted upon it very
much as we do upon an apple, in order to turn it out of a nar-
row pocket in which it is tightly embraced. After a few mo-
ments operating in this manner, I was able to obtain sufficient
36 PRACTICAL MIDWIFERY.
purchase upon the ovum to seize it between the points of the
fingers, as with a forceps, and to extract it entire, placenta and
all. The efforts of the left hand are greatly aided in such cases,
by pressing down the womb with the right, applied externally.
The haemorrhage immediately ceased, and then I selected a
remedy suited to the condition of the patient, and enjoined
perfect quietude, the room to be kept well aired, and all sources
of excitement and disturbance to be removed. Next day I
called, found the patient had fully rallied, pulse sufficiently
full and strong, and of very moderate quickness, and every
thing promising speedy recovery. Enjoined recumbent posture
as long as after confinement at term. The patient did well
and rapidly regained her strength.
It is not to be understood that any particular merit is
claimed for this management, or that there is, indeed, anything
peculiarly novel or original belonging to it. We have selected
the case simply to illustrate, in a more forcible manner than
could be done by direct didactic precept, the duties, which the
young practitioner is ordinarily required, in such emergencies,
to perform.
There is sometimes considerable difficulty in getting suffi-
cient hold upon the ovum or placental mass, when, as described
above, it is partially extruded and still embraced by the os
uteri. The fingers used for that purpose can only act by ap-
proaching each other sidewise, and in that direction cannot ex-
ert much muscular force. The points, moreover, by which
alone we can take hold, do not perfectly antagonize each other,
as the middle finger is somewhat longer than the index. I
have, however, I believe, generally succeeded with the fingers
alone, as indicated above. There are, nevertheless, different
forms of forceps constructed to aid in this operation, which,
properly used, may, in some instances at least, answer a valu-
able purpose. Were I to use an instrument, I would prefer one
constructed in a manner similar to the larger ones employed
for removing nasal polypi, the mandibles being somewhat
broader, and a slight curve given to the blades, to accommodate
it the better to the curve of the pelvis. To employ it, we in-
troduce the fingers as if we intended to use these alone, pass
ABORTION AND PREMATURE DELIVERY. 37
them up till they impinge upon the mass to be removed. We
then glide the point of the forceps along the palmar surface of
the fingers till it reaches the same point. The blades are then
opened and, directed by the fingers, are made to take hold of
the partially extruded ovum or placenta as the case may be.
The instrument is then carefully withdrawn, bringing in its
grasp the object seized. Special care must be taken that the
instruments do not fasten upon the maternal parts, and to
avoid this it is well to appeal to the feelings of the patient
when compression is first made.
The hand, however, so far as it can be used, is always the
best obstetric instrument; for the obvious reason, that as
obstetric operations are usually performed without the aid of
the sense of sight, the hand furnishes, in its stead, the sense of
touch. The hand, moreover, if perseveringly educated, is
capable of much more extensive application than is generally
supposed.
I have since attended the same woman whose case I have
above detailed, in a second abortion, but at a somewhat more
advanced stage of utero-gestation. The foetus had been ex-
truded before my arrival, but the placenta was retained and
the os uteri contracted. I could not by any effort reach the
after-birth, which, I suspected, was not yet detached. I left
the patient tincture of Ergot, to be taken in small, repeated
doses, so as to keep up uterine action for several hours. I
visited her again in the evening, when I found the os uteri
somewhat dilated and the after-birth slightly protruding, but
not sufficiently so, to be taken hold of, as in the case before
related. I administered chloroform to the patient, introduced,
very gradually, the whole hand into the vagina, carried the
fingers up sufficiently far to take hold of the placenta, and
withdrew it completely with the adherent membranes. Dr.
Playfair, I observe, in his late work, also recommends this
method. s
When the ovum and its appendages have been removed, if
the haemorrhage does not cease, we should then carefully select
a remedy in accordance with the symptoms. If, however, this
should not soon succeed, and the flow be so profuse as to
38 PRACTICAL MIDWIFERY.
endanger life, or, at the least, cause great loss of blood, with
extreme prostration and other attendant evils, we had better
at once resort to the tampon. This expedient, although not
to be thought of, in cases of post partum haemorrhage follow-
ing delivery at term, is altogether allowable, and likely to
prove efficient in arresting the alarming discharge which some-
times follows abortion. A clean silk handkerchief is pushed
up into the vagina, little by little, until that canal is com-
pletely filled—the first portion introduced to be carried up
into contact with the os uteri. Dr. Playfair recommends
instead of the handkerchief pledgets of cotton-wool soaked in
water and covered with glycerine to prevent offensive smell.
Each of the pledgets should have a string attached to facilitate
withdrawal, and the whole should be removed in six hours.
In such cases it will be well to administer some septicaemic
remedy, such as Ars., Arn., or Bap. t.
When abortion takes place at a quite early period of gesta-
tion, the entire ovum with all its appendages is generally ex-
truded. But at a later period the foetus alone is usually ex-
pelled, leaving behind, at least for a time, the placenta and
membranes. When these latter do not follow spontaneously,
or cannot be removed by measures such as we have detailed, it
is sometimes difficult or even impossible to extract them,
owing to the slight dilatation of the os uteri, which may even
obstinately close and thus imprison the secundines. It has
therefore been a question upon which opinions have differed,
how far our efforts at extraction should proceed. From the
impossibility of introducing the hand, and the difficulty of in-
sinuating even the fingers, into the womb, if we would suc-
ceed in the removal of the placenta we must resort to the use
of instruments. We have then to encounter, on the one
hand, the risk of using an instrument pretty much at random,
undirected either by the sense of sight or touch, and on the
other that of haemorrhage from retained placenta, and this
is often very profuse—even alarming. Ultimately there is
danger of the decomposing mass, if still retained, giving rise
to serious, if not fatal septicæmia.
If the haemorrhage be not very violent and unyielding to
ABORTION AND PREMATURE DELIVERY. 39
well selected remedies, including mechanical appliances, we de-
cidedly prefer taking the latter risks. I have seen the pla-
centa, when the haemorrhage had been controlled by remedies,
after being retained for some days, extruded, at least so far as
to be within reach, in a very putrid condition, and no ill effects
followed. Indeed we believe this will often happen, and by
watching our opportunity we can ultimately succeed in re-
moving the mass. On the other hand when the haemorrhage
is violent at the beginning, and after being apparently arrested,
sets in again and again, so that the patient’s life is manifestly
jeopardized, it is then our duty to act more perseveringly in
our efforts to remove the placenta. In such cases we may de-
rive much aid from the use of Barnes' dilators, to open the
passage and give us more perfect access to the interior of the
womb. The method of using this instrument will be given
further on. Ergot. in small doses, perseveringly continued,
will often succeed in expelling or bringing the secundines
within reach in a few hours. I strongly advise its use. Ergot.
may be given in alternation with Act. rac. In our efforts to
control such haemorrhages the various medicines usually em-
ployed should be consulted—Trill. pen. has often been found
efficacious—Sabina also when indicated will prove an excellent
remedy. For the slow, continuous and wasting haemorrhage
which often follows abortion I have found Nux mosch. 1st dec.
prove effectual.
It not unfrequently happens, after abortions attended by pro-
fuse haemorrhages, that the patient remains for some time in a
very feeble condition, the return to health being slow and
often interrupted. This sometimes is the mere effect of loss of
blood; at others there may be a chronic inflammation of the
womb existing, more or less extensive and severe, as commonly
indicated by the symptoms. In the former case Cinchon. will
be of service, together with proper hygienic regulations, in-
cluding gentle exercise in the open air, the cherishing of a
cheerful and hopeful state of mind, and perfect regularity in
domestic habits. The diet should be nourishing, and such as
is best suited to replenish the system with an abundant supply
of rich and pure blood. For this purpose good milk, where it
40 PRACTICAL MIDWIFERY.
agrees with the stomach, will do well. Meat broths, beef,
chicken, turkey, unless the stomach be too weak for the diges-
tion of the latter or the season too warm, may also be allowed
with the prospect of benefit.
When the symptoms indicate the existence of inflammation,
this of course should be treated according to indications.
Where debility depends, as it mostly does, upon positive dis-
ease, nothing can be more absurd than to attempt, as many do,
to brace up the system with the so-called tonics, which may
have no curative relation whatever to the case. In the condi-
tion of things which we have here in view, sometimes depend-
ent upon a slight degree of septicaemia, we have found Ars. a.
very serviceable. Nux vom. is recommended by Hartmann,
and Bell. where there is bearing down pain.
When the contents of the gravid uterus are expelled after
the close of the sixth month and before the period of normal
labor, the accident is usually termed premature delivery. The
distinction laid down between this and abortion on the one
hand or labor at full term on the other is not of much practical
importance. There is nothing peculiar in the treatment to
distinguish it from that of abortion when the foetus is dead, or
from that of normal labor when it is living, unless we may
except the management of the after-birth. In the case of
abortion at an early stage the adhesion of the placenta to the
surface of the womb is very slight, and hence the ovum with
its appendages is expelled at once; whereas at a later period
the adhesion is more firm, and consequently the placenta is
not only often left behind, but even difficult of detachment.
But as gestation approaches its natural limit, the connection
between the placenta and womb becomes less firm and thus,
although it may not be extruded by the contractions of the
womb which expel the foetus, it is generally not difficult of de-
tachment and extraction, as dilatation of the parts is greater,
and being larger than in cases of abortion, it is more important
to effect its removal.
When a child is prematurely born and living, we should
resort to all suitable means to preserve its life. The manage-
ment most suitable to secure this end will be given in the
chapter upon Induction of Premature Labor.
I, ABOR. 41
The management of the mother differs in no respect from
that we have indicated in cases of abortion, or that we shall
hereafter recommend as proper after normal labor.
CHAPTER IV.
LABOR.
When the patient escapes the accident of which we have
fully spoken in the preceding chapter, as happens in the very
large majority of cases, the foetus continues to develop within
the womb until it has attained to that degree of maturity
which fits it for extra-uterine life. A vital process now sets
in, by which the contents of the gravid uterus are expelled,—
a process attended usually with much suffering, and even
voluntary effort, and, therefore, called labor.
The time at which labor takes place, is commonly at or near
the tenth catamenial period, reckoning from the one last
before conception. And as the catamenia usually ceases im-
mediately when gestation commences, we commonly reckon
upon the tenth epoch after the last appearance of the flow.
The above is the general rule—to it, however, there are fre-
quent exceptions, more or less divergent. Mauriceau states
that out of four hundred and five cases at the Hôtel Dieu the
term of pregnancy varied from six months to eleven months
and eight days. These, however, are extremes very far from
common. The normal term of utero-gestation may be set
down at two hundred and seventy-five days. Dr. James Reid
recorded forty-three cases in each of which there was but a
single coitus, and found that the average time of delivery was
as above, two hundred and seventy-five days. Dr. Mont-
gomery, from similar observation, places the average at two
hundred and seventy-four days, and Dr. Matthews Duncan at
42 PRACTICAL MIDWIFERY.
two hundred and seventy-five days, or thirty-nine weeks and
one or two days. Conception may be assumed to take place
in the vast majority of instances within a few days of the dis-
appearance of the menstrual flow. This is stated upon good
authority, at from seven to ten. Puchet, an eminent French
naturalist, held that there were no exceptions to this rule, and
the late Prof. C. D. Meigs was, at least, strongly inclined to the
same belief. The exceptions to the law are undoubtedly rare,
while, at the same time, they no doubt occasionally occur. It
is possible that the fecundation of the ovum may, in rare
instances, not take place for some days after coitus, as it has
been shown that the spermatozoa may retain vitality for at
least a week after the intromission of the semen.
It is, in most cases at least, very desirable to be able to pre-
dict the time of the expected confinement of a patient whom
we are engaged to attend. Women themselves have usually
fixed upon a time, but they are frequently very wide of the
mark. They mostly calculate from the date when they re-
member to have first noticed the movements of the child.
This, for various reasons, is very fallacious. The first move-
ments may not have arrested their attention; nor is it certain
that these, in every case, occur at or very near the middle of
utero-gestation, as they assume. A foetus of strong and vigor-
ous growth is likely to make itself felt, by some days, earlier
than a feeble one. Besides, other sensations in the mother
may readily be mistaken for the movements of the child; an
instance of which, we think, we once met with, causing an
error in computation of perhaps two months. When we wish
to ascertain, with as much precision as possible, when we shall
be called to attend a patient in labor, we should learn from
her the time of the disappearance of the catamenial flow.
“Labor, according to our experience,” says Dr. Hodge, “gen-
erally occurs two hundred and eighty or two hundred and
eighty-three days after the last appearance of the catamenia.”
Brof. Naegelé advises us to count back three calendar months
from the disappearance of the menstrual flow, and then add
seven days, which will give us the month and day of the
month upon which we may expect labor to set in. Thus, if a
LABOR. 43
woman tells us her last menstrual flow disappeared on the 10th
of January, counting back three months, brings us to the 10th
of October, adding seven days, gives us the 17th of October,
when may expect her confinement to take place.
Much discussion has been indulged in as to the immediate
cause of labor. Why does the uterus contract at a fixed time
and expel its contents? Numerous answers have been given
to this question, claiming to account for the phenomenon of
labor upon strictly physical principles; but all are open to
serious objections, and some absolutely untenable. The most
reasonable solution of the problem is that it has been so
arranged by the Omnipotent Creator, that when the foetus has
reached that degree of development by which it is wholly
fitted to maintain an independent life, it shall be extruded
from the womb of the mother, where it can attain no higher
perfection, and enter upon another stage of existence, in which
its faculties may be more fully developed, and where it may
be fitted for a still higher and immortal state. It is an
original law of woman's constitution, which, it is true, dis-
turbing causes may occasionally affect, that she should give
birth to her offspring at the end of nine months after concep-
tion, as it is that her customary evacuations should take place
at a period of twenty-eight days. This may be said to be
nothing more than a virtual confession of our ignorance of
the intimate nature of the cause of labor; it may be so, but is
perhaps as near an approximation to an explanation of it as
we shall be able to reach.
There are usually well-marked precursory signs which herald
the near approach of labor. The abdominal tumor, which had
risen so high as nearly to approach, or even reach the ensiform
cartilage, sinks lower, the abdomen flattens and spreads toward
the sides. The woman suffers uterine pains, and occasional
contractions of the womb are felt. Respiration, which had
been embarrassed from pressure upon the diaphragm, is now
more free, that pressure being, to some extent at least, relieved.
As the womb has sunk lower into the pelvic cavity, the blad-
der is crowded, and the necessity, to urinate frequently, often
urgent. The external parts become relaxed, and discharges of
44 PRACTICAL MIDWIFERY.
a glairy fluid take place. The woman becomes more and more
helpless and uncomfortable. She is often despondent and tear-
ful, longing for the arrival of the hour when she can say her
troubles are, for the present, past.
After frequent premonitions labor sets in. The patient is
often awaked from her slumbers in the night, with severe pain
in the back or region of the womb, which entirely incapacitates
her from further sleep. These pains are generally paroxysmal,
occurring at first at long, but usually regular, intervals. Some-
times, however, they set in at once with violence and frequency,
leading her to the belief that her child will very shortly be
born, which, occasionally, but very rarely happens. More fre-
quently, even when the pains are close at first, they become
more distant, and the termination of labor is postponed much
longer than was expected. It is not, however, every accession
of pain, as above described, that ushers in labor. Sometimes
these symptoms pass away and real labor does not take place
for two or four weeks. As labor, perhaps, usually sets in at
or near a catamenial period, it not unfrequently happens that
such an onset of pain occurs at the epoch just preceding that
at which labor eventually takes place—that is, about four
weeks previous. It is of some importance to be able to dis-
tinguish these “false alarms,” as they are designated by the
women, from the commencement of genuine labor. In the
latter case, if a vaginal examination be made, the os uteri will
generally be found low, sometimes at least slightly open, the
neck of the womb effaced, and upon the occurrence of each
pain, the OS uteri, if the finger be placed in contact with it,
will be felt to be distinctly affected. This symptom, especially,
is wanting in the case of false pains. Such pains do not neces-
sarily increase in severity, whereas those of genuine labor do;
this increase, however, may be so gradual at first, and even
interrupted, that it is not always available as a diagnostic
symptom.
When the pains are really those of labor, if the hand be
placed upon the abdomen, the womb will be felt to contract,
harden and alter its shape. This circumstance, too, will dis-
tinguish incipient labor from a fit of colic, which some females,
LABOR. 45
wishing to conceal their condition as long as possible, will pre-
tend to have.
The pains of labor are always conjoined with uterine con-
tractions, so that in common language the former term is con-
sidered synonymous with the latter. Why the contractions of
the womb should be attended with pain, is by no means easily
comprehended. This organ may be regarded as a hollow
muscle, and its contractions similar to those of any other
muscle, which take place without any suffering. We raise a
weight with the hand by means of the contraction of the
muscles of the arm. We are conscious of exertion, but not of
suffering. Various explanations of this phenomenon have been
given, but as they are all unsatisfactory we need not repeat
them. We here speak of the pain accompanying the contrac-
tion of the womb—that arising from pressure of any part of
the child upon the soft and tender structures of the mother is
easily accounted for.
At the commencement of labor the os uteri is usually found
soft and yielding, through a preparatory physiological process
which has been going on for some time in anticipation of the
great approaching event. We say great, for rightly considered
in all its aspects it is truly so—nothing less than an immortal
being born into the world. This softening and distensibility
of the OS may, in very many instances at least, be aided by
proper treatment, begun a few days previous to labor. This
will be found more fully treated of in another place. The first
contractions of the uterine fibres, are directed to the dilatation
of the Os, so as to permit the foetus to pass.
When true labor sets in the muscular fibres, of which the
structure of the womb is principally composed, begin to con-
tract at pretty regular intervals, and with increasing energy.
These contractions have indeed been going on for some time
insensibly—some allege during the greater part of utero-gesta-
tion—but now they become painful. The intervals gradually
shorten as their force increases. The fibres of the womb being
distributed in all directions, and all contracting, not even ex-
cepting the circular fibres of the OS, it is manifest that the
action of the latter must be antagonistic to that of the longi-
46 PRACTICAL MIDWIFERY.
tudinal fibres of the body of the womb. The latter however
being the more powerful, those of the os gradually yield, the
result of which is the gradual dilatation of the outlet of the
womb. When dilatation is partially accomplished, the lower
segment of the membranes containing a portion of the amni-
otic fluid, is usually forced down through the opening, forming
what is called the “bag of waters,” and which, by its wedge
power, under the continued action of the womb, seems to com-
plete dilatation.
That the os uteri may be dilated by mechanical force, is
manifest from the effect upon it, of Barnes' dilators and other
like contrivances; that it may dilate without mechanical force,
is proven by the fact that it is sometimes found almost fully
dilated, when no mechanical force has been employed, and
when from the nature of the presentation the presenting part
did not press upon it, and no bag of waters was protruded.
When the general condition of the patient and especially
that of the parts concerned in parturition is normal, no extra-
neous aid is needed in producing dilatation of the mouth of
the womb. It is one step in the process and an indispensable
one, and we have reason to anticipate a priori from analogy,
that an all-wise Creator would make as ample provision for
this as for any other, so that when the moment arrives that
dilatation is needed, as a general thing dilatation will be ac-
complished. Indeed it is often effected by a kind of spon-
taneity, which we are at a loss to explain.
When the os uteri is fully dilated, the character of the pains
is changed. Instead of those of a worrying, grinding nature,
felt in the early stage of labor, they now become forcing and
expulsive. The patient is disposed to bear down, and the
action of the abdominal muscles is invoked to aid in the com-
pletion of the great work. Indeed every muscle of the body
is subsidized to bear its part. The feet are propped against
some solid object, the hands take hold of whatever may be
within their reach, the face is distorted and congested, the
lungs are inflated with air, to serve as a fulcrum or prop, and
respiration is suspended, giving a dark, suffused appearance to
the countenance, the membranes rupture, and the liquor amnii
LA BOR. 47
is discharged frequently with a gush, the head of the child de-
scends, reaches the floor of the pelvis, distends the perineum,
and finally with a throe of inexpressible agony, and often a
terrific shriek is born into the world. This accomplished, the
uterus generally rests for a moment. But the whole task is not
yet completed, and soon it resumes its action. The next pain
usually expels the shoulders, trunk and lower limbs of the
child, and then the labor is complete, only that the after-birth,
consisting of the membranes and placenta yet remain behind.
The placenta, the organ through which the connection between
mother and child has been maintained during the intra-uterine
life of the latter, and which it will be remembered is intimately
attached to the inner surface of the womb, is usually separated
by some of the last contractions, but is not generally thrown
off with the foetus itself. After a few moments repose, the
womb again makes a final effort to get rid of its remaining
contents, and the placenta and its appendages are extruded at
least into the vagina, whence they are readily removed by the
hand of the attendant. Such is the process and such the ter-
mination of the simplest form of labor.
It has been customary with authors to classify labors with a
view to practical advantage. It is doubtful however whether
any such advantage has been hitherto gained by such attempts.
Almost every writer proposes a classification differing some-
what from that of all others, so that confusion rather than
elucidation seems to be the result. The most simple arrange-
ment is that which divides labors into two classes, natural and
preternatural. But even here the definitions given differ so
much, that little practical advantage results; what would be a
natural labor in the hands of one practitioner would become a
preternatural one in the hands of another. If we take for
instance the definition, natural labor is that which may be ter-
minated by the natural powers alone—preternatural that which
requires manual or instrumental aid, it is manifest that such
classification would indicate no real and permanent practical
distinction; for in the judgment of one it would be proper in
a given case to leave it to nature, whereas another would deem
it expedient in the same case to interpose the resources of art.
48 PRACTICAL MIDWIFERY.
It is not always possible to say with certainty whether the
labor may be terminated by the natural powers or not—and if
with the idea of classification in our heads, we rank it with
natural labors we may let it alone when the safety of the
patient requires our aid, and on the other hand should we
classify it with preternatural labors, we may interfere when
nature does not thank us for our intermeddling.
We shall therefore leave those who are desirous of studying
the various classifications of the authors, to consult larger
works, and if they can derive any practical benefit from their
labors in so doing, it will be so much the better. Within the
limited space we have proposed we will give the best instruc-
tions we can furnish by individualizing cases and designating
their management accordingly. And if we can induce the
student to adopt and follow out this method in practice we
will not consider our efforts as expended in vain, nor do we
think that either he or his patients will ever regret his having
adopted that course.
CHAPTER W.
MECHANISM OF LABOR.
As already stated in the preface of this work, we assume that
the student of practical midwifery has already made himself
familiar with the structure of the female pelvis, in his study of
anatomy. It is therefore unnecessary to repeat the descrip-
tion here, which will be found in any anatomical work; pre-
ferring to reserve the space for other purposes. We may also
make the same assumption with regard to the foetal head. It
will be necessary, however, to add something to the usual des-
criptions given of the latter in books on anatomy, in order to
understand more clearly the relation of its diameters to those
MECHANISM OF LABOR. 49
of the pelvis, in the mechanism of labor. They are the objec-
tive parts to be considered in the discussion of this subject.
And here we would premise that the student should not con-
tent himself with studying merely the bony structure of the
pelvis, but should make himself familiar with it in its recent
state, as lined with soft structures. No plates, however well
executed, can give an adequate idea of the pelvis with which
the obstetrician has to deal, as made up, not only of a bony
frame, but, as in the living woman, of flesh and blood. This
study is properly commenced in the dissecting room, but com-
pleted at the bed-side, by careful examinations of the patient
under obstetrical management.
The entrance from above into the true pelvis, or space inclu-
ded in its bony structures, is called the superior strait; the
portion immediately below this is the cavity of the pelvis;
whilst the lower outlet is called the inferior strait. The seve-
ral diameters of these divisions are of the utmost importance,
in treating of the mechanism of labor. These are the antero-
posterior, measured from before backward; the transverse,
measured from side to side, and the two oblique, measured dia-
gonally. We are in the habit of considering the different parts
of the pelvis mentioned, as having each its plane upon which
its diameters are measured:—thus we speak of the plane of the
superior strait, of the cavity and of the inferior strait. The
antero-posterior diameter of the superior strait extends from
the sacro-vertebral angle, or promontory of the sacrum, to the
symphysis pubis—the transverse from one side of the pelvis to
the other, and the two oblique from the sacro-iliac symphysis of
the one side to the linea ilio-pectinea of the opposite. Definite
measurements have been assigned to each of these diameters,
but of course they vary in different subjects. The antero-pos-
terior diameter of the superior strait is reckoned at four inches
—the transverse on the skeleton at five inches; but in the re-
cent state it measures about an inch less, on account of the
space Occupied by the psoas and iliac muscles. The oblique
diameters measure each four inches and a half.
The antero-posterior diameter of the cavity of the pel-
vis extends from the middle of the symphysis pubis to the
4
50 PRACTICAL MIDWIFERY.
y
middle of the sacrum, and measures about five inches, in con-
sequence of the hollow of the sacrum, which is about one inch
deep. The transverse diameter is, at its superior part, about
four and a half inches, diminishing, however, as we descend.
The antero-posterior diameter of the inferior strait extends
from the point of the os coccygis to the inferior part of the
symphysis pubis—the transverse from one tuberosity of the
ischium to the other—the two oblique from the tuberosity of
the ischium on the one side, to the middle of the sacro-sciatic
ligament of the other. All these diameters are reckoned at
about four inches, but the antero-posterior one may be extended
to five inches, by the retrocession or yielding of the os coccygis.
As regards the diameters of the foetal head, it is manifest, as
many may be imagined as there are opposite points upon the
cranium. Those most important, however, in relation to the
mechanism of labor, are the following: the occipito-mental, ex-
tending from the occipital protuberance to the point of the
chin, estimated at 5.25 to 5.50 inches—the occipito-frontal,
from the occiput to the centre of the forehead, 4.50 to 5 inches
—the sub-occipito-bregmatic, from a point in the sub-Occipital
space midway between the protuberance and the margin of the
foramen magnum, to the centre of the anterior fontanelle 3.25
inches—the cervico-bregmatic, from the anterior margin of the
foramen magnum, to the centre of the anterior fontanelle, 3.75
inches—the transverse, or bi-parietal, lying between the parie-
tal protuberances, 3.75 inches—the bi-temporal, between the
ears, 3.50 inches—and the fronto-mental, extending from the
apex of the forehead to the chin, 3.25 inches.
We give the above as the estimates laid down by Dr. Play-
fair. Authors, however, differ very considerably upon this point,
as might be expected from the very nature of the case. Their
measurements have doubtless been made under different cir-
cumstances, and this alone would account for discrepancy of
result. In addition to this, every one knows that infantile
heads differ very much in size and shape, a circumstance which
would cause a proportionate difference in their respective dia-
meters. We are, therefore, not to regard the foregoing esti-
mates as exact, but sufficiently near approximations to the
truth to answer all practical purposes.
MECHANISM OF LABOR. 51
The object of nature, so to speak, in the process of parturi-
tion, is to bring and maintain the long diameters of the head,
or of whatever may be the presenting part, throughout its
whole descent, in coincidence with the long diameters of the
pelvis. This is effected by forces which we are about to con-
sider, and according to a law which we will shortly attempt to
elucidate.
When the membranes have been ruptured, naturally or arti-
ficially, and their contents at least partially discharged, the
head, in normal labor, more or less strongly flexed, with the
chin resting upon or approximating the thorax, enters the up-
per strait or brim of the pelvis in a transverse position, more or
less deviating toward the oblique. Thus the sub-Occipito-breg-
matic, or occipito-frontal diameter of the head, the one or the
other, according as flexion is more or less complete, corresponds
with the transverse or oblique diameter of the superior strait.
There are commonly reckoned four primary positions which
the head is wont to assume upon entering the brim of the pel-
vis. First, the left occipito-anterior; second, the right occipito-
anterior; third, the right occipito-posterior, and fourth, the left
occipito-posterior. These are sometimes abbreviated as follows:
L. O. A., R. O. A., R. O. P., L. O. P.
By far the most frequently, the occiput of the child is turned
to the left side of the mother, and directed obliquely forward
toward the left acetabulum. The forehead then points to the
right sacro-iliac synchondrosis.
When the womb has discharged its fluid contents, its expul-
sive power is concentrated upon the child. Its fibres in all
directions contract with redoubled energy. The upper part of
the foetus, that is, in the vast majority of cases, the breech, re-
ceives its propulsive force which is communicated through the
spinal column, and indeed through all the solid structures in
continuity, to the head or part in advance, which, if not pre-
vented by some obstruction, descends toward the inferior strait
or lower outlet of the pelvis. In the progress of descent, flex-
ion usually becomes more and more complete. But the head
does not generally retain its position as above described, upon
entering the brim of the pelvis, throughout its whole descent.
52 PRACTICAL MIDWIFERY.
It is a well known law in mechanics, that a solid body acted
upon by a propelling force, and free to obey its impulse, moves
in the direction of the force applied, and if it meet with par-
tial resistance, turns in the direction of least resistance. As a
corollary to this law, it may also be stated, that a solid body
whose diameters differ in length, passing through a channel or
aperture whose diameters also differ, under the influence of an
intermitting force, tends to assume such a position that its long-
est diameter shall correspond to the longest diameter of the
channel or aperture, provided it cannot easily pass without such
accommodation. A familiar illustration of this will be found
in drawing a harness line with a large buckle attached to the
end, by means of a jerking movement, through a terret, one of
whose diameters may have been lengthened and another short-
ened by compression. The buckle may at first bring its long
diameter to correspond with the short diameter of the terret
and cannot pass, but continuously acted upon by an intermit-
tent, jerking force, it will finally bring its long diameter in ac-
cord with the long diameter of the terret, and, unless there be
still a disparity, pass through it.
As the head descends, through the propelling force of the
womb, it does not, as we have said, generally maintain its
transverse or oblique position; for the diameters of the pelvis
change their relative lengths—so that on the plane of the
cavity the antero-posterior is longer than the transverse, which
latter diminishes as we descend. Hence the head, in attempt-
ing to descend in the position first assumed, meets with resist-
ance, from the narrowing of the transverse space, and there-
fore, according to the principle just stated, and the illustration
above given, turns in accommodation to the changed diameters
of the pelvis, so as to bring its long diameter into accord with
the long diameter of the part of the pelvis it now occupies.
This law controls the movements of the head throughout its
whole descent, until its exit is effected at the outlet, and the
consequence is that the occiput, rotating from left to right or
from right to left, according to the original position, finally
becomes stationary under, or nearly under the symphysis pubis.
It need hardly be said that the intermittent action of the womb
MECHANISM OF LABOR. 53
is best suited to cause the rotation of the head as above
described ; having an effect upon it similar to that of the jerk-
ing force upon the buckle in the illustration above given.
If the head be much compressed and elongated, or, as it is
commonly called, “wire drawn,” the vertex will be driven
beyond the os pubis, the head still being flexed, and resting
upon that bone by the sub-occipital space. If otherwise the
head, in its passage downward, has still retained nearly its
normal shape, the occiput having turned under the symphysis
pubis, or nearly so, becomes fixed there before it emerges.
This point becoming for the time stationary, and the action of
the womb still continuing, even with increasing vigor, its
force is now reflected upon the forepart of the head, which is
consequently driven down upon the perineum, forcibly distend-
ing its tissues, which yield more readily forward in the region
of the posterior commissure, than backward toward the anus,
where they are thicker and more muscular. The forehead,
therefore, moving in the direction of least resistance, traverses
the more unyielding structures of the perineum toward the
more relaxed, that is toward the outlet. While the occiput
remains stationary, near or underneath the pubic arch, it will
be readily seen that the forehead is the only part capable of
motion, and moving around a point as it necessarily must, viz.,
its articulation with the atlas, its only possible motion is the
movement of extension. The chin departs from the thorax,
the forehead traverses the inner surface of the perineum, and
afterward the face and the chin follow in the direction of least
resistance, until the latter reaches and passes the posterior
commissure. When the chin has fully emerged, it instantly
falls backward toward the anus of the mother, and thus
unlocks the occiput, which latter then passes under the arch of
the pubis, and the whole head is born. The head, when born,
if left free to move, assumes its natural position in relation to
the shoulders, and this movement is commonly called resti-
tution.
It is probable that after the forehead has come to press upon
the perineum, an impulse may be given to the movement of
extension, by the elastic force of the muscles in the posterior
54 PRACTICAL MIDWIFERY.
part of that organ, where they are less relaxed, as it were,
shelling out the head, as we force the seed out of a cherry by
compression. It is moreover probable, that when the forehead
comes to press upon the perineum, the middle portion of that
organ lying on either side of the raphe, distending more freely
than the more remote lateral regions, and, therefore, offering
less resistance, may invite the forehead to turn more directly
backward, and, therefore, by its leverage power, throw the
occiput more directly forward under the pubic arch. This
agency, I apprehend, has more to do in effecting rotation than
is generally supposed, especially in the case of wide pelves or
small heads, when resistance has not sooner compelled that
movement to take place higher up.
The above is the usual process at the close of labor. But
where the head is very small, relatively to the outlet, and the
action of the womb vigorous, it may be born at once without
passing through the successive stages we have detailed. Where
the disproportion in size between the head and pelvis is very
great, it is possible it may even descend and effect its exit
without rotation, for in that case there would be little or no
resistance encountered to its direct descent.
When the head has been wire-drawn in descending through
the cavity of the pelvis, and the vertex protruded beyond the
pubic bone of the mother, the same movement of extension
takes place; but as the face sweeps over the perineum, the
occiput also turns up in front of the os pubis, thereby giving
more room for the completion of extension. This is a beauti-
ful modification of the close of the process of labor, in cases
where the head is so much elongated, that extension would be
very difficult if necessarily executed by the movement of the
forehead, or long arm of the cranial lever alone, and entirely
within the limits of the pelvis.
As the head is born the shoulders are made to enter the
superior straight, their long diameter corresponding with the
transverse or oblique diameter of the brim of the pelvis. They
descend through the cavity in a manner similar to that we
have described, and upon the same principle. Rotation brings
the one under the arch of the pubis and turns the other into
MECHANISM OF LABOR. 55
the hollow of the sacrum, to traverse the inner surface of the
perineum, and, usually, first to pass the outlet by gliding over
the posterior commissure. When the posterior shoulder is
born, the foetus bends sidewise and toward the anus of the
mother, which movement relieves the other shoulder detained
under the arch of the pubis, and which is now immediately
born.
The descent of the shoulders, provided there be no unnatural
obstruction, is much more rapid than that of the head. This
is partly owing to this part of the foetus being more yielding
and more readily accommodating itself to the parturient canal
which it traverses; but principally to the maternal structures
being so thoroughly dilated by the passage of the head that
they offer but little resistance.
When the head presents in the right occipito-anterior posi-
tion—that is when the occiput is turned to the right of the
symphysis pubis, and points toward the right acetabulum of
the mother, it descends in a manner similar to that already
described, only its rotation movement is in the opposite direc-
tion, that is from right to left. This position is, however,
much less frequent than the former.
Left Occipito-posterior positions are sometimes, some say fre-
quently, converted by rotation into the left occipito-anterior,
and, consequently, the occiput turns under the symphysis
pubis. But this failing to occur, the occiput is thrown into
the hollow of the sacrum, and the forehead is turned under
the pubic arch. In this case the labor is usually considerably
retarded, and requires greater expulsive force, in order to be
completed by the natural powers. The occiput here instead of
traversing the shorter route measured by the width of the os
pubis, must pass over the curve of the sacrum and the whole
extent of the inner surface of the perineum, commonly called
the curve of Carus, until it emerges at the posterior commissure;
and, until this takes place, extension cannot be effected, nor
the head be born. The forehead, too, owing to its greater
breadth, is probably arrested further up, after turning under
the arch of the pubis, than the occiput would be. This would,
of course, increase the difficulty. Similar remarks apply to the
right occipito-posterior position.
56 PRACTICAL MIDWIFERY.
In these occipito-posterior positions the rotation forward or
backward is no doubt determined by the attendant circum-
stances, such as the size and peculiar shape of the foetal head,
for these greatly vary, the size and shape of the pelvis of the
mother, for these differ considerably even within the limits of
deformity, and the strength and direction of the uterine force.
These circumstances all tend to modify the resistance met with
by the descending part, and therefore also its movement of de-
scent. In such cases it is better to leave the head to follow its
own course without using at least any violence to divert its
movement. The moving part will follow the direction of least
resistance, and in doing so cannot go very far wrong. If the
powers of the mother are likely to prove inadequate, we have
the forceps and ought to use them.
The same principles apply to other presentations of the
foetus as well as that of the head. The breech, for instance,
enters the superior strait, the long diameter of the presenting
part corresponding with the long diameter of the brim of the
pelvis of the mother. As it descends rotation takes place as
we have already seen, till at the inferior strait one hip of the
child is brought under the arch of the pubis and the other
thrown into the hollow of the sacrum. The pelvis of the
foetus passes the lower strait in a manner similar to that de-
scribed in the passage of the shoulders in cases of presentations
of the head, while the behavior of the shoulders when they
arrive at the outlet is similar to that detailed when they
follow the head, only of course in a reversed order. Even
transverse presentations of the foetus are subject to the same
law. Here, too, the long diameter of the child seeks to accom-
modate itself to the long diameter of the pelvis of the mother,
but even this done, in such unfortunate cases extrusion cannot
take place, unless it be when the foetus is very small or the
pelvis very large, or both these circumstances coincident. In
such cases the child sometimes passes doubled. But this so
rarely happens that it can hardly be hoped for in any given
C3 Se.
In the presentation of the arm and shoulders it occasionally
happens that, through the powerful but intermitting action of
MECHANISM OF LABOR. 57
the womb upon the foetus, whose parts are still to some extent
free to obey its impulses, the shoulder and arm ascend while
the head comes down to occupy their place, and one of the
most unfortunate presentations is converted into the simplest
one, namely that of the head. But this too, rarely takes place,
except through manual interference such as will be described
in another place.
If the head in descending, owing either to its size or pecu-
culiar conformation, or to the smallness or irregular outline of
the pelvic canal, does not find space to evade the obstruction
with which it meets, by moving off in the direction of least re-
sistance, it becomes locked and does not move at all. It can no
longer obey the propelling force, and the process of parturition
ceases. The action of the womb may continue, its energy may
for a time even be increased, but there is no advance, because
the presenting part can no longer obey the law already indica-
ted, and the womb itself at last, wearied out and as it were dis-
couraged, becomes quiescent. In this state of things without
a resort to the resources of art, the life of both mother and
child must inevitably be sacrificed.
In speaking of the propelling force by which the foetus is
made to descend, we have noticed that only which has its
origin in the womb itself. But this, although powerful, is not
the sum of the forces employed. The abdominal muscles in
the last stage of labor, also furnish their part and that no in-
considerable one, a circumstance to which we have already ad-
verted in the preceding chapter wherein we have noticed the
phenomena of labor. Their action has generally been consid-
ered as under the control of the will, and so it is to some
extent, but not wholly so. They are subject to reflex influ-
ence as well as the involuntary muscles. This is seen in the
woman's inability to resist the inclination to bear down, even
when most urgently exhorted to refrain, and also from the
fact that their activity is generally but little impaired when
the patient is in a state of deep anaesthesia.
If we have correctly stated the law controlling the descent
of the presenting part of the foetus, especially of the head, it
will be seen that absolute uniformity in its movement in all
58 PRACTICAL MIDWIFERY.
cases is not to be expected. The great diversity that exists in
the shape and size of the foetal head, as well as in other pre-
senting parts, though in a less degree, will greatly modify the
character of the resistances encountered, and therefore the
movement of descent. The same is true as before intimated,
with regard to the varying shape and size of the maternal
pelvis.
It is not therefore surprising that reputable authors have
differed in their views as to the precise movements of the de-
scending head, and that each, founding his opinion upon his
own observation, should be very positive as to its correctness.
These opinions may indeed considerably vary and yet be
founded upon and consistent with correct observation. The
possible diversity however which follows as a corrollary from
the law which we have just enunciated should teach us, that
while we may be very positive as to an individual case, or
indeed many cases in our own practice, we should not dogmat-
ically insist upon all others being wrong who differ from us.
Before closing this chapter it may not be out of place to
remark that the movements of the presenting part, to accom-
modate its diameter in its descent to those of the pelvis, are
greatly facilitated by the lubrication of the internal surface or
the parturient canal for which nature has so bountifully pro-
vided.
CHAPTER VI.
MANAGEMENT OF LABOR.
Before entering upon the discussion of what properly belongs
under this head, I would premise that I have been in the habit
for many years, when my services were engaged some time pre-
vious to the occurrence of labor, to request the patient to take
MANAGEMENT OF LABOR. 59
thrice daily, for ten days or two weeks previous to the expected
confinement, a dose of the tincture of Act. rac., or if much
troubled with uterine pains, apparently of a rheumatic character,
Cauloph., in alternation with the above. In the latter case two
doses of each may be taken every day. The doses I have pre-
ferred, are five drops of the mother tincture or ten of the first
decimal. If the patient suffer from very severe pain, resem-
bling dysmemorrhoea, perhaps Viburn. opul., or Viburn. prun.,
or Xanth. frax. might give relief. This preliminary treatment
is specially applicable in the cases of primiparae and of those
whose first stage of labor is usually protracted through rigidity
of the os uteri. That this measure shortens this stage, I think
I have no reason to doubt, having frequently tried it with
almost unvarying results. I have detected a difference of one
to several hours in the same woman, according as the medicine
was given or not given, and I could not discover any circum-
stance in these cases to account for this disparity, without
assigning it to the action of the drug.
When we know that the patient usually has rapid labors,
this preliminary treatment should be omitted, as it is not
required, and may be productive of bad consequences. But
even in this class of cases, if the patient usually suffer much
from extremely acute pain in the preliminary stage, the Act.
rac. may do good, by relaxing the soft structures, and thereby
disposing them to yield with less suffering.
Where we have, previous to labor, made out, or even sus-
pected a mal-position of the foetus, we are advised by Mercy
B. Jackson, to give Pulsat.”, with the assurance that it will,
at least in many cases, avail to correct the abnormity. Of the
efficacy of this expedient I am unable, from any experience of
my own, to say anything for or against it. According to
Credé and others, mal-positions are frequently corrected by the
natural powers. Indeed I have often thought that the pains
experienced in the region of the womb some time before labor,
were not unfrequently caused by an effort of that organ for
the proper adjustment of its contents. There is no position of
the foetus so well adapted to the shape of the cavity wherein
it is contained, as that with the head downward and the back
60 PRACTICAL MIDWIFERY.
turned toward the abdominal walls of the mother. Any
deviation from this position, we may suppose, creates more or
less uneasiness, and by reflex action excites the efforts of the
womb to correct it. We would, however, advise the faithful
trial of the Pulsat. treatment, for, strange as the result claimed,
may seem, it can, at least so far as we can see, do no harm.*
It is of the utmost importance, however, if we are apprized of
a mal-position previously, to see the patient as soon as labor
sets in, and, at the proper moment, to make an effort, by the
bimanual method, to correct the unfavorable presentation.
One of the first duties of the accoucheur is to hold himself,
as far as possible, in readiness to obey promptly the calls that
may be made upon him to attend cases of confinement.
Patients very often engage the services of their chosen attend-
ant, some time beforehand, in order that he may “keep at
home” when he is likely to be needed. To be always found
at home is, of course, an impossibility with the busy prac-
titioner. It is, however, generally in his power so to arrange
his business that the least possible time may be spent in find-
ing him, and to have all appliances he is likely to need, so far
within his reach as to put them up for transportation in a few
moments. To be promptly at the bedside of the patient, is
not only gratifying to her, but often of importance in the
further management of the case. In first labors there is gener-
ally considerable lapse of time before the physician is really
needed, but it is better to be several hours too soon than one
too late.
Arrived at the house of the patient, it is not generally neces-
sary he should at once rush into her presence. On the con-
trary, unless urgently requested to enter her apartment imme-
diately, he had better seat himself in another room, until he
becomes cool, if in hot weather, or warm, if in cold, and in
either case until he regains his composure, if that has been
disconcerted. The attendant should never approach the bed-
* Since writing the above I tried the Pulsat. in a case where I thought
I detected the head high up upon the left side, about three weeks before
confinement. When labor set in I found the head so nearly above the
upper strait that I easily brought it there.
MANAGEMENT OF I, ABOR. 61
side of his patient in an excited, flurried manner. He should
manifest all the calmness and composure he would do were he
about to engage in one of the most ordinary transactions of
life. Nothing is more likely to upset the confidence of the
patient or destroy her equanimity and excite her apprehen-
sions, than to see her attendant approach her in a state of per-
turbation and anxiety. She naturally infers that either he is
distrustful of his ability or that he sees something in her case,
unknown to herself, that excites his alarm. On the contrary
he should show by his countenance and demeanor that he feels
himself to be master of the situation.
When he is invited, let him quietly, but in a sufficiently
dignified manner, enter the lying-in room. After some general
conversation with his patient, and when both begin to feel
easy in each other's presence, he may inquire how long she
has been suffering pain, ascertain the particular character and
frequency of the pains, examine her pulse, inquire into her
previous health, if this be not already known—ascertain the
condition of the bowels, whether or not they have been recently
and freely evacuated, etc. If there be any doubt, he may
inquire whether the membranes have ruptured or not; but
this may generally be inferred from the character of the pains
and other apparent circumstances.
If the pains be still distant from each other, mostly in the
back, at least not of the bearing down character, he may leave
the patient to herself, without further interference for the pres-
ent. It will be well, however, to ascertain from the nurse or
some one in the room, what arrangements have been made as
to the bed and the patient’s dress, as these are matters of no
small importance. As to the former, the best plan is probably
to lay a piece of oil-cloth or a gum blanket upon the sheet
next to the mattress, and upon this another sheet, which can
be removed after delivery, if wet or soiled. The oil-cloth will
prevent the discharges from passing into the mattress, and
ensure dryness and comfort. With regard to the person of the
patient, I have preferred to have her skirts drawn up above
her hips and a folded sheet pinned around her, with the open-
ing behind, so as to admit of easy access in making examina-
62 PRACTICAL MIDWIFERY.
tions, etc. This can be also removed at the close of labor and
the skirts drawn down. When the patient is likely to be very
restless, the sheet may be an encumbrance, and therefore
objectionable; but the skirts may be kept dry, in any case, by
being drawn up as above directed.
If the bowels of the patient have been constipated, so that
there is reason to believe the rectum is loaded with indurated
faeces, it would be well, where practicable, to administer an
enema of warm water, so as to procure a free evacuation.
This will very considerably increase the space for the passage
of the child’s head. The patient should also be frequently
reminded to pass her urine, so as to prevent accumulation in
the bladder. To give her an opportunity so to do, I need
hardly say the attendant should, for the time, retire from the
I’OOIſl. &
When the pains begin to increase in severity, and especially
if they assume a bearing down character, the accoucheur should
propose to his patient the propriety of making a vaginal
examination. This, when properly proposed, is very seldom
refused. If, however, any reluctance be expressed by the
patient, which occasionally happens, especially with primipara,
he should explain to her his object and the importance of the
operation, at the same time assuring her that it is not likely
to give her any additional suffering, while it may contribute
much to her safety as well as that of her expected offspring.
When her consent is obtained, the attendant places her upon
the left side near the edge of the bed, with her knees drawn
up, so that her thighs are about at right angles with her body.
He then washes his hands in quite warm water with soap,
smears the index and middle finger of the left hand with lard
containing no salt, or with olive oil, and takes his position
behind the patient to await the approach of a pain. When
he observes her begin again to writhe, he carries his hand
up under the bedclothes until his fingers impinge upon the
perineum, thence carried forward he detects the genital fissure.
One or both fingers (I much prefer one) is gently insinuated
and carried up its whole length following the axis of the vagina.
In so doing it is somewhat curved forward, and in making an
MANAGEMENT OF LABOR. 63
exploration at this height, the palmar surface of the point will
generally impinge upon the os uteri. This will probably be
found somewhat dilated—perhaps to the size of a quarter dol-
lar, perhaps even more or it may be less. The os is sometimes
fully dilated, or nearly so, at the first examination. The
young practitioner should never satisfy himself that he has
made an examination at all, until he is certain that he has
found the os; nor should he withdraw his finger until he has
thoroughly explored that organ and made himself fully
acquainted with its degree of dilatation, and its condition as
to thickness of its edges, suppleness, etc. If the os be situated
so high up that we cannot reach it with the point of the index
finger, if that be of ordinary length, we have great reason to
doubt whether labor has set in. I have, however, met with a
few cases where I could not touch the os at first, but it never-
theless came fully within reach as the labor advanced. When
the foetus lies transversely, the os may not at first be within
reach of the finger, although labor may have set in. Again,
if the os have in no degree dilated, and the neck of the womb
surrounding it, can be felt, that is, is not yet obliterated, we
may be pretty certain labor has not yet begun. The pains are
probably of a rheumatic or neuralgic character, and should be
treated accordingly. Caulophyllin, Ergot, Acetate of Morphia,
Ignatia or Atropine, 3d decimal, one or the other, according
to indications, may serve to relieve them, and permit the
attendant to go home and take his rest.
The presenting or lowest part of the foetus may mostly be
ascertained at a first examination. But if the OS be imper-
fectly dilated and the membranes still entire, we are often
unable to determine the position. This, however, will gener-
ally be made out in the course of the labor by repeated exami-
nations.
As we are now speaking of the management of the simplest
form of normal labor, we assume that the head presents. Of
this we may assure ourselves by its shape and solidity. No
other part offers such unyielding resistance to the touch, and
none is so spherical in its contour. The fontanelles and
sutures, when felt, also assist very materially in the diagnosis.
64 PRACTICAL MIDWIFERY.
When the breech presents and the finger impinges upon the
sacrum of the foetus, it may possibly be at first mistaken for
the head, but it lacks its sphericity and smoothness, and other
parts are at the same time felt incompatible with a cranial
presentation.
When we have satisfied ourselves that the presentation is a
normal one, and that there is no obstacle to the further pro-
gress of the labor, we have only to wait patiently for the
natural powers to complete the process thus favorably initiated;
but, at the same time, we must be intently vigilant, so as to
discover at once the occurrence of any symptom requiring our
interference. Examinations need not be very frequently re-
peated, as they more or less annoy the patient ; and when the
OS uteri is found progressively to dilate, to become softer and
more distensible, while the pains are recurring at regular and
gradually shorter intervals, we may be assured that all is
advancing favorably. When the membranes protrude or grow
tense at the occurrence of each succeeding pain, and the OS is
dilated to a diameter of three inches or nearly, but they still
do not rupture, it is better to discharge the waters by artificial
means. Much unnecessary suffering is often saved by this
expedient. The membranes are sometimes of unusual tough-
ness, and refuse to yield to the normal contractions of the
womb. In such cases this organ becomes, as it were, exasper-
ated and takes on unwonted energy, at the expense of great
suffering and exhaustion of the patient. Besides, the head
does not usually descend until the waters are evacuated. This
measure, too, sometimes becomes necessary when the amniotic
fluid exists in greater quantity than ordinary, and so distends
the womb that it cannot efficiently contract to expel its con-
tents. In such cases its action will usually become much more
energetic when the fluid is evacuated.
To rupture the membranes, various expedients are resorted
to. Some effect the object with the finger nail; but this
requires it to be long, and we should not attempt to handle
these delicate structures unless our nails be pared short and
smooth at the ends. A much better plan is the following. A
porcupine quill, probe or knitting-needle is provided and laid
MANAGEMENT OF LABOR. 65
within reach. At the commencement of a pain the forefinger
of the left hand is introduced and carried up until it impinges
upon the distended sac. We must be sure that it is the sac
we feel. This may be known by its smoothness and elas-
ticity, and by its becoming more tense during each uterine
contraction. Seizing the moment of its greatest tension, the
point of the selected instrument is carried up in close contact
with the palmar surface of the inserted finger until it im-
pinges upon the membrane. It is then gently pressed with a
kind of scraping or dragging movement until it penetrates the
sac, which is felt by the hand which operates, as well as ascer-
tained by the gush of water upon the inserted finger.
If the pelvis be well formed, the uterine contractions ener-
getic, and there be no preventing cause on the part of the
foetus, the head will generally begin to enter the superior
strait and descend into the cavity, soon after the membranes
are ruptured. Indeed, in some cases, but a very few throes,
after this occurrence, are necessary to effect the birth of the
child. This is, however, unfortunately not always the case.
The young practitioner must not, therefore, be discouraged if
the descent be slow.
While the head is descending the attendant should carefully
watch its progress. This cannot be too urgently enjoined, for
in the latter stage of labor the descent is sometimes unexpect-
edly rapid, especially in multiparae, or when the child is small.
He will find, as he makes successive examinations, that its situ-
ation still becomes lower and lower. The bones of the cranium
overlap each other at the sutures, to a greater or less extent,
according to the greater or less degree of tightness with which
the head traverses the parturient canal. Unless there be abun-
dant space it will also become elongated or wiredrawn. This
will sometimes take place to such extent, that at birth it is
thought by the inexperienced bystanders to be a deformity, and
they can hardly conceive how soon, under proper management,
it will entirely disappear.
When the occiput turns under the arch of the pubis, it is
sometimes well to place the point of the index finger of the
right hand upon it, and by firm but gentle pressure force the
º
O
66 PRACTICAL MIDWIFERY.
head somewhat backward, toward the sacrum of the mother,
holding it for a few moments in that position. This manoeuvre,
generally of easy execution, permits the fluid that may still be
ponded up above the head, to escape, and thus enables the womb
to concentrate its force more directly upon the foetus.
When the head begins to distend the perineum, especially if
the pains be very active, it becomes the practitioner to be on
the alert. He should carefully watch the dilatation of that or-
gan, and by carefully inserting his finger, in the absence of a
pain, between it and the cranium, carefully estimate the degree
of its distensibility. If rigid, and the pains be still increasing
in violence, there may be danger of serious rupture. To aid in
preventing so formidable an accident, he should, contrary to
the general advice of bystanders, exhort the woman not to bear
down, so far as possible to bring her will to aid in holding in
check the energies of the womb—an exhortation I admit not
always easily obeyed, and seldom of much avail. But some
women have more control of themselves through a strong will
than others, and the expedient here advised may at least pre-
vent them calling to their aid the powers of the voluntary mus-
cles. In first labors the perineum often distends very slowly,
and to a very great extent before the head is born.
Further instruction will be given for the management of
cases wherein laceration of the perineum is threatened, or has
actually occurred, in a future chapter devoted to that subject.
It would be out of place here, where we are treating of simple,
natural labor.
When the head is born we should ascertain whether the cord
surrounds the neck, and if so, we should immediately remove
it, by drawing it over the occiput. The head should be steadied
with the left hand, while with the right we grasp the womb,
through the abdominal walls, and thus stimulate it to contrac-
tion, so as to expel the other parts of the foetus. As the
shoulders and body pass, we should follow up the receding
womb by firm and equable pressure downward and backward,
thus aiding in the expulsion of the child, and forcing the
organ to close after this is effected. This compression should
be kept up for Some minutes after the birth has taken place.
MANAGEMENT OF LABOR. 67
If, however, a reliable assistant, as a well-trained nurse, be pre-
sent, it is better to instruct her how to perform this latter
duty, and leave the accoucheur the use of both his hands for
other purposes.
If the extrusion of the shoulders and the trunk do not soon
follow that of the head, and especially if the womb, exhausted
by the work already accomplished, seems unable to rally to
complete its task, we should render such manual assistance as
may be necessary to supply the deficiency of the natural powers.
This is done most efficiently by hooking a finger in the axilla
of the shoulder which has turned or which will turn toward
the sacrum, and by gentle extractive force drawing it down-
ward in the axis of that part of the passage in which it is
found, until it passes the posterior commissure, when the other
will soon follow underneath the pubis. If this aid be found
necessary, an assistant should apply external pressure upon
the womb, following it up as the body of the child recedes.
If the head has been much compressed during its passage,
there will be found at birth, a soft tumor upon that part which
had been in advance during the descent. This need give no
concern, as it always entirely disappears in a short time. Per-
haps its disappearance may be hastened by the application of a
little Arnica. These tumors have been called, according to
their supposed contents: caput succedaneum, Sanguineous tumor,
or cephalhaematoma.
When the child is wholly born and has cried, it is fitted for
a separate independent existence. The finger should be imme-
diately swept through its mouth to remove any mucus that
may be between its lips or lodged in the upper part of the
throat. The next duty of the accoucheur is to separate it from
the mother. The instructions formerly given upon this sub-
ject were quite uniform and simple. We were directed to seize
the cord near the umbilicus with the thumb and forefinger of
the left hand, strip it up toward the placental end, so as to
empty it of blood, to a distance of about three fingers’ breadth
from the abdomen of the child. At this point a ligature of
linen braid or other material was tightly applied with the right
hand, and tied with the usual simple knot. About an inch
68 PRACTICAL MIDWIFERY.
further on, toward the placenta, another ligature was in like
manner thrown around the cord, which was then severed with
a pair of scissors midway between them. The child was
wrapped in a warm flannel cloth and turned over to the care
of the nurse.
Of late several modifications of the management just detailed
have been proposed. Some advise that we should not remove
the child from the mother till the cord has entirely ceased to
pulsate. This practice, however, would sometimes entail very
inconvenient delay, as the pulsation will often keep up for a
considerable time. The advantage too, secured by this delay,
may be only imaginary. At least we have seen no evils follow
the almost immediate removal of the child when it is vigorous,
and respiration is fully established. g
We admit, however, that this is a question not to be dis-
posed of in a flippant manner. At a meeting of the Society of
Biology, of Paris, held December 11th, 1875, Dr. Budin com-
municated a paper in which he maintained that the cord should
not be severed till one or two minutes after it has ceased to
pulsate. From repeated observations he had made, he con-
cluded that the blood received by the infant through the pla-
centa during that space, furnishes the extra supply required to
fill the pulmonary circulation just being established. By this
delay, moreover, he contended that the placenta is exhausted,
rendered flaccid, and consequently more easily delivered.
Again, we are told we should not ligate the cord at all—that
the pent-up blood produces infantile colic and jaundice. For
ourselves we have not been much troubled with the colic of
infants, although we have followed the practice of ligating,
with but one exception up to the present time. Our cases of
colic have been generally traceable to the ignorance of the
nurse, in giving the child immediately after birth some of the
panada destined for the mother, or later, to the peculiar quality
of the milk. As to infantile jaundice, it is probably owing to
quite another cause. Unless some very great advantages were
gained by leaving the cord untied, the practice is certainly cen-
surable on account of the risk of haemorrhage. Whatever may
be said to the contrary this risk certainly does exist, unless in
MANAGEMENT OF LABOR. 69
all cases we wait till pulsation entirely ceases before the separa-
tion of the child, and we are by no means certain that even then
it does not threaten us. It is to no purpose to plead the case
of the inferior animals. We have had abundant opportunities
of witnessing the births of these so as to know that the analogy
is not sufficiently close to base any practice upon it. The cord
in the case of animals is separated by laceration. The larger
ones, as the cow, often give birth to their young on foot, and
the cord is separated by the falling weight of the foetus; the
vessels are therefore torn by overstretching, and the lacerated
coats, by their resiliency, contract upon, and close their orifices.
In other cases the cord is severed by the teeth of the dam, and
therefore the vessels are mangled and torn as by an operation
with the ecrasseur.
We have never tried the experiment of omitting the liga-
ture but in a single case. This was an unusually robust male
child, and we thought a little loss of blood would do no harm,
if it should occur. We watched the case however very care-
fully, as the condition of the mother required us to remain
for some time with her. At our first examination we dis-
covered no haemorrhage, but at the second we found blood
oozing through the cloths, and upon the removal of these, a
jet spirted forth like a fountain. We have no reason to doubt
had the cord in this case been left untied the haemorrhage
would have resulted in the great injury, if not the death of
the child. This although but a solitary case, at least proves
that the unligated cord may bleed, and if there be no great
advantage in the practice of non-ligation, it is certainly not
worth while to incur the risk or suffer the anxiety inseparably
connected with it.
It sometimes happens when the child is born it does not im-
mediately cry. This circumstance should always attract our
attention. If the mother have been for some time under the
influence of chloroform, it need create no alarm, for the off-
spring, owing to its intimate connection with the parent in
intra-uterine life, will through the placental circulation be
affected by the anaesthetic in the same manner as herself. In
the case of the child however, as with herself, the effect soon
passes off, and its behavior is as usual.
70 PRACTICAL MIDWIFERY.
Another cause, although a very rare one, may prevent the
child from crying when born. When the membranes have
ruptured some distance above the mouth of the womb, or when
very unusually tough and the opening small immediately over
the presenting part, the evacuated membrane is carried down
covering the head in the manner of a hood. The child is then
said to be born with a caul. This accident of course prevents it
from inhaling the air, and consequently it cannot cry. The
membrane should be immediately torn and drawn off, as neglect
of this will very soon cause the death of the child. The in-
ferior animals, as the mare, very promptly attend to their off-
spring when this accident occurs. The effort to breathe pro-
duces a peculiar sound which attracts the attention of the
dam, and she immediately removes the membrane with her
lips or teeth. This I have seen her do.
|But the child may be, from various causes, born more or
less asphyxiated. The countenance is livid, from stagnation
of blood in the capillaries of the face, and often all signs of life
are absent. This is sometimes owing to long continued pres-
sure of the head in the last stage of labor, and sometimes to
the other parts being too long retained after the head is born,
causing compression of the cord. But from whatever cause, it
demands our prompt attention and whatever methods of resus-
citation may be adopted, we should persevere in them until
we completely accomplish our purpose or until we are con-
vinced beyond a doubt that life is extinct. It should be re-
membered, however, that our efforts if persisted in will some-
times be crowned with ultimate success when for a long while
they seemed utterly unavailing. The first sign of returning
animation is usually a kind of sobbing effort to breathe,
always encouraging. e
As soon as the child has been satisfactorily disposed of, the
mother again demands our attention. The placenta with its
adherent membranes, commonly called the secundines or after-
birth, has probably not yet been extruded. The proper man-
agement of the delivery of the after-birth is one of the most
important duties of the accoucheur. There is no point in the
conduct of labor where a serious error is more likely to be fol-
MANAGEMENT OF LABOR. 71
lowed by disastrous consequences to the patient or discredit to
the attendant.
Where a well instructed assistant has applied the hand over
the uterus and followed up its receding walls as the body of
the child is being expelled, the hand thus applied should re-
tain its position, making gentle pressure till the attendant is
ready to complete the delivery.
The question how long should we wait for the removal of
the after-birth has not been definitely settled, nor can it be.
The time must necessarily vary according to varying circum-
stances. When there is nothing requiring immediate action,
such as present or threatening haemorrhage, it is best to let
the patient enjoy a few minutes rest, so as partially to recover
from her exhaustion. The womb, fatigued from its former
efforts, is not immediately disposed to second our attempts.
By a little delay we give time for the blood to coagulate
within the uterine sinuses, thus affording greater security
against flooding, while that already extravasated within the
uterine cavity is permitted to form clots, and may thereby be
more readily extruded along with the other contents.
Our delay, however, should not be too protracted, otherwise
the parts may contract to such an extent as to greatly increase
the difficulty to the operator and pain to the patient. Fifteen
or twenty minutes is a space ordinarily sufficiently long, often
it may be considerably shorter.
The method of delivering the after-birth has greatly varied
at different times and in the hands of different practitioners,
and as yet there is no one universally agreed upon as the
best. Dr. Churchill, whose work on Midwifery has been very
justly held in high estimation, gives us the following advice:
“When the binder is applied the patient may be allowed to
rest awhile, if there is no flooding, after which, when the uterus
contracts, gentle traction may be made by the funis to ascertain
if the placenta be detached. If so, and especially if it be in
the vagina, it may be removed by continuing the traction
steadily in the axis of the upper outlet at first, at the same
time making pressure upon the uterus.” This is the method
probably still practiced by a majority of accoucheurs, if not in
72 PRACTICAL MIDWIFERY.
the United States, at least in England. It is certainly open
to many objections, and amongst them a very prominent one
is its great liability to abuse. Inexperienced practitioners are
apt to make injurious traction upon the cord when they fail
to succeed by gentle force. Velpeau tells us of the case of a
student who by a misdirected and too violent force had failed
to accomplish his purpose, and had separated the cord from
the placenta. We often meet with similar accidents in cases
which have been attended by ignorant midwives.
The method termed “Expression of the Placenta” seems to
be growing into favor both in this country and upon the con-
tinent of Europe. Although foreshadowed by the Dublin
School of Obstetrics, the credit of bringing it prominently
before the profession is given to Credé and other German
writers. It consists in applying to the delivery of the after-
birth a “vis a tergo” instead of, as fomerly, a “vis a fronte.”
Dr. Playfair, a late British author, who is very enthusiastic
in favor of this method, gives us the following directions for
its successful performance. He advises an interval of fifteen
or twenty minutes before interference, during which the at-
tendant should sit by the bedside with his hand upon the
womb, but not kneading or forcibly compressing it. “When
we judge that sufficient time has elapsed, we may proceed to
effect expulsion. For this purpose the fundus should be
grasped in the hollow of the left hand, the ulnar edge of the
hand being well pressed down behind the fundus, and when the
uterus is felt to harden, strong and firm pressure should be made
downwards and backwards in the axis of the pelvic brim. If
this manoeuvre be properly carried out and sufficiently firm
pressure made, in almost every case the uterus may be made to
expel the placenta into the bed along with any coagula that may
be in its cavity. If we do not succeed at the first effort, which
is rarely the case if extrusion be not attempted too soon after
the birth of the child, we may wait until another contraction
takes place and then reapply the pressure. I repeat, that after
a little practice, the placenta may be entirely expelled in this
way, in nineteen cases out of twenty, without even touching
the cord, and the bugbear of retained placenta will cease to be
a source of dread.”
MANAGEMENT OF LABOR. 73
However successful this method may generally be, we will
Sometimes find patients whose abdominal walls are so exqui-
sitely tender that they would scarcely bear the requisite
amount of pressure without extreme suffering. There are
others again, in whose cases the placenta is, almost immedi-
ately after the birth of the child, extruded from the womb
and lodged almost entirely in the vagina, where the former
organ could no longer exercise force upon it sufficient for its
expulsion.
Upon the whole, I would prefer to regard each case accord-
ing to its own peculiar exigencies, and adopt such method as
experience and common sense would suggest as best suited.
After waiting an interval, such as above indicated—longer or
shorter, according to existing circumstances, I introduce all
the fingers of the left hand, well oiled, into the vagina, in the
gentlest manner possible, and generally without causing much
pain. If the placenta be found lying loose in that canal, I
remove it by compressing it with all the fingers, the points
being applied around its edges, so that it readily follows, or
rather accompanies the hand when withdrawn. If it be still
within the womb, I endeavor to ascertain, by gentle manipula-
tion with the left hand upon the cord, whether it be detached
or not. If detached, I endeavor to stimulate the womb to
contraction by pressure with the right hand, applied exter-
nally. When it is felt to contract, I apply a stronger force
with the right hand downward and backward, and, as the pla-
centa is extruded from the uterus, receive it with the fingers
of the left hand, and withdraw it as before described.
By whatever method the placenta may be delivered, great
care should be taken to prevent the membranes from tearing,
so as to become separated from it, and be left behind in the
womb. The best method to prevent this, is to twist them
into a cord as we remove the after-birth.
When the placenta is found to be as yet undetached, we
should desist from further attempts at removal, give a dose of
Puls., and wait until we think proper to make another effort.
We will mostly find, if not adherent, that it can be removed
with surprising ease upon a second trial.
74 PRACTICAL MIDWIFERY.
It sometimes happens that owing to inertia of the womb,
the after-birth remains undetached from its surface, even where
there is no morbid adhesion, longer than we think advisable to
wait upon its extrusion. Perhaps, in these cases, Ergot might
generally procure its detachment and expulsion; but we do not
advise its use, because it may, if given in any considerable
quantity, produce irregular contractions, and increase the diffi-
culty it was intended to remedy.
Abnormal adhesions of the placenta will be elsewhere treated
of as one of the accidents occasionally accompanying childbirth.
but where we think best not to wait longer upon the powers
of nature, we should gently introduce the hand into the womb,
guided by the cord, and having found the site of the placenta,
ascertain if any portion of the margin be detached. If so, we
insert the fingers between the detached portion and the surface
of the womb, and by a waving, side to side movement of the
fingers held together, peel off the still adherent portion of the
placenta until the whole is detached, and then carefully inclos-
ing it in the hand, bring away the whole mass. Where the
adherance is very slight, it may be broken up by spreading
the finger tips around the borders of the placenta and, as it
were, gathering it toward the centre. When thus detached,
it is already wholly in the hand and ready for extraction.
If no portion of the margin be found detached, we can
separate it at such spot as it may seem least firmly adherent,
or where the manipulation may seem the most easy of execu-
tion.
I would here say and may think proper even to repeat in
other places, that in all operations within the womb, the unem-
ployed hand should be applied externally and firmly support
that organ, or aid, in any practicable manner, the object in
view.
When the after-birth is removed, the cloths that may have
been placed under the patient, to receive the discharges, should
be taken away, with all the blood and, as far as possible, wet
of every kind. Where these cannot be wholly removed,
contact with the patient’s body may be prevented by interpos-
ing dry and warm skirts or such other material as may be at
hand.
MANAGEMENT OF LABOR. 75
It has been usually customary to apply a binder around the
lower part of the body, with the object to support the womb
and the relaxed abdominal muscles. It has been supposed
that this also tends to preserve the symmetry of the woman
and prevent what has been called pendulous belly. Of late,
however, the propriety of this measure has been called in
question, and it has even been charged with causing the very
evils it was intended to prevent. Some physicians have, there-
fore, entirely discarded the binder, preferring, in all cases, to
dispense with its use. This is probably going to an unwar-
rantable extreme. Most women think the support of the
binder contributes greatly to their comfort. When this is the
case, they ought to be indulged in the use of it, unless there
be manifest counter-indications; for, if judiciously applied,
the supposed evil consequences are doubtless imaginary. At
least we have never seen them, and if they have any real
existence, one would suppose they would sometimes appear.
I admit the binder may be applied so as to do more harm than
good; but the evils of the abuse, which may be always
avoided, should not be charged to the proper use. I have,
however, myself often omitted this appliance where I supposed
it unnecessary; and thus far I have had no reason to regret
the omission. Where it seems to be a matter of indifference,
I commonly leave to the patient to take her choice.
Women of strong elastic muscular fibre, will do very well
without any abdominal or uterine support; but those of feeble
constitution and relaxed muscles will, no doubt, feel the better
to have a binder well applied; but we should always be well
assured that the womb is fully and permanently contracted
before its application. If we use this appliance, a simple
towel, well spread and tightly drawn around the body, extend-
ing from the hips upward to near the ensiform cartilage, and
securely fastened with pins, will be the best arrangement, at
least for the first few days after childbirth. The nurse should
be instructed to have a constant care that it retains its place
as at first applied, and it may be, from time to time, slightly
tightened, as the womb and abdominal muscles regain their
normal condition. Where we suspect the occurrence of
76 PRACTICAL MIDWIFERY.
uterine relaxation and probably consequent haemorrhage, it
will be well to place a compress under the binder, over the
region of the womb. &
The patient may mostly be allowed to wear the binder for a
longer or shorter time, pretty much according to her own
inclination; it must be admitted, however, that if too long
worn, there is danger of causing atrophy of the abdominal
muscles. Dr. Goodell recommends its removal after the first
few hours, an advice which I have no doubt it would be well
to follow, except in cases where there are special reasons to
adopt a different course.
When there is not an absolute necessity requiring the
attendant to leave, he should remain with the patient at least
for an hour after the birth of the child. Before his departure
he should ascertain the condition of the pulse, whether the
womb still maintains its contraction, or whether, as sometimes
happens, it has again become relaxed—whether there be any
indications of threatening haemorrhage—and this may be
pretty confidently expected if the pulse be very quick—say up
to 100° or nearly—the patient restless, and the womb relaxed
or imperfectly contracted. The womb should be felt hard and
round like the foetal head, and just above the pubic bone.—
He should enjoin upon the patient the importance of attempt-
ing to evacuate the bladder within two or three hours after
delivery, and this altogether irrespective of her inclination;
for, owing to the relaxed condition of the abdominal tissues,
she may be insensible of her need until great distension has
taken place. In order to pass her urine, if she be very weak,
or if there be any indications of threatening haemorrhage, she
should be raised as little as possible from the horizontal posi-
tion. Some women cannot evacuate the bladder, at least
immediately after delivery, unless they are taken up; and it
has been recommended to seat them upon a chair, to encourage
the expulsion of clots. This expedient may be useful, and
from experience we would earnestly advise it, if the patient
suffer pain, apparently from the presence of clots, and if she
be sufficiently strong. On the other hand, if she be very much
exhausted, or there be reason to apprehend flooding, it will be
MANAGEMENT OF LABOR. 77
better to use the catheter at once. This should be done in all
cases, when several ineffectual attempts to pass water have
been made, and before painful distension has taken place.
Tincture of Ergot has been recommended, as a substitute for
the catheter, in the retention of urine in the case of the lying-
in woman. Twenty drops every half hour, according to Allo-
pathic advice. I have given ten drops with apparently good
results; but, as this is a powerful drug, if no less quantity will
answer, and I am not sure that it will not, we had better, per-
haps, at once resort to the catheter, which we know to be
harmless. Ergot, however, according to some published obser-
vations, is probably homoeopathic to the retention of urine.
The nurse should be admonished to examine the child occa-
sionally, to see that there be no haemorrhage from the cord,
for this sometimes happens, although a ligature may at first
have been well applied. When the cord is unusually thick
and gelatinous, it becomes flaccid and shrinks, the ligature
loosens and haemorrhage may supervene.
The patient usually requires some additional clothing to be
laid over her shortly after the termination of labor. She is
often bathed in perspiration, and when the excitement is over,
and she suffers from the exhaustion and shock, consequent
upon preceding efforts, she is liable to chill. Indeed she will
often experience a tremor of her whole frame, which is not,
properly speaking, a chill, but altogether of a nervous char-
aCter.
But, on the other hand, we must carefully guard against too
much clothing, as this will invite haemorrhage and tends
unduly to excite perspiration. The patient should be kept
simply comfortable, neither too warm, nor too cool. The
accoucheur should scrupulously see to all these things before
leaving the house. Especially should he make arrangements
for the free but safe ventilation of the apartment. Before his
departure he should have an express understanding that he is
immediately to be notified in case any untoward symptoms
manifest themselves.
When the accoucheur has completed his duties in the deliv-
ery of the woman and the proper disposal of the child, he
78 PRACTICAL MIDWIFERY.
should in no instance abandon the case without further atten-
tion. If he have left his patient doing well so far as can be
seen, it may be sufficient to visit her again in twenty-four
hours. If, however, she had manifested before his departure
any suspicious symptoms, he should see her in a much shorter
time. Her safety depends much upon his vigilance, upon his
early detecting any departure from normal convalescence, and
his promptly resorting to suitable remedies. He cannot wholly
depend upon the information which has been promised him, in
case anything seem to be going wrong, for the nurse or
friends may not be able to interpret unfavorable symptoms, or
may think, what they suppose to be a trifling matter, will in
due time correct itself; and too often they themselves under-
take to prescribe.
At his first visit after delivery he should carefully inquire
after the general condition of the patient. Her countenance
upon his first entering the room will give him pretty reliable
information upon this point, if he be capable of reading it. If
she tell him with a smiling face and natural aspect that she is
“doing very well,” he has not much reason to doubt her word
—but not to be deceived, he must see that present symptoms
do not contradict her assertions. He should ascertain the
temperature, frequency and character of the pulse, of the secre-
tions, and their amount, the degree of abdominal tenderness,
whether she have passed water, whether she has had any sleep
—as to the bowels, we do not expect them yet to be moved,
and therefore the normal condition at this period is quies-
cence. In leaving his further directions let the physician em-
phatically instruct the nurse not to give his patient castor oil.
The bowels will often resume their action spontaneously. If
not, after the fourth day a suitable remedy may be given.
What is the best position for a woman in labor is a question
which has called forth much discussion and is still “sub
judice’—undecided. Indeed so strong is national and indivi-
dual predilection in regard to this subject that it seems almost
impossible to discuss it with anything like impartiality. .
In the first place, there is no position which can properly be
indiscriminately adopted in all cases. The peculiar condition
MANAGEMENT OF LABOR. 79
of the woman, in all respects, is to be regarded in our selec-
tion, and even her whims when not incompatible with her
own safety and that of her offspring, or the convenience of her
attendant are not to be wholly overlooked. *
During the early stage of labor, if the patient be strong and
so inclined, it is better for her to remain out of bed, occasion-
ally to stand upon her feet supported by the bed-post or to
step about the room in the intervals of her pains. Women
generally believe that uterine contractions are rendered more
energetic by this course. Some patients however who are fee-
ble, or very helpless from the size and weight of the womb,
prefer to lie down from the beginning. When in bed it is
generally best, until the pains become forcing and the head
has fairly commenced its descent, to allow such change of posi.
tion as may be necessary to avoid weariness. Indeed through-
out the course of labor till near its close, the patient, if she
desires it, may be allowed for a short time to leave her bed.
As by turning from side to side the axis of the womb is
somewhat altered, and therefore the direction of its force not
always in accord with the axis of the parturient canal, it is a
good plan to secure a suitable binder around the body. This
may be a towel or bolster case, or anything else that will
answer the purpose. A little ingenuity would devise a binder
to tighten with straps and buckles that would answer the
purpose admirably. An apparatus of this kind has been pro-
posed, but it is too complicated and too expensive for common
|UIS62.
When we wish to make examinations, if the left hand be
trained as it should be, it is by far the best for the woman to
lie upon the left side. Of this, however, we have spoken
before. The same position I consider for many reasons vastly
preferable to any other in the last throes of labor and delivery
of the child. It allows the easiest possible access to the
patient, and is exactly suited to manipulations with the left
hand. It is, so far as I have observed, more agreeable to the
patient than any other position in bed.
In France the parturient woman is placed upon her back,
and by way of imitation, the same practice seems to be grow-
80 PRACTICAL MIDWIFERY.
ing into favor with some in this country. To say nothing of
its immodesty, I cannot see any advantage it possesses over
that upon the left side, and it is certainly a much more incon-
venient one, unless habit alone may make it otherwise. Ac-
cess to the patient is indirect, as we have to reach over the
thigh and twist or bend the arm to introduce the fingers into
the vagina; unless we assume a position so much face to face
with her, as to be certainly offensive to any modest woman.
The handling of the child, too, in the act of being born I
should consider much more awkward, to say nothing of its
safety.
Some women think they can “help themselves” much better
standing upon the knees. It is probable that uterine action is
more energetic with some in this position than when lying
down. It is much more difficult, however, for the attendant
to render them assistance, and, unless adroitness has been ac-
quired through practice, to take the proper care of the child.
When there are good reasons for indulging the woman in the
knee position, she had better kneel upon the bed, supported by
her husband or a strong nurse or assistant. If this position be
adopted, the bed should be well protected by suitable covering
beneath the patient. When labor is about to terminate she
can be easily laid down upon the left side.
As a temporary change of position I have seen the follow-
ing expedient answer a good purpose. An arm chair with a
very wide bottom is selected. A folded quilt or cushion is
laid upon the seat. The husband seats himself far back upon
the chair, his limbs separated as widely as possible, his wife
sits upon the front edge of the seat supported by his arm
around her chest, whilst her limbs are extended and her feet
are propped against some solid object.
MANAGEMENT OF THE CHILD. 81
CHAPTER VIII.
MANAGEMENT OF THE CHILD.
We have already spoken of the separation of the child from
its connection with the parent, in our chapter upon the man-
agement of labor. We will now briefly notice the further at-
tention it requires, just entered, as it has, upon an independent
state of existence.
The infant should always be folded, as soon as separated from
the parent, in a soft, dry, and warm flannel cloth, well enve-
loped and laid where it will be comfortably warm. This is
particularly necessary in cold weather. It should be remem-
bered that it experiences a great change in the temperature of
the medium with which it is surrounded, when born into the
world. When the child is well developed and healthy, it will
sufficiently maintain its temperature with the care above
directed. But if it be feeble, or born prematurely, artificial
heat, as by the application of warm bottles, is absolutely neces-
sary to its Safety.
The first operation, when all is right, to which the new-born
baby is subjected, is a more or less thorough ablution. This is
apparently a very simple one, but yet requires great care in its
performance. The child when born is usually found covered
all over its body and limbs with a sebaceous substance, which
it is necessary to remove. This is best done by smearing the
surface with lard, and then immediately washing with warm
water and castile soap. A place sufficiently warm should be
chosen for the operation, and the water of such a temperature
as to secure against giving the child a cold. The washing
should be performed as tenderly and as rapidly as possible, and
the whole surface quickly wiped dry, with a warm, soft, flannel
cloth. We then envelope the stump of the cord in a piece of
patent lint, Canton flannel, or unglazed cotton batting, turn it
across the abdomen toward the left side, and apply over it the
bandage or binder. It should be occasionally noticed lest it
6
82 PRACTICAL MIDWIFERY.
bleed. In these days of progress some prefer to leave the cord
dangling, after the manner of the brutes; for which it is claimed
that it dries sooner, is less likely to become offensive, and sepa-
rates more perfectly.
When the cord is disposed of, the clothes are then put on,
and the little stranger made ready for presentation to the joy-
ous mother and no less joyous father.
We have before intimated, in treating of the conduct of
labor, that the child is sometimes born asphyxiated, or in a
state of apparent death. We adverted to the use of means for
its resuscitation, but did not particularly speak of those gene-
rally and most successfully employed. As this would there
have been a digression, we have reserved a description of them
for this place.
It will sometimes be found that the face has a swollen, con-
gested appearance, is of a dark, almost purple hue ; in other
cases the whole surface appears exanguious, the limbs pliant,
and the muscles soft and flabby. These may be regarded as
different stages of the same condition, the latter, however, the
further advanced, and therefore holding out less promise of
success in our efforts at resuscitation. But so long as the heart
pulsates, however feebly, we are encouraged to persevere.
Cases are on record which have been ultimately saved, when
respiratory movements were delayed even for half an hour, or
in some rare cases it is said even an hour. When, however,
the heart has ceased to beat, it is doubtful whether any means
have ever succeeded. The heart is last to die, and when it is
dead all else is dead with it. But even when we are unable
to feel or hear the heart’s action, we still should not despair,
for in the trepidation of our unavoidable anxiety we may be
deceived. By hoping against hope, and making persevering
efforts, if unsuccessful, we shall at least have the consolation
that we have done all that could be done.
When the face of the child is much congested, it is recom-
mended by some to cut the umbilical cord immediately, and
allow the escape of a few spoonfuls of blood. Sometimes, how-
ever, the circulation is so enfeebled, that the cord when cut
does not bleed. In such cases it is recommended to plunge the
MANAGEMENT OF THE CHILD. 83
child into warm water, which usually causes the blood to flow.
I may here remark that when a labor is in progress, especially
near its termination, we should always enjoin upon the family
to have in readiness a good supply of warm water, and the ves-
sels necessary for its use, in any case wherein it is likely to be
needed.
When we have succeeded in relieving the capillaries of their
engorgement, the color of the surface changes to a more
roseate hue and respiration usually sets in, feeble and irregular
at first, but gradually improving in force and regularity. In
all cases, but especially when the child is born in an asphyxi.
ated condition, all mucus should be immediately removed from
the mouth and upper part of the throat, by means of the finger
of the accoucheur. If there be any important mechanical ob-
struction, the child, of course, cannot breathe.
The above method is directed principally to the relief of the
capillary engorgement, which arrests circulation and prevents
respiration.
“The first respiratory act,” says M. Cazeaux, “is the conse-
quence of the excitement of the medulla oblongata, produced
by the impression of the temperature of the surrounding air
upon the skin of the new-born child.” Assuming this theory
to be correct, we may suppose that in cases where respiration
fails to be excited by the cause just referred to, the sensibility
of this portion of the brain controlling respiratory movements
may have been so much obtunded, that it does not appreciate
the reflex action set up by contact of the skin with the sur-
rounding atmosphere. A stronger impression is necessary to
call its dormant power into action. Hence a very efficient
method in many cases of exciting respiratory movements, is to
dip the ends of the fingers into cold water, and sprinkle the
child’s face and body. Everſ in cases marked by considerable
congestion, I have seen this measure followed by success.
Dr. Marshall Hall advises, after vigorous sprinkling of the
face and body of the child with cold water, to immerse it im-
mediately into a warm bath, and then wrap in warm flannels.
This operation may be repeated several times, and its success is
said to depend upon the rapidity with which it is executed.
84 PRACTICAL MIDWIFERY.
Another method of exciting reflex action very worthy of
trial, is to slap the child’s shoulders and buttocks with the
palm of the hand. Perhaps it would be better still to flagellate
the thighs and shoulders, or thorax, with a wet towel, of course
not so heavily nor so vigorously applied as to inflict injury.
Where there is reason to suspect considerable accumulation of
mucus in the air passages, Dr. Dewees advises to place the child
on its belly, taking care to elevate the feet higher than the
head, at the same time gently shaking it so as to clear out the
trachea, and thus facilitate the introduction of air. “This,”
says he, “is a measure of great utility, by which I am every
way persuaded that I have preserved the lives of many
children.”
That which is called the Sylvester method is worthy of much
confidence, at least it is one I should not be disposed to neglect
where some or all of the foregoing had failed to succeed Dr.
Meadows says of it: “I have tried it many times and with al-
most uniform success.” Such high testimony in its favor
would recommend an early trial rather than to leave it as a last
resort. It is performed by placing the child in a sitting pos-
ture, and alternately lifting it up by its two arms and setting
it down again, drawing down the arms close to the sides of the
body. By this means the natural movements of respiration
are more closely imitated than by any other method. I have
lately tried this plan in the case of a large child, the offspring
of a small primiparous mother. The breech presented, and I
had some trouble with the after-eoming head. The delay was
inconsiderable, but the child was found asphyxiated, very re-
laxed, pallid, and wearing the general aspect of death. The
movement above described was resorted to almost immediately,
and after very few repetitions I had the satisfaction to see signs
of returning animation. The experiment proved a perfect suc-
cess, and the child lived and did well.
Dr. Bruce read a paper at a meeting of the Obstetrical Society
of Edinburg, June 13th, 1877, wherein he very strongly recom-
mended the direct inflation of the lungs of the asphyxiated
child as the most certain means of resuscitation. This method,
performed by applying the mouth of the accoucheur to that of
MANAGEMENT OF THE CHILD. 85
the child, has been recommended by writers of no very recent
date. But Dr. Bruce prefers the passage of a tube, such as a
female catheter, immediately into the larynx of the child and
through it, to force air directly into the lungs, either by the
mouth or some mechanical contrivance. For the tube, a Brit-
ish catheter would probably answer the purpose well. A per-
foration might be made in the extreme point, as less liable to
be obstructed by pressure against parts with which it might
come in contact, or by mucus, than the usual opening at the
side of the instrument, near the termination. A gum elastic
bag furnished with a stopcock, the nozzle of which would fit
air tight in the end of the catheter, would probably be the best
contrivance for the purpose of inflation. To introduce the tube
the forefinger of the left hand of the accoucheur is passed over
the tongue of the child till the point reaches the rima glotti-
dis. This will serve as a guide and at the same time depress
the tongue, so that the tube may be introduced without much
difficulty. If the mouth be used for inflation, the operator
should quickly inhale a much larger portion of air than he
needs for the purpose of his own respiration, and quickly force
it into the lungs of the child, so that it may retain as much
oxygen as possible. Whatever means of inflation be used, the
operation should be conducted with gentleness, lest the tender
structures of the child's lungs be injured by too rapid or violent
distension.
The portion of the umbilical cord left attached to the child,
requires the attention of the physician until it has separated.
This separation usually takes place within a week from birth.
If properly dressed at first it soon dries, and usually comes
away so as to leave the umbilicus in a healthy condition.
Sometimes, however, it continues to hang on by a mere hard-
ened fibre, which irritates the part and, if let alone, causes
ulceration. When separation is thus prevented, we should
with a pair of scissors, sever the fibre by which the desiccated
cord is still attached. If there be irritation of the skin of the
umbilicus, a little diluted tincture of Arnica should be applied,
or if ulceration has already taken place, a pretty strong solu-
tion of nitrate of silver, by means of a feather or camel's hair
86 PRACTICAL MIDWIFERY.
brush. A small quantity of muriate of hydrastia, dissolved
in glycerine, would also be a good application.
A very obstinate form of haemorrhage sometimes takes
place from the umbilicus. To arrest this we may apply
pledgets of lint moistened with a solution of perchloride, or
persulphate of iron. The strength may be such as to make a
strong styptic impression by contact upon the tongue. The
pledgets may be made sufficiently large and firm to exert com-
pressive force under the bandage, which will also aid in closing
the bleeding vessels. Dr. Churchill advises, in very obstinate
cases, to fill the depression with roasted plaster of Paris,
which, by its sudden hardening, would form a plug that would
press upon and close up the bleeding vessels. I would appre-
hend some difficulty in removing the hardened plaster, when
no longer needed, and fear that by its pressure it would give
rise to ulceration. I cannot, however, confidently say that
there is ground for these apprehensions, never myself having
had occasion to resort to the expedient.
It sometimes happens that the child does not wet its diaper
for a longer time after its birth than is deemed normal. The
nurse should of course attend to this; but if inexperienced, it
is well to remind her of it. When there is unnatural reten-
tion of urine, it is generally relieved by placing the child in a
warm bath. When there is reason to suspect that the func-
tions of the kidneys are not duly performed, remedies should
be selected to correct this defect. Ars. alb. and Canthar. may
be found useful. A popular remedy is the tea of the dog-rose
—of the virtues of which I can say nothing. A weak infusion
of parsley root is also used by nurses, and I think with good
results.
It is generally advised to put the child to the breast as soon
after it is born as the strength and condition of the mother
will admit. Sometimes, however, it causes so severe after-
pains as to create great annoyance, or even unbearable suffer-
ing. As a general thing there is, properly speaking, not much
nourishment to be derived by sucking at so early a period.
The first secretion of the breasts, called colostrum, doubtless
has its uses, but probably affords but little nourishment, there
MANAGEMENT OF THE CHILD. 87
being but a small amount of the essential constituents of milk
therein contained. It has a purgative effect upon the child’s
bowels, clearing them of the accumulated secretion called
meconium. This our Allopathic brethren, partly from their
partiality for purgatives perhaps, consider very important. It
doubtless has its uses, as it is a provision of the Creator; if no
Other, it at least forestalls the old-fashioned administration of
Senna and manna, or castor oil, for a similar purpose. Some
nurses, instead of the above nauseating drugs, administer a
few teaspoonfuls of molasses and water, which, in their opinion,
answers the double purpose of laxative and food.
When the child is born at full term, is well developed and
healthy, it probably requires no nourishment until the secre-
tion of milk takes place;—provided also that the mother be
healthy, and that her labor has been a natural one. Under
the opposite circumstances, if the child seems to demand
sustenance, before that usually provided by nature is furnished,
the best substitute is cow's milk, diluted somewhat with water,
say two parts of the former to one of the latter. To this is
usually added a small quantity of pure sugar, sufficient to give
it the sweetness of breast milk. A few teaspoonfuls of this
may be given at a time, but care should be taken not to over-
load the stomach. On the contrary it is best not to fully
Satisfy the appetite of the child, otherwise it will be reluctant
to take the nipple when applied.
The practice of ignorant nurses of giving the newborn infant
a portion of the panada or gruel destined for the mother's first
meal, cannot be too strongly reprobated. It is almost certain
to cause griping, sometimes diarrhoea, and uniformly restless-
ness, thereby greatly disturbing the quietude which the mother
at this time ought to enjoy. The colic complained of by some
practitioners, and attributed to the tying of the cord, can, we
think, more philosophically be traced to improper food given
through the ignorance or carelessness of the nurse. It should
be remembered that the infantile stomach, a very small and
feeble organ, is altogether incapable of digesting such crude
articles of diet. The only nutriment well suited to its powers
is milk, especially human milk, which in its composition SO
88 PRACTICAL MIDWIFERY.
nearly resembles the blood into which, by the digestive pro-
cess, it is destined to be transformed. “Of all the fluids of the
economy,” says Cazeaux, “it approaches nearest to the blood
in composition.”
It sometimes happens, when the child is applied to the breast,
it refuses to take the nipple, or seems unable to hold on to it
so as to suck. This may arise from various causes, which
should be carefully scrutinized, and the particular difficulty, if
possible, removed. If the face be pressed against the mother's
breast, the nose is flattened and the nostrils closed, so that
respiration is prevented, and the child, therefore, cannot suck.
It lets go the nipple from the necessity of breathing through
the mouth. Again the nipple may be so short, or wholly
depressed, that it cannot be taken hold of. This may be
remedied by suction by the mouth of the nurse or some other
person, or by drawing it out by means of the breast pump or
exhausted whiskey bottle, or by wearing nipple glasses, or
wooden or metallic shields.
Occasionally, although not so often as some suppose, the
fraenum of the tongue is inserted so near the point of that
organ, and is so short from below upward, that the tongue can-
not be protruded between the lips, or at furthest beyond their
outer margin. The infant is then unable to suck, or sucks
with great difficulty. This malformation is called tongue tie.
It is to be remedied by a very simple operation, which, if the
hindrance to sucking be considerable, should be performed at
an early day. In order to effect this, “the head of the child
being held slightly backward, an assistant pinches the nose to
oblige it to open its mouth. The fraenum is engaged in the
slit of the plate attached to the grooved director” (or that in
the end of the spatula for depressing the tongue), “and then
raising the tongue forcibly, the surgeon, holding a pair of
blunt scissors in his right hand, divides the fraenum at a single
stroke, taking care to direct the point of the scissors down-
ward and the farthest possible from the tongue.” Cazeaux.
It is surprising how small a slit will completely relieve this
difficulty. Care should, therefore, be taken in the performance
of this simple operation, not to cut too deep, partly because it
MANAGEMENT OF THE CHILD. 89
is unnecessary, and partly because, neglecting this precaution,
it is very possible to sever bloodvessels so as to give rise to
very troublesome haemorrhage.
Sometimes the nipple, instead of being caught between the
upper surface of the tongue and the roof of the mouth, passes
into the mouth beneath the tongue, in which case suction is
impossible. The correction of this difficulty is too simple to
need description.
I was once called to the case of a child several weeks old that
could not suck, as it was supposed by the parents, from tongue
tie. Upon examining the fraenum linguæ, I could see no
deformity, but found the cause of the difficulty in cleft palate
of such a nature as to admit the air from the nasal passages,
and thus render it impossible to form a vacuum within the
mouth. The only resource left was to feed the child by hand.
It died in a few weeks of dysentery.
Finally, the child may refuse to suck, from the nipple being
in some way or other offensive to its taste. This may arise
from the neglect of proper cleanliness on the part of the nurse
or mother. The secretions from the skin, covering or sur-
rounding the nipple, may have accumulated in its fissures, and
by its unpleasant taste produce disgust in the child. The
remedy here is obviously, to wash carefully the parts with
warm water and a soft cloth before the child is applied, and to
remove by the same means the secretions of its own mouth
left upon the nipple, as soon as it is done sucking.
When the child suffers from coryza or cold in the head, it
is unable to hold the nipple, because it cannot breathe through
the nose, and must necessarily keep the mouth open for the
purpose of respiration. In this case the milk should be drawn
and fed to the child by hand, as otherwise it might suffer for
want of nourishment before it should be able to take it in the
natural way. At the same time remedies should be used to
procure relief as soon as possible. Aconite in the beginning,
if accompanied by high fever—otherwise Ars.”—also Apoc.
can. is a good remedy.
A late writer has endeavored to show that attempts on the
part of the infant to suck when the nose is obstructed, is a not
90 PRACTICAL MIDWIFERY.
unfrequent cause of permanent deafness. Such, therefore,
inevitably become deaf mutes, and from this cause he main-
tains, that that condition in many cases arises. We cannot
here enter into the argument in full, but thought it not with-
out force, and would by all means advise mothers to draw the
milk and feed their infants with the spoon, when there is any
considerable obstruction of the nasal passages from coryza or
any cause whatever.
CHAPTER VIII.
MANAGEMENT OF THE LYING-IN WOMAN
AFTER CHILDBIRTH.
When the patient is delivered, comfortably put to bed and
the proper instructions given to the nurse, it has been my uni-
form practice, when no other medication was specially de-
manded, to leave a solution of a few drops of tincture of
Arnica in a tumbler or half tumbler of water, a teaspoonful to
be taken every two hours for at least the first twenty-four
hours. After this I give Ars. a. 2d or 3d at a like interval for
the next succeeding twenty-four. Whatever virtues these may
have or lack, I can only say that since I have adhered to this
practice I have had but little trouble with the usual ill
sequences of labor, even the old stereotype milk fever seldom
makes its appearance. From the known effects of Arnica in
contusions we may expect it to be useful after severe labors,
wherein there is always more or less injury done to the soft
parts of the mother. The properties of Arsenic as an antiseptic
are also well known. The Arnica itself is probably a direct
antidote to septic poisoning.
The proper adjustment of the lying-in-room is a matter of
great importance. It should be sufficiently large to contain
MANAGEMENT OF THE LYING-IN WOMAN AFTER CHILDBIRTH. 91
such a volume of air, as will suffice the patient for healthy
respiration through the night, while the windows cannot be
safely raised. All suspended clothing and unnecessary furni-
ture should be removed. It should be as remote as possible
from all unavoidable sources of noise. It should be well sup-
plied with windows for the admission of fresh air, and these
should be so arranged as to admit the air without producing
a draft immediately upon the patient. The bed should be
placed so as to avoid this source of great danger. I knew a
woman lose her life through spinal inflammation brought on by
having her bed so placed that a door opening into a cold room,
in the depth of winter, was directly opposite to her shoulder.
The room should be partially darkened, as a strong glare of
light is very injurious to the patient for the first few days
after delivery. The eyes are especially sensitive to light, and
through them the brain becomes irritated. The patient should
be guarded against the intrusion of strangers and even friends,
except those of her own family, for at least the first ten days
after delivery. Nothing, perhaps, is more likely to injure her
than the excitement necessarily attendant upon seeing and
entertaining strangers. This is especially true of nervous,
excitable women, and those generally of feeble constitution.
I remember a case which gave me a great deal of trouble and
which well illustrates the evils arising from this quarter. The
patient was a young woman of nervous temperament and rather
imperfect health. Her mother had died of fungus hæmatodes.
It was her first confinement, and knowing her delicacy I had
attended her with special care, and as I thought, had brought
her quite safely through a rather tedious labor. The child
was born at 1 o'clock P.M. Shortly after my departure, and
during the same afternoon, some friends who were about to
leave for the West called to congratulate her and at the same
time to bid her good bye. Several of her young female friends
with great indelicacy came in “to see the baby.” All this
tended greatly to excite her, and when I made my morning
visit next day, I found her feverish, with quick pulse, perhaps
headache, and generally very unwell. Her convalescence was
afterwards slow, interrupted and very unsatisfactory.
92 PRACTICAL MIDWIFERY.
At our first visit after delivery, if this be within a few
hours, we are often called upon to prescribe for “after pains.”
By this we understand a severe spasmodic, bearing down pain
resembling those of labor, and occasionally represented by the
patient as being equally severe. This suffering arises generally
from an effort of the womb to expel clots which have accumu-
lated within its cavity, and if not very severe need not be in-
terfered with. Women in their first confinement are gener-
ally exempt from suffering from this source. We should be
very careful to distinguish between after pains and other affec-
tions which they resemble. The former are intermittent or
paroxysmal. They come on at pretty regular intervals, last
for a few moments and then subside. In the intervals the
patient is free or nearly so from suffering, and unless the labor
has been severe or protracted there is no extraordinary tender-
ness in the region of the womb. Unless arising from some
other cause there is no accompanying fever, nor unusual
quickness of the pulse excepting during the paroxysm. Gen-
rally no antecedent chill has ushered in this phenomenon.
The patientdoes not from after pains alone complain of feeling
unwell. -
The affections with which after-pains are liable to be con-
founded are incipient peritonitis, and what has been called
false peritonitis. The former is ushered in by chill, mostly
severe, followed by intense fever—the pain, too, is continuous,
not intermittent, and is associated with extreme tenderness of
the abdominal region. In false peritonitis, the pain sets in
suddenly, is not always and perhaps not often preceded by
chill and is unaccompanied by febrile symptoms, unless it be
through the intense suffering which it often causes. There is,
too, in this case extreme tenderness of the abdominal region to
the touch, unless the hand at first be very cautiously applied.
It is said, however, that if so applied, the pressure may be
gradually increased without inflicting pain.
The remedies proposed for after-pains are the following:
Coffea, in nervous subjects, Chamomilla, Caulophyllin, Morph.
acet., Sec. cor., Cupr. ars. Place the patient upon the vessel
to encourage the expulsion of clots, if there is reason to sus-
MANAGEMENT OF THE LYING-IN WOMAN AFTER CHILDBIRTH. 93
pect an accumulation of these within the womb. The student
will be most effectually aided in making his selection by a
thorough study of the pathogenesis of each of these medicines
and a careful comparison of this with the symptoms of the
case before him. To construct cases from our imagination or
even from the drug symptoms as enumerated in a symptomen-
codex, would be for the most part to give such as are seldom
found, at least, in most of their details, at the bed-side. We
may however say, perhaps with advantage, that Coffea is gen-
erally recommended in the case of nervous women, especially
if they are suffering at the time with nervousness or fidgety-
mess. The old fashioned Acetate of morphia, in the first or
second dec. trit., will often be found in practice quite as good
as anything else. This may be given by dissolving a few
grains, say fifteen, of the second decimal trit. in half a
tumbler of water—the patient to take a teaspoonful of the
solution every half hour until some relief is procured—when
the intervals should be lengthened or the medicine altogether
discontinued. Xanthoxylum frax. is recommended by Dr. O.
B. Gause. Viburnum opulus and Viburnum prunifolium are
also worthy of trial. In feeble labors, which are perhaps most
frequently followed by severe after-pains, the latter may often
be forestalled, by now and then administering toward the
close, a few drops, from six to ten, of the tincture of Ergot in
water. This not only excites the womb to more vigorous
action and thus hastens the termination of labor, but it also
causes it to contract more firmly, after the expulsion of its
contents, and thus prevents the formation of clots, the great
source of this trouble. I recently attended a lady, who in her
former confinements had been greatly annoyed by after-pains,
to whom I administered Ergot as above, and who on this
occasion almost wholly escaped her accustomed sufferings.
Belladonna ought to do good service, when the bearing down
sensation is very intense, as if prolapse or even inversion of
the womb was likely to take place. Ergot may be adminis-
tered likewise subsequent to delivery, and after the pains have
set in, if they seem to be associated with irregular contractions
of the womb, unless these have been caused by excessive doses
94 PRACTICAL MIDWIFERY.
of that drug previously given. The Ergot should here be
given in much smaller dose, as it is the homoeopathic or cura-
tive effect at which we aim.
There sometimes occurs shortly after delivery a kind of pain
more continuous than the after-pain, very severe and annoying,
but without its distinct characteristic bearing down sensation.
Atropine, 3d decimal, is the remedy for this.
Occassionally, about the end of the second or beginning of
the third day after delivery, the patient experiences headache,
slight rigors, stinging in the breasts, accompanied by febrile
excitement more or less intense. This is what has been called
“milk fever.” My patients generally escape it in any noticeable
degree. It is supposed by some, and I am disposed to agree
with this opinion, to be a slight form of septicaemia, and is
almost completely antidoted by Arnica. It usually passes off
within twenty-four hours, and convalescence, after this slight
interruption, advances in a satisfactory manner. If the fever
runs high, with full bounding pulse, we may administer Acon.
Ars, alb. will likely be useful when septicaemic symptoms pre-
dominate.
The condition of the breasts should be closely observed and
excessive engorgement carefully guarded against. This is pre-
vented by diligently applying the child, which should have
been kept up to the time of lacteal secretion, at least in ordi-
nary circumstances, without extra nourishment, but frequently
induced to take hold of the nipple, so as to become an adept
in sucking by the time nature has provided its aliment.
If the child fail to exhaust the milk, as it will sometimes
do when small or feeble, or when the secretion is too rapid
and abundant, other means must be resorted to in order to
prevent engorgement. The best method will be the applica-
tion of the mouth of the nurse or of some one else. But most
nurses in our day cannot or will not overcome their aversion
to this operation. The breast pump, if tenderly used, will
usually succeed very well. That known as Dr. Meigs', is very
simple in its construction, and can be applied by any one of
ordinary dexterity. The milk may also be drawn in many
cases, such in particular where the nipple is well formed, by
MANAGEMENT OF THE LYING-IN WOMAN AFTER CHILDBIRTH. 95
means of a common long necked bottle. After warming the
bottle, a small quantity of hot water is thrown into it, and
briskly shaken until the bottle is filled with steam. It is
then immediately, if not too hot, applied to the breast, so as
to include the nipple in its mouth, and held in that position
firmly, so as to exclude the entrance of the air, until the steam
condenses. The nipple will be more and more forced into the
neck of the bottle by the external pressure of the atmosphere,
and the milk forced out.
When any portion of the mammary gland becomes solid, or
caked, as the women sometimes term it, while, at the same
time, it is not very tender or painful, and is free from redness,
indicating inflammation, gentle friction with the hand should
be applied, forward in the direction of the nipple, the pressure
being very gentle at first, but somewhat increased as the opera-
tion proceeds. The hardness will generally soon disappear
under this treatment. It is well to lubricate the hands before
rubbing with a little olive oil or other soft grease, simply to
avoid abrasion of the skin. It is to be remembered, however,
that the force is not to be such as to endanger the bruising of
these tender structures.
If, in despite of all these precautions, inflammation of the
breasts should set in, it should be promptly treated, as it is
only by so doing that that terrible calamity of the lying-in
woman, mammary abscess, can be avoided. As this occur-
rence, should it happen, is not in the course of ordinary con-
valescence, we will speak of the proper treatment under another
head.
The nipples require our particular attention while the lying-
in woman is under our care. We will often find this organ so
retracted, or buried in the substance of the breast, that the
child cannot seize it so as to suck. This, if not remedied, al-
most always leads to engorgement, and this latter to inflamma-
tion and mammary abscess. The sunken nipple may usually
be drawn out by means of the breast pump, assisted by wearing
the ordinary nipple glass.
Excoriations or chaps of the nipples also claim our attention;
first, the prevention, the most important, and next, if this be
96 PRACTICAL MIDWIFERY.
unsuccessful, the cure. If our patient have placed herself un-
der our care, some time before her confinement, especially if it
be her first pregnancy, we should advise her to prepare her nip-
ples by such processes as tend to harden or tan the skin of this
delicate organ. Before going to bed every night for some
weeks previous to labor, she should bare her breasts and expose
them to the air. This will so change the skin as to make it
more like that covering the hands or face, which is constantly
exposed to the air, and therefore less tender than upon those
parts from which air and light are excluded. It would be well,
too, especially for women of delicate complexion, to apply to
the nipples the leaves of green tea, upon which hot water has
been poured, or decoction of oak bark. These applications
harden the skin by a process perhaps somewhat resembling that
of tanning. Their astringency, too, probably diminishes the
vitality of the nervous filaments within the skin covering the
nipples, and thus renders them less irritable.
When the child has been put to the breast, the nipple should
always be washed with tepid water, after it is done sucking.
This removes the Saliva, and leaves the organ clean and free
from any external irritant. If there still seem to be danger of
excoriation, it will be better before this takes place, to procure
a good nipple shield, and accustom the child to sucking through
it. Most forms of the gum elastic shield are faulty, and often
cannot be used. Many years ago the skin of the ends of heifer's
teats was used. These teats generally answered well, but were
troublesome, as they must always be kept in water or alcohol,
and it was difficult to preserve them in a state of entire purity.
If, notwithstanding all our efforts to prevent it, the nipples
should become sore, it is proper we should immediately resort
to measures for their relief. Women suffer beyond all compu-
tation from this apparently trifling affection—often so much so
as to create the utmost horror of nursing the child, and to ren-
der life itself a burden for the time.
Various remedies have been recommended by different au-
thors—more than we care to recount. In case of excoriation of
the top of the nipple, we have found nothing answer so well as
the topical application of a weak solution of muriate of hydras-
MANAGEMENT OF THE LYING-IN WOMEN AFTER CHILDBIRTH. 97
tia, in glycerine. Just sufficient of the muriate should be dis-
solved to give the solution a slightly yellow color. A small
portion of this may be applied when the child has done suck-
ing, and the nipple is washed off and dried. The application
should be removed before applying the child to the breast, as
the bitter taste may cause it to refuse to suck. Nipple glasses
should be worn during this treatment, otherwise a dry scab
will form, and be repeatedly torn off by the child's mouth, in
the act of sucking, and thus give rise to deep ulceration.
If the lesion be in the form of fissures or chaps, an ointment
composed of fresh lard and a few grains of the first dec. trit. of
Graphites, occasionally rubbed on, will often answer an excel-
lent purpose. If indicated, a higher trituration of Graphites
might at the same time be given to the patient internally.
A pretty strong solution of the nitrate of silver applied to
the nipple in the case of ulceration—as also superficial excoria-
tion, chaps, etc., will generally be found efficient. Some
speak highly of the oil from the kernel of the butternut
(juglans cinerea) as an excellent application. I have not tried
it, having always succeeded with one of the foregoing reme-
dies, and I have seldom been obliged to go beyond the one first
named above.
The food of the lying-in woman is a matter of no small im-
portance, if we would secure a satisfactory convalescence. Pro-
fessional opinion and consequent practice has undergone consid-
erable change within the last few years, upon this subject.
Formerly we kept our patients for the first few days upon oat-
meal gruel, or something as nearly equivalent as possible.
After the milk fever had passed, toast and tea were allowed, and
later still, chicken broth. Occasionally women boldly over-
stepped these restrictions with apparent impunity, and this cir-
cumstance, perhaps, contributed at least somewhat to procure a
revision of the old code. &
We are, perhaps, now in danger of going to the opposite ex-
ireme. In this, as in most of the concerns of life, it is well to
regard the maxim of the illustrious Roman poet: “in mediis
viis tutissimus ibis.” There can, indeed, be no specific rules
for diet given, that will be found applicable to every case. One
7
98 PRACTICAL MIDWIFERY.
patient may eat with impunity what will be injurious to
another, apparently under the same circumstances. Even the
same woman may safely partake of food in one confinement,
and in another, under different circumstances, be injured by the
same or similar diet.
There are, however, general considerations which will guide
us in prescribing a proper regimen, and we will here premise
that where there is any doubt, it is always best to be upon the
side of safety.
After prolonged and severe labors, there is mostly great pros-
tration of the vital powers, a condition lasting a longer or
shorter time, according to the recuperative energies of the pa-
tient. The digestive organs are, for the time being, involved
in the general asthenia of the system, and disqualified from
performing vigorously their appropriate functions. The secre-
tions are deranged, or at least may be so, so that healthy bile
and gastric juice are not furnished in appropriate quantity and
quality to aid in the digestive process. Hence digestion is
feebly and imperfectly performed, while at the same time there
may coexist with this state of things, exalted irritability of the
nervous filaments supplying the coats of the stomach. Hence
it is plain that food difficult of digestion would be very inap-
propriate, and very likely to do harm. In such cases we would
say, be, by all means, careful to allow the patient nothing but
the most simple and digestible aliment, and having secured
these properties, let it be as nutritious as possible, until she has
in a good degree regained her strength and rallied from her
prostrate condition. By no means allow her anything that has
disagreed with her while in health. Many years ago I attended
a young woman in her first confinement, who had a very tedi-
ous and difficult labor. Her convalescence proceeded about as
well as could be expected, up to the tenth day, when, according
to custom, she made an effort to sit up out of bed. Her
mother, who nursed her, joyous at the event, prepared her a
sumptuous dinner, followed by a rice custard and cream, as
dessert. Milk in all forms had always disagreed with her,
causing cholera morbus whenever she took it. In this instance
it was followed by severe purging and vomiting, and the irri-
MANAGEMENT OF THE LYING-IN WOMEN AFTER CHILDBIRTH. 99
tation of the bowel extended to the womb. After several days
of suffering, excessive haemorrhage came on, and within a few
hours death closed the scene.
On the other hand, where the labor has been short and easy,
and the patient has retained almost her usual strength—espe-
cially if she have previously been healthy—with good digestive
powers, she may with safety be allowed a better diet. As a
general rule she should have as nutritious food as we have
good reason to believe she can bear with safety. In all cases
we should cautiously feel our way. If we have doubts of the
safety of any article, if given at all, let it first be given in
small quantity, and not repeated until we are satisfied that it
will do no harm.
Throughout the whole course of her confinement the patient
should carefully avoid all exertion beyond her strength.
Nothing more retards convalescence and renders it imperfect
and unsatisfactory, than premature or too great taxing of the
strength. After the exhausting efforts of labor, and the haemor-
rhage which usually attends it, under all circumstances the
strength is slowly recovered. So great, too, is the change pro-
duced upon the womb and other abdominal organs by gestation,
especially in the latter stages, that considerable time is required
for these organs to regain their normal condition, and until
they in a great measure do so, health and strength are not fully
re-established.
As to the time when the woman may safely leave her bed,
no rule can be given applicable to all cases. The Indian squaw,
it is said, is sometimes taken with the pangs of labor when her
party is upon the march—turns aside and gives birth to her
offspring, and again overtakes her companions before the close
of day. I have known rare instances among our German pop-
ulation, where the same woman at the time of her confinement
performed the functions of parturient, accoucheur and nurse,
doing all for herself and child that the exigencies of the case
absolutely required, and in a day or two resumed her household
duties. Indeed the latter could hardly be said to have been
suspended, and yet these women made good recoveries, and con-
• © © C.
tinued to enjoy robust health. : : :"... ::" §:
100 PRACTICAL MIDWIFERY.
But on the other hand I have known patients leave their
bed on the tenth day, and shortly thereafter engage in their
accustomed employments, and apparently, in consequence, suffer
prolapse of the womb and all its attendant evils.
The old rule generally accepted by women, at least in rural
districts, to leave the bed on the tenth day is entirely too arbi-
trary. This, perhaps, had its origin in the belief that within
this limit there is danger of secondary haemorrhage from undue
exertion. Be this as it may, there are some women who may
safely sit up, and even walk about the room, at an earlier pe-
riod, while many cannot, without risk, do so upon the tenth
day, or even several days later.
The rule which I would lay down and emphasize, is this:
Regard the condition and strength of the patient, and bear in mind
what we have before in substance stated, that any effort un-
suited to these, is premature and damaging, and tends to retard
rather than to accelerate recovery. It is well, even from an
early stage of her confinement, when the patient will bear it,
that is, when she experiences afterwards a feeling of increased
comfort, and not that of exhaustion, to take her up from her
bed while it is being made, or, for the sake of change, to lay
her for a time upon a couch near to her bed. But if she be
feeble, feverish, and with quickened pulse, then beware of pre-
mature exertion—its effect will certainly be not to make her
condition better, but worse.
As soon as she is sufficiently strong, and provided we have
no reason to suspect lurking disease, as evidenced by quick
pulse, abnormal temperature, etc., she should enjoy passive ex-
ercise in the open air, when the weather is suitable. A car-
riage ride in the early part of the day, while she is invigorated
by the rest and sleep of the past night, will greatly contribute
to complete her convalescence. We should always aim at the
perfect recovery of our patient's health. A young and healthy
woman, after giving birth to her child, should regain her for-
mer status, and feel nothing the worse on account of her ma-
ternity.
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:
DEVIATIONS FROM NORMAL LABOR. 101
CHAPTER IX.
DEWIATIONS FROM NORMAL LABOR.
Unfortunately the process of partition is not always as
simple as that we have described in a preceding chapter. On
the contrary, every practitioner will encounter many devia-
tions from it, more or less divergent. The causes giving rise
to departures from what may be regarded as typical labor, will
be found to exist in the mother, in the child, or simultaneously
in both. And first we will speak of such as arise from some
peculiar condition of the mother.
RETARDED LABOR,
The deviation from the simple form of labor most frequently
met with, and least divergent therefrom, is that wherein the
process is merely protracted beyond the usual length of time
which we are accustomed to regard as normal. Such delay
may, it is true, be caused by some condition of the child, but
here, it will be remembered, we are speaking only of that hav-
ing its origin in the mother.
There is no definitely fixed period which, strictly speaking,
characterizes normal labor. In primiparae, labor generally
advances more slowly, and occupies longer time for its com-
pletion, than in those who have already given birth to one
child or more. This is especially true of primiparae somewhat
advanced in life; at least it has been so in my own experience,
however it may have been in that of others. Still we have
no difficulty in deciding, in individual cases, whether a labor
has or has not been prolonged beyond the limit within which
we might reasonably expect it to terminate.
A very common cause of tedious labor is the lack of suffi-
cient expulsive power in the womb. The pains are perhaps of
102 PRACTICAL MIDWIFERY.
infrequent occurrence, the contractions are not energetic or
they are so brief as to have little effect. This defect may
arise from various causes. A common one is a debilitated
condition of the nervous or muscular power of the womb,
either inherent in that organ itself and of a purely local char-
acter, or else derived from the natural constitutional feebleness
of the patient, or from debility caused by antecedent or co-
existing disease. Patients who inherit a feeble constitution or
who have, previous to their confinement, been reduced in
strength by disease, will often be found very deficient in par-
turient energy, and their labors will usually be accordingly
protracted. To this, however, there are exceptions. The
feebleness of constitution, causing proportionally diminished
uterine power, may also have prevented the full development
of the foetus, so that, at birth, it may be unnaturally small,
while, at the same time, the generally relaxed condition of
the system may so modify the soft parts that they oppose little
resistance. Both these circumstances are favorable to speedy
delivery; and this is sometimes the unexpected result. Again
such women may have unusually wide pelves, especially so in
relation to the size of the foetus, if imperfectly developed.
We think, however, we have generally found antecedent
or simultaneous disease, so to modify labor as to render it
tedious. A lady, whom we had previously attended in several
confinements, who always gave birth to her children, of large
size, without manual or instrumental aid, and with as much
expedition as we could reasonably expect, had had a severe
attack of pleurisy, from which she was exceedingly prostrated.
She was taken with labor early in the morning, the pains were
regular, but distant, short and feeble, and continued so
throughout the day. By five o’clock in the evening the head
had only dipped into the superior strait, although the os uteri
was fully dilated when I first saw her in the morning, and the
membranes were artificially ruptured not long after. The
head having for a long time made no advance, she was deliv-
ered with forceps. Both mother and child did well.
Again the pains may be rendered feeble and inefficient from
the existence of too large a quantity of the liquor amnii within
DEVIATIONS FROM NORMAL LABOR. 103
the womb. This gives rise to overdistension, the natural con-
sequence of which is a thinning out of the muscular walls of
the organ, and of course, a diminution in their contractile
force. When overstretched the fibres become, no doubt, to
some extent paralyzed. We find an analogous case in the
overdistension of the urinary bladder, which sometimes takes
place after delivery, through neglect to void the urine at the
proper time. Owing to the extreme looseness of the surround-
ing parts, the patient does not feel her need, until a vast accu-
mulation has taken place, when she finds herself powerless to
relieve herself, on account of the paralyzed condition of the
overdistended bladder, and the use of the catheter becomes
absolutely necessary.
Another source of inefficient uterine action is found in
irregular contractions of that organ. The uterine fibres con-
tract, but not uniformly. The contractions may be attended
with suffering even greater than that experienced in normal
labor, but pain is one thing and efficient uterine action another.
They may and often do co-exist, but not necessarily, and they
are not by any means identical. When the contractions are
of this character, the various processes neeessary to the com-
pletion of delivery are not harmoniously carried on, and labor
is retarded.
Another cause of feeble uterine action will be found in ex-
haustion from long continued effort. The pains may at first
have been vigorous, but baffled, on account of some impedi-
ment to their success, they have grown weaker and weaker
until, perhaps, finally they entirely subside. It is truly won-
derful how long the womb will sustain its action—and how
often it will sometimes rally and renew its efforts after a season
of rest. But if the obstacle is beyond its power, it will ulti-
mately and hopelessly succumb. In the latter case labor is not
only rendered tedious, but arrested.
Dr. J. Matthews Duncan, in a paper read before the Obstet-
rical Society of Edinburgh, December 12th, 1877 points out a
cause of inefficient uterine action different from any of the
foregoing. It consists in a premature retraction of the body
of the uterus over the surface of the child, so as, so to speak,
104. PRACTICAL MIDWIFERY.
to lose its purchase in its propulsive efforts. This condition,
he says, is most apt to occur in primiparae, of nervous tempera-
ment and a high degree of excitability. In these cases the
pains continue vigorous, but produce little or no effect.
To enable us to distinguish between weak labor, arising
from inertia of the uterus and delay from the cause above
stated, Dr. Duncan makes the following statements “In the
former the pains are generally seldom, short, and cause little
suffering. In the latter they may be frequent, and of ordinary
duration and painful. In the former, bearing down is gener-
ally slight or absent. In the latter, it is unaffected and power-
ful. In the former, the uterus proper is flabby, and its feeling
under the hand during a pain, is never that of great tension.
In the latter, it is quite otherwise. In the former, the uterus is
deficient in irritability under kneading or friction. In the
latter it is otherwise. • In the former the lower margin of the
uterine body cannot be felt at all, or is indistinctly perceived
immediately above the symphysis. It cannot be felt and re-
cognized with ease. In the latter, it is rapidly elevated to
near the umbilicus as labor goes on, and is comparatively
easily felt; its hard and somewhat rounded edge marking a
limit between it and the cervix ; the former hard and firm
and allowing nothing to be felt through it while the pain
lasts; the latter thin and tight during a pain, and even then
allowing the foetal parts to be felt through it.” (Obstetrical
Journal of Great Britain and Ireland.)
Another source of delay, rendering labor tedious, is rigidity
of the OS uteri. The pains have set in, and perhaps for some
time manifested considerable activity, but upon examination
the OS uteri is found undilated, and it may be not even in the
soft condition which usually precedes dilatation. Hour after
hour passes and the same state of things remains, unless it be
altered by appropriate treatment. This condition may, if left
to itself, last for days, the womb acting energetically for a few
hours, and then wearied out, ceasing to act. When it has be-
come invigorated by rest it will resume its functions, only to
be baffled and sink again into inactivity. If the pelvis be
large, the lower segment of the womb, through which the pre-
DEVIATIONS FROM NORMAL LABOR. 105
sentation may be indistinctly felt, is sometimes forced down
so low that upon an examination the inexperienced might
suppose the child would soon be born. Upon the cessation of
pain, however, the presenting part mounts up to its former
position. One woman of whom I have known, remained in
this condition for seventy-two hours, and was afterwards de-
livered by the natural powers, another, about the same time,
remained as long, but the womb in her case sunk into perfect
quiescence, and, failing to rally, she was delivered with for-
ceps, and another still was in labor, from the same cause, for
a whole week. She was ultimately delivered by embryotomy,
and at that time one of her attendants informed me the os
uteri would admit only the ends of three fingers. The first
two recovered, both mothers and children doing well—the last
died. -
Again the rigidity of the os uteri, if any existed, may have
given way and the head may have come down so as to rest
upon the perineum, but may there have become arrested by the
unyielding condition of that organ, thus causing considerable
delay at the close of labor. This difficulty is most frequently
encountered in first labors, especially in the case of those
somewhat advanced in life. Under the proper management,
however, it hardly ever prolongs labor very much beyond its
normal limit. Exercising patience, and with the use of ap-
propriate means, the structures gradually yield and permit
the head to pass. Where the rigidity is extreme, the womb is
apt to take on unwonted action to overcome the obstacle, and
hence arises considerable danger of some form of laceration,
an accident often very serious in its nature and always care-
fully to be guarded against.
Again labor may be very considerably retarded by a slight
disproportion between the foetal head and parturient canal.
This may depend upon a reduction in the diameters of the
pelvis, not amounting to deformity, and still admitting of de-
livery by the natural powers. In this state of things the head
meets with more than ordinary resistance in its descent. Not
having space to avoid this resistance by moving away from it,
it accommodates itself to circumstances by undergoing the
106 PRACTICAL MIDWIFERY.
process of moulding, as it is called—that is, the cranial bones
overlap each other at the sutures, and the scull, being ordina-
rily very flexible, contracts in its diameters which lie across the
pelvis, and lengthens in its diameter corresponding with the
axis of the parturient canal,—in other words, it elongates or
becomes wire-drawn. This process of moulding requires con-
siderable time, and usually not only prolongs labor but adds
much to the suffering of the patient. It is truly wonderful,
however, how the powers ultimately triumph over this diffi-
culty. ºf
Another source of protracted labor, perhaps worthy of
notice, though not generally mentioned by authors, is hyper-
aesthesia, or extreme sensibility of the nerves of the patient,
supplying the parts concerned in parturition. Every effort
of the womb is attended with extreme suffering, although no
apparent cause exists why it should be so. The patient dreads
her pains and shrinks from their approach, and, as far as in
her power, suppresses them. If still upon her feet, as soon as
she perceives the commencement of contraction, she starts and
steps rapidly around, thus diverting nervous power from the
action of the womb, and thereby rendering it inefficient or
nugatory.
The extreme sensibility of the parts, moreover, interferes
with the regular dilatation of the OS uteri by causing spas-
modic constriction of its fibres, and thus gives rise to con-
siderable delay in the regular process of labor. It will be
well to remember that this spasmodic constriction is a different
pathological condition from the simple unyielding rigidity of
the os, of which we have spoken above, and requires a different
treatment.
Extreme suffering without apparent cause, is probably in
most cases owing to hyper-sensibility of the nerves, but not
always so. I once attended a patient whose sufferings were
intense, although her uterine contractions were scarcely as
strong as ordinary. In this case there seemed to be very con-
siderable delay from the influence of the will holding in check
the action of the womb. Upon examining the placenta after
delivery, I found its uterine surface interspersed with gritty
DEVIATIONS FROM NORMAL LABOR. 107
particles, causing in the finger drawn over it a sensation simi-
lar to that produced by sand-paper. Here the excessive suffer-
ing was probably owing to the action of these particles upon
the internal surface of the womb during its contraction.
TREATMENT.--When labor is protracted through want of
energetic uterine action, arising from feebleness of the womb,
inherent or sympathetic, the proper treatment will be to
excite that organ to greater energy. This, where the excita-
bility of the womb is not exhausted by excessive fatigue or
disease, can usually be done by administering Ergot in small
repeated doses. These should be given at short intervals, say
fifteen or twenty minutes, and the dose may be increased, if
after a few repetitions it should not produce the desired effect.
We may begin with six drops of the saturated tincture, or
somewhat smaller dose of the fluid extract, in water—or we
may prepare an infusion, by putting about a dram of the
freshly powdered drug, if possible of the last year's, or recent
growth, into a teacup, and filling the vessel within half an
inch of the top with boiling water. This should stand for
awhile, in a warm place to draw. A teaspoonful of the in-
fusion may be given, at the above named intervals, until the
object is attained. I have thought the infusion prepared from
the fresh drug, acted more promptly and certainly than any
other preparation. By giving the Ergot in this manner, in
small, frequently repeated doses, we avoid the ill effects usu-
ally attributed to that agent. We may, too, administer it in
this way with safety, even when contra-indicated, as formerly,
and still generally given. The contractions thus produced are
but the intermittent pain of labor intensified. If the OS uteri
be not fully dilated, but soft and dilatable, the increased en-
ergy evoked by the Ergot assists in its further dilatation. As
for the foetus, it is not subjected to any other than the normal
pressure and is, therefore, exposed to no additional risk. I
have never had a case of still-born child under this method
of management, except where there was abundant evidence
that the child had been dead some time before. I have used
the fluid extract of Caulophyllum for a like purpose. After
some considerable experience with the latter article, I have
108 PRACTICAL MIDWIFERY.
abandoned it in favor of the Ergot. There are, however,
cases where Ergot, and probably every other medicinal agent,
will fail to arouse the requisite expulsive power. This is
especially true where the womb is exhausted by long and
fruitless exertion. There must be in the organ a susceptibility
to the impression of the Ergot, or its administration will be
futile. In such cases, after a faithful trial without result, if
the patient’s condition do not seem to require immediate inter-
ference, we may wait awhile to see whether the resources of
nature may not bring about a favorable change. The refresh-
ing influence of a little quiet sleep will often do much good.
If this fail, and especially if the strength of the patient seem
to be suffering still further exhaustion, we must at once resort
to the forceps, unless contra-indications exist, which would
render this procedure unjustifiable. We say forceps, for we
here assume the presentation to be that of the head. If the
forceps do not succeed or be not available, turning or crani-
otomy will be our next resource.
When the feebleness of uterine action is owing to disease
still existing, we should endeavor to select the specific for
such diseased condition and administer it at once, with the
hope of at least suspending its effects. If we have been en-
gaged beforehand to attend the patient it is our duty to
inquire into the state of her health, and if in any respect de-
fective, we should endeavor to remove or at least palliate her
disease before her confinement takes place. For instance if she
have been suffering from a rheumatic or neuralgic affection of
the womb, which by the way is a very fruitful source of pro-
tracted labor, we should treat that condition. Puls. or Caul.,
or if the pains be very severe, Viburnum will often be found
useful and even remove the affection.
When feeble contractions arise from too great an amount of
liquor amnii, which may usually be known by the large size
and extreme tightness of the abdominal region of the patient,
we should, as soon as the os uteri is found to be soft and
dilatable, if not fully dilated, evacuate the waters. Shortly
after this is done the pains usually become more vigorous. If
they do not, Ergot given as above directed, will generally
suffice to evoke them.
DEVIATIONS FROM NORMAL LABOR. 109
When we have reason to suspect irregular contractions of
the uterus to be the cause of delay, and our suspicions may
be confirmed, if upon laying the hand during a pain over the
region of the womb, we find it do not assume the globular
form usual when its action is symmetrical, we may try small
doses of Ergot here with a view to its homoeopathic action.
Probably we should obtain good results from Cupr. met. But
perhaps no agent will SO certainly equalize these partial con-
tractions as chloroform administered in the usual way by in-
halation. As soon as a moderate degree of anaesthesia is pro-
duced, irregular action ceases and the labor generally pro-
gresses regularly to a favorable termination.
When the cause of delay may be traced to fatigue of the
womb, more or less nearly approaching to exhaustion, we may
again try Ergot as before indicated. But here it will very
possibly disappoint us. If the exhaustion be not too great the
womb usually rallies for awhile under the stimulus of this
agent, and if the labor be near to its close, the natural powers
may triumph. But this is too frequently not the case. Gen-
erally after a short spasmodic effort the womb lapses into a
more profound exhaustion than before.
When this occurs we need not wait longer—unless it take
place in the first stage of labor, when we may hope that sleep
may restore the patient to renewed strength. If she be nervous
and fidgety, Coffea will probably conduce much to this result.
I would even try a cup of coffee, which with some persons is a
great restorer of exhausted strength. But if the labor be
advanced, and the pulse become quicker and be losing its
force, while there are other symptoms of general exhaustion,
we must lose no time in our resort to the forceps, or to turning
if that operation be rather indicated, or to such other aid as
the exigencies of the case may require. If the labor be far
advanced when the action of the womb comes to a standstill,
that is, if the head be already resting upon the floor of the
pelvis and the perineum and other soft structures be suitably
relaxed, we may possibly terminate delivery by pressure upon
the fundus, in the proper direction, as advised by some of the
German authors. Even placing the patient upon her knees in
110 PRACTICAL MIDWIFERY.
the bed, may so far arouse vitality as to effect the expulsion
of the child.
Where delay is caused by premature retraction of the womb,
as pointed out by Dr. Duncan, it is evident that very different
remedial measures are required from those which may be
proper when labor is retarded through inertia. In such case
there is no lack of uterine energy, it may even be excessive,
and it fails to accomplish its purpose, simply because it has, so
to speak, not a sufficient hold upon the object upon which it
seeks to expend its force. The indication, therefore, is rather
to quiet uterine action, and to supply the additional force
which may be necessary to accomplish what the womb is
unable to do, because it works at a disadvantage. Chloroform,
judiciously used, will usually answer the first purpose, the
forceps the second. Nor should we, when a case of this kind
is fairly diagnosed, be slow to resort to these measures, as
neglect may subject the mother to danger through undue
extension of the cervix and vagina, and the child through
premature detachment of the placenta or injurious pressure
upon the umbilical cord.
When the labor is protracted by rigidity of the os uteri, we
have an excellent remedy in Actaea racemosa, if this has not
been given previous to labor, as before recommended, and with-
out result. A few drops of the tincture of the root may be
diffused in half a tumbler of water and a teaspoonful given
every fifteen, twenty or thirty minutes, according to the
urgency of the case.
If great rigidity exist, and should it not yield to this agent,
we may, with fair hope of success, try the effects of a jet of
warm water, thrown against the os for some time by means of
a syringe. The patient may be placed with her hips near the
edge of the bed and upon an oil cloth or gum blanket, and
this so arranged that the returning current will flow into a
bucket or tub, so situated as to receive it. This failing, we
may try the colpeurynter or Dr. Barnes' dilators. The former
is simply a gum elastic bag, terminating a tube of the same
material, which is furnished with a stopcock, to retain the air
or water injected. The bag is rolled up and pushed into the
DEVIATIONS FROM NORMAL LABOR. 111
partially dilated os in an empty condition. It is then, by
means of a syringe, inflated with air or filled with warm water
—the latter is preferred generally. The relaxing effects of
warmth are hereby superadded to the gradually distending
force of the colpeurynter. Air is more elastic than water, but
some danger from it is apprehended in case the gum elastic
bag should burst, an accident which, in careful hands is not
very likely to happen. Barnes' dilators are constructed upon
the same principle, and are to be preferred to the colpeurynter,
on account of their easier introduction and more perfect reten-
tion. The bags, when flattened, have the shape of a violin,
and on account of the middle being narrower than the ends,
when in sitā, they are not so likely to be extruded. Being of
three different sizes, they can be introduced one after the other
as dilatation progresses. To facilitate their introduction, there
is a little flap arranged externally, in the form of a pocket, into
which the end of a female catheter or sound can be thrust, for
the purpose of carrying them up and pushing them through the
os uteri.
Chloroform, administered by inhalation and pushed to pretty
deep anaesthesia, is perhaps, in most cases at least, the very best
relaxing agent. If its effects be kept up for some considerable
time, relaxation seldom fails to follow. If the anaesthesia be
not very deep, it may be used simultaneously with repeated
doses of the Actaea racemosa. Dr. Playfair highly extols .
chloral, given in water, fifteen grains per dose, at an interval of
twenty minutes, until three doses are taken—if unsuccessful,
another dose, at an interval of one hour. It is very seldom that
the os does not yield to some of these appliances. It is, how-
ever, recommended by some authors, where other measures do
not succeed, to resort to incisions, for the purpose of procuring
an artificial outlet for the foetus to pass. This may be justifi-
able where all other means fail—but very seldom will it be
necessary if the foregoing expedients be fairly tried—and espe-
cially the Actaea and chloroform.
Not unfrequently the resistance to dilatation in the os uteri
is of a spasmodic nature, termed spasmodic constriction. It is
important to distinguish this from simple rigidity. The re-
112 PRACTICAL MIDWIFERY.
sistance of the latter to dilatation is of a passive character, a
kind of vis inertiae, SO to speak, whereas the former is active.
We may anticipate spasmodic constriction when we find the
nervous system of the patient in a highly excited, sensitive
condition, when she is very intolerant of her pains, and, per-
haps, more particularly in subjects who have suffered from
dysmenorrhoea of a crampy character. If then, upon examina-
tion, we find the edges of the os uteri thinned and tense, and
very intolerant of the slightest touch, and, perhaps, at the
same time, dry and hot, we may conclude the case to be one of
spasmodic constriction. In simple rigidity the os is usually
thick, soft and moist, and mostly manifesting no unusual
tenderness.
When the difficulty is of a spasmodic character, as it not
unfrequently is, Acetate of morphia, one grain 1st dec, trit.,
may be given in repeated doses, at not long intervals, until the
desired effect is produced, or there is reason to believe that drug
will not answer our purpose. Of course the repetition should
be stopped short of narcotism. It needs not be apprehended
that the above indicated dose will, in this state of things, arrest
the progress of labor, or even produce narcotism, unless re-
peated with unreasonable frequency.
If Morphia, for any reason, good or otherwise, be deemed
objectionable, we may try some of our remedies which we have
found so valuable in rheumatic or neuralgic dysmenorrhoea,
such as Viburnum prunifolium, Xanthoxylum fraxineum, etc.
Where spasm is very plainly a feature of the case, arsenite of
copper is worthy of trial. Chloroform, given by inhalation, is
also here eminently applicable, and if Morphia have already
been tried without success, this latter following it, will almost
certainly succeed.
If rigidity of the perineum, after the head has come to rest
upon it, interpose difficulty and cause delay, one of the very
best remedies is to exercise patience, for sooner or later it will
yield. We should be careful, however, not to stimulate the
womb to unwonted action in this state of things. On the con-
trary, we should exhort the woman not to bear down—to con-
trol, by a strong will, the disposition there is at this stage of
DEVIATIONS FROM NORMAL LABOR. 113
labor to call the abdominal muscles into play to aid in the ex-
pulsion of the foetus. If the perineum be very rigid and uterine
action be very violent, we should always bear in mind that
there is great danger of serious rupture. Gelseminum I have
thought useful in rigid perineum. Some, I believe, commend
Lobelia—I have never tried it, and therefore can say nothing
certainly about it; but if its relaxing powers be not exerted
short of nausea, it would be very objectionable. Chloroform
extends its relaxing effects equally to this organ as to the os
uteri. There is a method of manipulation which, I think, I
have seen do much to hasten relaxation. The four fingers of
the right or left hand are so arranged that they form, with
their palmar surface, as they lie in close contact, side by side,
a Somewhat curvilinear line. They are thus introduced, in
the absence of a pain, between the head of the child and the
perineum, upon which it is resting. The perineum is thus
gently stretched and held in a state of tension until the head,
propelled by the next uterine contraction, is again forced
down. The fingers are then withdrawn, leaving the head to
keep up distension as long as the pain lasts. When the head
recedes, the fingers are again introduced, and the same manip-
ulation repeated as before. The rigid muscular fibres of the
perineum are thus soon wearied out and lose their resiliency,
so that the head is permitted safely to pass. I had long prac-
ticed this method upon my own responsibility, but lately see
it referred to by others. Dr. Clay advises, with much confi-
dence, to grease the perineum internally and externally with
lard, and to apply long continued rubbing to the outside.
Where the cause of delay is a slight disproportion between
the foetal head and the parturient canal, we are again called
upon to exercise patience. Here to stimulate the womb to
more vigorous action, would generally be to expose both
mother and child to unwarrantable risk. Time is required for
the process, as in these cases there is a tight fit, so that the
head is not free to obey the vis a tergo which urges it onward,
and has not space to move away from the resistance opposing
its descent. It gradually, however, under the propelling force,
becomes moulded by the overlapping of the cranial bones, so
8
114 PRACTICAL MIDWIFERY.
as to fit more loosely the diminished passage it must traverse.
The passage, too, becomes more thoroughly lubricated by the
secretions of its lining membrane, so as to facilitate the move-
ment of the foetus. By encouraging the patient, and thus
keeping up her strength and spirits, she will usually triumph
over the difficulty. It becomes us, however, to watch the case
with the utmost care. If we find the powers failing, unmis-
takable signs of the strength giving way, unless it be very
near the close of labor, we should at once furnish the aid
which art provides. The forceps should be introduced and
properly and securely adjusted, and, if the symptoms are not
urgent, we may, for the present, only give assistance during a
pain, relaxing our effort when the pain goes off. When the
womb finds itself thus aided and the sensation of the move-
ment of the child is felt, it is, as it were, encouraged, and
takes on more vigorous and successful action. The pulse and
other symptoms should, however, still be carefully noticed,
and if instead of resuscitated powers, we observe a still further
decline of strength, delivery should at once be effected. Where
there is extreme suffering in such cases, and there usually is,
and no contra-indication present, we should at least suggest to
the patient the use of chloroform, which, if properly given, will
annihilate her sufferings.
When delay is caused simply by extreme sensibility to pain,
we may try Coffea, especially if it be associated with general
nervousness. If this fail, and we find the patient’s peculiar
sufferings are almost unbearable, and interfering with the pro-
gress of labor, we here again have in chloroform a precious re-
source. When the patient is brought under its influence, her
extreme suffering generally ceases altogether, or is at least
greatly mitigated, and labor, held in check by the controlling
power of the will, resumes its normal course and goes on tran-
quilly to a fortunate close.
DEVIATIONS FROM NORMAL LABOR. 115
ABNORMAL LABOR ARISING FROM DEFORMITY OF THE
PELVIS OF THE MOTHER.
The pelves of different women, as we have before said,
vary in size—some are larger and some are smaller than that
regarded as the normal standard. In fact a standard size may
itself be considered as somewhat arbitrary. Properly speak-
ing, a pelvis simply differing in size from that usually accepted
as well formed, whether it be larger or smaller, so long as the
different diameters retain their proper ratio to each other, can-
not be called deformed. The necessary influence of such vari-
ation upon labor is simply, on the one hand to accelerate, and
on the other to retard, but not in either case to arrest.
There are, however, pelves so far deviating from the normal
in form, as to render a natural termination of labor exceed-
ingly difficult or impossible, unless the diminutive size of the
child counterbalances the obstruction. Such deviations are
properly regarded as deformities.
Deformities of the pelvis arise from various causes, and pre-
sent distinct forms. In early life rickets, and later mollities
ossium may give rise to pelvic distortion. Bony growths and
fractures may also be enumerated as causes of deformity.
Distortions of the pelvis may exist at the brim, in the cavity
or at the lower strait or outlet.
Deformities at the brim are mostly caused by the promon-
tory of the sacrum projecting unduly forward, and thus nar-
rowing the entrance to the strait. Those of the cavity, by
the sacrum being too straight, or, on the contrary, too much
curved.
Those at the outlet or lower strait, by too close an approxi-
mation of the tubera ischiorum, or by the spines of the ischia
projecting inwards, or by the bones of the coccyx having lost
thein mobility through extreme ossification. The first of these
varieties is said to be the most common.
In addition to the foregoing deformities, the symphysis
pubis may be depressed toward the sacrum or may be driven
forward or elevated. M. Naegelè has pointed out a variety of
deformity in which “the symphysis pubis is pushed to one
116 PRACTICAL MIDWIFERY.
side, the sacrum to the opposite side, the pelvis is flattened on
one side, bulging on the other; the oblique diameter on one
side is shorter, that on the other longer than natural.” To
this deformity the term “obliquely distorded pelvis” has been
applied. Yet another form of distortion is said occasionally
to be met with, although rarely, to which the name “funnel
shaped pelvis” has been given. In this case the upper strait is
of the normal size, but the pelvic canal narrows downward to
the lower outlet.
Professor Naegelè gives us the following external character-
istics as frequently associated with, and therefore indicating,
deformed pelvis. “The lower jaw projecting beyond the
upper; the chin very prominent; the teeth grooved trans-
versely ; unhealthy appearance; pale, ashy color of the face;
diminutive stature; unsteady gait; when the woman walks
the chest is held back; the abdomen projects and the arms
hang behind ; there is deformity of the spine and breast; one
hip higher than the other; the joints of the hands and feet are
remarkably thick; curvature of the extremities, especially the
inferior, even without distortion of the spine, is a very import-
ant sign; whenever 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 work in manufactories.”
Professor Rigby tells us in reference to deformities at the
brim that “besides the general appearance of the patient, we
frequently find that the uterine contractions are very irregu-
lar; that they have but little effect in dilating the os uteri;
the head does not descend against it, but remains high up; it
shows no disposition to enter the pelvic cavity, and rests upon
the symphysis pubis, against which it presses very firmly,
being pushed forward by the promontory of the sacrum.”
As it is very desirable in cases of deformity of the pelvis to
be able to form a pretty accurate opinion not only of the par.
ticular variety, but of its degree or extent, various expedients
have been devised for that purpose. Numerous instruments
under the name of pelvimeters have been contrived for meas-
DEVIATIONS FROM NORMAL LABOR. 117
uring the width of the superior strait. Of these, so far as I
know, that invented by Dr. Earle, of Birmingham, and that
by Prof. Lazarewitch, of Charkoff, Russia, are most worthy of
regard. The former consists of a pair of curved steel blades,
so arranged that when closed the one lies within a groove con-
tained in the other. A spring is so adjusted between the
handles as to keep the blades closed, while by pressing upon
the handles the force of the spring is counteracted and the
blades opened. Each arm or blade of the instrument measures
about seven inches. A scale graduated in inches is attached
to the end of one of the handles which passes through a slit in
the corresponding part of the other. This scale is furnished
with a sliding self-registering index, by which the distance of
the extremities of the blades from each other when separated
is indicated. The instrument is introduced closed and carried
up till the point reaches the promontory of the sacrum, when
by pressure upon the handles the blades are separated till we
have one resting upon the promontory, the other upon the Os
pubis, while the index points out upon the scale the distance
of their separation and consequently the width of the upper
strait. This in theory is very simple, in practice perhaps not
always found so easy. .
The instrument of Prof. Lazarewitch is more complicated,
and probably could not be understood by mere description. It
is applicable to both external and internal measurement of the
pelvis, and not only to the superior strait but to the cavity.
British practitioners prefer the finger or such instruments
as require the finger to perform the principal part in the opera-
tion. With the fingers unaided we shall probably be able, in
most cases, to get all the information necessary for practical
purposes. There are two principal methods by which we may
employ this means of information. The index finger may be
introduced, as in making a vaginal examination, the point is
carried upward and backward, until it impinges upon the
promontory of the sacrum, if that part can be reached. The
dorsal aspect of the finger nearest the hand is pressed against
the os pubis and the point of contact noted. Measurement
from this point to the end of the finger will give us, not
118 PRACTICAL MIDWIFERY.
exactly the width of the superior strait, but an approximation
to it. It measures the hypothen use of a triangle, of which the
width of the superior strait constitutes the next greater side,
and the width of the os pubis the third and smallest. The
angle, however, contained by the two latter sides is not a right
angle.
The other method, to which reference above is made, is to
introduce all the fingers, or as many as the space will allow,
into the pelvis side by side. When carried up so far that the
points may be opposite the promontory, they are separated till
one rests against that part, and the one on the opposite side
against the os pubis. Measurement of the extent of separation
of the points of the fingers will give us approximately the
length of the conjugate or antero-posterior diameter of the
superior strait.
When the promontory cannot be reached by the fingers in-
troduced according to the first method, we may consider the
upper strait as not much contracted.
In cases of deformity of the pelvis, no method of treatment
can be given as universally applicable. Much will depend
upon the degree of contraction, upon the size of the child,
especially of the head, the more or less. advanced Ossification
of the bones of the scull, etc. Our estimates of the degree of
deformity by any of the means at our command, should be
regarded, as we have said, rather as approximations than as
calculations absolutely correct. The same may be said of the
head in regard to its size, form and degree of compressibility.
Nor can we absolutely decide as to the powers of the womb, or
the degree of endurance of the patient. It is proper, there-
fore, that we should watch the case carefully and let the re-
sources of nature have a full chance to do all in their power
before we interfere, unless we are very confident, upon suffi-
cient ground, that they cannot unaided accomplish their task.
It is truly wonderful how great obstacles they will sometimes
ultimately surmount. But should any unfavorable symptom
be manifest as the herald of others soon to follow, we should
be on the alert to act at the opportune moment. We should
not suffer the woman to become dangerously exhausted while
DEVIATIONS FROM NORMAL LABOR. 119
we look on in culpable inactivity. Vigilance to discern the
exact moment to act and promptness to embrace it, are essen-
tial to the proper discharge of our duty on such trying occa-
sions. We should make ourselves sufficiently acquainted with
the case before us to determine with precision the particular
operation it demands, and then promptly, conscientously and
skillfully perform it.
Authors are by no means agreed as to the minimum space
compatible with the passage of a living child. When the nar-
rowing is but slight, but yet requiring instrumental inter-
ference, we can generally succeed with the forceps in effecting
delivery, unless the head be very large or the cranial bones and
sutures unusually Ossified. In the case of a patient whom I
attended some years ago in her first labor, and who has a some-
what contracted pelvis, I succeeded with the forceps in deliver-
ing a living child, without experiencing any great difficulty.
It was a female child, of ordinary size for the sex. In her se-
cond labor I again attended the same woman, when the head,
making little or no descent, I made several persevering but un-
successful attempts with the forceps, until finding the patient's
strength rapidly sinking, I opened the head. The perforation
was very difficult, and I found, after delivery, the sutures
nearly obliterated and the cranial bones of very unusual hard-
ness. The child was a male, and of good, but not unusual size.
As a general rule, where we do not detect very great narrowing
of the pelvis, we should carefully and perseveringly try the
forceps. But where we are unable to succeed with this instru-
ment by applying a reasonable amount of force, I cannot think
it our duty to persevere, to the great risk of the mother's life.
I am aware that even violent, persevering efforts are sometimes
ultimately crowned with success—both mother and child are
saved, it may be contrary to all hope. But, on the other hand,
the compression upon the child’s head, necessarily or uncon-
sciously exerted, frequently destroys its life, while the mother
too often succumbs to the injuries she has sustained. In ope-
rations with the forceps in cases such as we are speaking of, the
exercise of a discriminating judgment is necessary, aided by
some experimental knowledge of the capabilities of that instru-
ment, such as no mere didactic instruction can impart.
120 PRACTICAL MIDWIFERY.
When the narrowing of the pelvis is such that we cannot suc-
ceed with the forceps without using unwarrantable force, some
authors advise us to resort to turning. This of course supposes
the head not to have engaged, or very slightly so, in the upper
strait. The reason assigned for this procedure is, that the scull
is narrower at the base than at the top, and may therefore be
made to enter the superior strait as a wedge; that having done
so, by virtue of the vis a tergo supplied by the womb, and the
vis a fronte, by the hand of the operator, the head may more
readily be moulded so as to pass, than when it enters by the
top. Should, however, ossification have advanced so far as to
prevent this, or should we from any other cause not succeed, we
have the head in a far less favorable position for craniotomy
than before turning was executed. The latter may, however,
still be performed.
If, by turning, the larger part of the head be made to corres-
pond with the wider part of the deformed pelvis, we shall pro-
bably gain an advantage. But we cannot, I think, easily fore-
see such a result with sufficient certainty before operating, even
although possible, to calculate upon it with much confidence.
When however the deformity is so great as to reduce the
diameter of the pelvis beyond a certain limit, both forceps and
turning will fail. If the contraction be so great that a living
child cannot pass, the forceps cannot be employed for its bene-
fit, and in that case certainly not for the benefit, but at the
great risk of the mother. Here craniotomy comes in, which of
course sacrifices foetal life, if that be not already extinct, but if
well executed is less hazardous to the mother than the forceps,
where extreme violence would be necessary, even though it
might succeed in extraction.
No very definite limit can be given beyond which it is im-
possible to deliver a living child. Attendant circumstances
may greatly modify a particular case. The head may be unu-
sually large, or it may be very small. Ossification may be far
advanced, or the scull may be cartilaginous and yielding; the
sutures may be nearly closed or obliterated, or they may be
open and admit the free overlapping of the bones. It is mani-
fest that under these different circumstances there may be a
DEVIATIONS FROM NORMAL LABOR. 121
very considerable range of limit, compatible with the birth of
a living child. Dr. Meadows, one of the latest writers upon
Midwifery, remarks: “As a general rule, it may be stated that
the case is a fit one for the application of the forceps, if there
be a conjugate diameter of from 34 to 4 inches; if less than 3}
inches the forceps will be unsuccessful, but between that mea-
surement and a conjugate diameter of 2% inches, the operation
of turning will probably succeed; if there be less than 2;
inches but more than 1; then craniotomy must be resorted to ;
but to perform this operation with any reasonable hope of suc-
cess as regards the mother, there ought to be a clear available
space of at least 13 inches; if the conjugate be less than that,
then a mutilated child cannot, with safety to the mother, be
extracted, and the Caesarean section is our only choice. Some
have thought that 2 inches is the narrowest through which a
mutilated child can be extracted, while others have fixed one
inch as the lowest.”
When deformity of the pelvis has been ascertained suffi-
ciently early, it has been advised upon very good authority, to
forestall the inevitable difficulties that await us if labor be de-
layed till full term, by inducing it prematurely. This method
has undoubtedly been often practiced advantageously as regards
the mother, and not unfrequently saving the life of the child,
which otherwise would have been lost. This is, however, an
expedient not without its opponents, and, indeed, it may be
asked what expedient has ever met with the approbation of all.
It must be admitted that the induction of premature labor is
not without its dangers to the mother, and does not always
hold out flattering prospects of safety to the child. As regards
the physician, if he succeed it is well, but if any disastrous re-
sults follow this operation, he is more likely to be subjected to
censure than if such had been encountered at the natural close
of gestation. If such a measure be contemplated, it is best for
him simply to state its probable advantages, and leave the pa-
tient to make her own choice and take her own risks.
If the induction of premature labor be decided upon, it is a
matter of no small moment to determine the best time for the
performance of the operation. This will, of course, vary under
122 PRACTICAL MIDWIFERY.
different circumstances, as, for instance, the different degrees of
deformity that may exist. To quote again from Dr. Meadows
upon this subject: “Supposing,” says he, “a conjugate diame-
ter of 3} to 4 inches, labor may be completed at the seventh
month, with no other operation than is necessary for its induc-
tion; if the conjugate be not less than 34 inches then forceps
will be applicable at the same period; from 3} to 1; inches,
turning will probably succeed at the seventh month ; but if the
diameter be less than 1% inches, nothing short of craniotomy
will suffice, even at this early period of gestation.”
DEWIATIONS FROM NORMAL LABOR HAVING THEIR ORIGIN
IN THE CHILD.
Deviations from the natural or typical form of labor, attri-
butable to the child, may arise either from some abnormal con-
dition appertaining to it, or from its relation to the pelvis of
the mother in regard to its presentation or position at the time
of labor.
Under the first of these divisions we may notice the extraor-
dinary general size of the foetus. The cause of this extreme
intra-uterine growth cannot usually be assigned ; but it may
sometimes be ascribed to the vigor of one or both parents,
especially the mother, or it may, perhaps, Occasionally be
owing to the child being carried longer than the ordinary
period of gestation. There can be no doubt but that labor is
in some instances considerably postponed beyond the usual
epoch. Some women think they habitually carry their chil-
dren ten calendar months. Extreme cases are quoted even in
excess of this period. It is to be presumed, where the mother
is vigorous, that the child still continues to increase in size up
to the time of its birth, and in any given case will, of course,
be of larger size at the close of ten months than at the expira-
tion of nine. The degree of deviation from normal labor,
caused by excessive growth of the foetus, will much depend
upon the vigor of the mother and the conformation of the
parts concerned in parturition. If she be strong and well
formed, having a wide pelvis and moderately yielding soft
DEVIATIONS FROM NORMAL LABOR. 123
structures, the size of the child will modify labor in no other
way than by causing a little delay and more or less additional
suffering. It will ultimately terminate unaided, with perfect
safety to both mother and child. But on the other hand, if
the woman be feeble, lacking courage or possessing a pelvis
below the standard size, even short of deformity, labor may
not only be protracted, but require the assistance of art, or
even end disastrously to mother or child, or both. On the
part of the mother we may look for extreme exhaustion, some-
times even fatal, rupture of the womb, of the perineum, or
post-partum flooding, owing to failure of the womb to con-
tract after delivery. Fortunately, however, excessive growth
of the foetus during intra-uterine life is rare, and where it
occurs, its ill effects are mostly counterbalanced by the posses-
sion of rare parturient powers on the part of the mother.
More frequently, perhaps, we meet with cases where the
general size of the child is not extraordinary, but some par-
ticular part is abnormally developed. The head, for instance,
may be so large as to prevent its entrance at the superior strait,
or, if it enter, its passage through the excavation of the pelvis
may be much retarded, or possibly even arrested. This
abnormal size may be owing to monstrosity, but more com-
monly, perhaps, to effusion within the cranium.
Again the abdomen of the child may be enlarged much
beyond the natural size, through a collection of fluid within
its walls, the result of intra-uterine ascites. The child, it will
be recollected, is subject to various maladies before, as well as
after it is born. Dropsical effusions may also take place in
other situations, directly or indirectly complicating labor. I
was once called to a case in which, upon my arrival, I found
the os uteri fully dilated, but the pains were feeble. After
waiting for some time without any improvement in uterine
action, I administered small doses of the tincture of Ergot.
The womb very promptly responded in a very satisfactory
manner, the pains becoming vigorous, but of the usual inter-
mitting character. The pelvis was well formed, and there was
no apparent impediment to the satisfactory progress of the
labor. The membranes were artificially ruptured at the proper
124 PRACTICAL MIDWIFERY.
time, but the head showed little disposition to enter the upper
strait. Upon examination I found little or no flexion; instead
of the vertex, the top of the head presented. By means of the
fingers pressing upon the forward part of the head or longer
arm of the cranial lever, I compelled flexion during the con-
traction of the womb, and by this means the presenting part
was enabled to enter partially the Superior strait. But very
soon all progress was arrested, although the action of the
womb was still vigorously maintained. Symptoms of exhaus-
tion on the part of the mother becoming manifest, delivery
was effected with the forceps, and as the head had neither
flexed nor rotated, one blade rested upon the forehead and the
other upon the occiput. As soon as the child was born, the
cause of the difficulty was clearly apparent. A large collec-
tion of fluid had formed immediately beneath the chin, com-
pletely filling up the whole space between that part and the
thorax, and by its tension entirely preventing flexion of the
head, unless compelled by considerable force. This large col-
lection of serous fluid gave to the child the appearance of
hopeless deformity, but entirely disappeared in the course of
the first night. An unusually large amount of urine was
evacuated, and with it the tumor disappeared.
Another case occurred to me in the same neighborhood,
which, although not exactly similar, may be mentioned in the
same connection. When I reached the bed-side I found the
labor had been at a standstill for some time, although the
pelvis was well formed and uterine action very vigorous. Upon
examination I detected the brow presenting and the head
arrested through want of a proper correspondence of diameters.
The mal-position was, however, easily corrected, and this being
accomplished, the child was soon born. Upon examination I
found a singular redundancy of integument beneath the chin,
preventing due flexion, as in the preceding case, and undoubt-
edly leading to the unfavorable position mentioned above.
This slight deformity eventually disappeared, but not so sud-
denly as that in the former case.
Monstrosity of the child in some of its parts, from abnormal
development, is occasionally encountered, causing a greater or
DEVIATIONS FROM NORMAL LABOR. 125
less deviation from normal labor, according to its kind and
degree. Omitting to notice such deformities as do not modify
labor, we sometimes meet with duplications of the members of
the child, as of the upper limbs. Sometimes the foetus will
be found having a double head. A case of this kind occurred
to Dr. Pfeiffer, of this county (Adams, Pa.), many years ago.
The child was delivered without separation of its parts, and
exhibited in the city of Philadelphia and elsewhere. The case
is referred to by Dr. Hodge, in his work on Midwifery, as re-
lated to him by the late Dr. C. D. Meigs. Two foetuses are
sometimes found connected together, and this is said to be the
most frequent form of duplication. Of this, the Siamese
twins, now lately deceased, furnish a striking example. “The
union may be either by the abdomen, the side, or the back, or
more rarely by the head. I have in my possession a photo-
graph of two children who were joined together at the top of
the head, end to end as it were.” (Meadows' Manual of Mid-
wifery, p. 384).
Two girls, Millie—Christine, lately on exhibition in Paris,
were examined by MM. Tardieu and Robin, by order of the
authorities, and the result reported to the Académie de Médé-
cine. “The girls, 22 years of age, are united at the sacrum.
The upper portions of the body are separate; they have two
hearts, which do not beat in unision, and the radial pulse in the
two is not isochronous, while there is complete synchronism in
the pulsation of the lower extremities in both subjects. The
sensibility of the upper limbs is distinct and separate in each
subject, while any impression on the lower limbs is felt at the
same time by both subjects. MM. Tardieu and Robin endeav-
ored to persuade the girls to permit an examination of their
pelvic region, and one seemed inclined to assent, but the other
most indignantly refused, showing each had her own independ-
ent will.”
Another cause of deviation from normal labor, which may be
properly spoken of in this connection, is the presence of more
than one foetus within the womb at the same time. There
may be two or three, and it is even asserted there are occasion-
ally four or five. Twin births are not very uncommon, vary-
126 PRACTICAL MIDWIFERY.
ing somewhat in the course of different years, and very consid-
erably in different countries. Thus they are said to occur in
England about once in 76% cases; in France, once in 108 cases;
in Germany, once in 81% cases. I am not in possession of sta-
tistics to speak of their frequency in the United States, but if
I may be allowed to judge from the results of my own practice,
which has been altogether private, I would suppose the ratio to
be quite as high as any of the foregoing. Triplets are of much
less frequent occurrence. In England they are said to be met
with only once in 6,000 cases; in France, once in 6,568 cases,
and in Germany, once in 8,454 cases. Plural births are said to
occur more frequently in Ireland than in any other country.
The presence of more than a single foetus does not necessarily
seriously complicate labor, although, in general, it at least re-
tards delivery. In cases of this kind, especially if triplets, the
children are small, and therefore meet with less resistance in
their passage. But, on the other hand, these cases combine
several elements of delay. The womb is necessarily over-dis-
tended, and, as we have already seen, its powers of contraction
are thereby greatly diminished. The propelling force, more-
over, which it exerts, is indirectly applied to the presenting
foetus, often acting only through the other child or ovum. It
is, from the same cause, often misdirected from the proper line
of propulsion. The infants do not generally both present in an
equally favorable manner, and not unfrequently the one lies in
the way of the other's egress. I remember a case where, upon
my first examination, my finger impinged upon the thorax of
the first child, a presentation distinctly made out by the pres-
ence of the ribs. Here, as both foetuses were of good size, de-
livery by the unaided natural powers was perhaps impossible.
In plural births the first stage of labor is usually considera-
bly retarded, but when one child is born the other generally
soon follows. This happens in the first place, because in plural
births the infants are, as we have already said, mostly smaller
than in single, but principally because the parts are so com-
pletely dilated by the birth of the first child, that there is but
little resistance to the passage of the second.
So fortunate a result, however, is not uniform. On the con-
DEVIATIONS FROM NORMAL LABOR. 127
trary, the birth of the second child is sometimes postponed for
hours, and even days, if left to nature alone, and such delay is
generally fatal to its life. According to Dr. Collins, “experi-
ence has shown that the second child is very likely to be still-
born, if left longer than two or three hours unassisted.”
Another circumstance connected with the child which may
cause parturition to diverge somewhat from its normal course,
is the occurrence of its death some days before labor has set in.
We need not stop to inquire how such an accident may hap-
pen—it may be from defective nutrition, from disease, or from
external violence upon the person of the mother. Whatever
the cause the effects are the same.
Some have denied that the previous death of the foetus has
any effect whatever upon the subsequent labor. Probably some-
times it has not. When the child has gradually pined away,
from mal-nutrition, or chronic disease from any cause "what-
ever, and has therefore attained but a very imperfect growth,
it will find but little resistance in passing through the parts of
the mother, and may therefore be speedily born. But if fully
developed, and of a large or good size, the case will be different.
A dead foetus manifestly has not the firmness and resiliency of
a living one. The spinal column lacks the stiffness necessary
to receive and transmit the propelling force to the part in ad-
vance, and hence it does not favorably progress. The flacidity
of the whole body causes it to spread under the force of the
womb, and to fill up and crowd the cavity of the pelvis, which
necessarily interferes with its free passage. If, moreover, the
head lack the usual firmness, as we think it generally does,
when the foetus has been for some time dead, it fails to dilate
the os when it comes to press upon it, as the head of a living
child is found to do. The resultant of these different causes is
delay—a prolongation of labor beyond the limit necessary for
the birth of a living child of equal size.
In pointing out the treatment of the foregoing deviations
from normal labor, we will notice them in the order in which
we have taken them up. The difficulty arising from the unu-
sual size of the child, generally being greater suffering and
longer delay in the labor, will mostly be surmounted by the
128 PRACTICAL MIDWIFERY.
natural powers alone if the woman be well formed, vigorous,
courageous, and endued with the power of endurance. Such
cases are, however, exceedingly distressing to witness from the
vast amount of suffering they entail. The humane physician
should never allow himself to look on such suffering with in-
difference, if he can in any legitimate way do anything to miti-
gate it. Something may here be done by his confident and yet
sympathizing demeanor toward the patient; by his assurance
of her ultimate triumph; by his busying himself in doing, or
at least seeming to do, everything that can be done to make
her comfortable; by diverting her mind between her pains
from her sufferings and occupying it with pleasant subjects;
by using all the little appliances that may really tend to her
comfort, such as pressing upon the back or Sacrum, Sustaining
with the hand the walls of the abdomen during a contraction;
giving her something to grasp with her hands, etc. All these
measures to some extent do good, and yet such is sometimes
the inconceivable agony of the woman, especially of the primi-
parous woman, that we must excuse her, if in the midst of all
this, she turn to us with the exclamation, “miserable com-
forters are ye all.”
If symptoms develop themselves in the course of the labor
corresponding with our knowledge of the power of homoeo-
pathic remedies to relieve, we should by all means at once
administer them. If these means fail and if the sufferings of
the patient be unbearable, I hope I may be pardoned for say-
ing most positively, that if no very manifest contra-indication
be present, we should give her chloroform to the complete relief
or at least great mitigation of her sufferings. Pain is itself an
evil, and a great one, but I am not as yet convinced that
chloroform in this relation of it is. We do not hesitate to
give it to a woman under the knife, in the operation of ovari-
otomy—and without it, I do not know that the sufferings of
the patient would be more excruciating than those of the
woman in the severest forms of labor. They would at least,
generally, be of shorter duration. Under the influence of this
agent, if its administration has not been too long delayed, the
excitement of the patient gradually and beautifully subsides,
DEVIATIONS FROM NORMAL LABOR. 129
the expression of agony upon the countenance gives place to
One of calm placidity, the passages become relaxed, the mucous
surfaces lubricated by an abundant secretion, the quick, irri-
tated pulse returns to nearly the normal standard, and the
labor is generally found to progress more in one hour than it
had done in many hours before. These results I have too
often witnessed with inexpressible delight for any man to con-
vince me that it is all a delusion, and have too frequently seen
the patient make a speedy and perfect recovery to be per-
suaded by any sophism that I have killed or injured her by
the operation. We think, too, the use of chloroform lessens
the liability to the worst consequences sometimes following
long compression of the mother's tissues. By obtunding the
sensibility of the parts there is less irritation, consequently less
afflux and less congestion, and therefore less danger of inflam-
mation and sloughing.
If we find the patient's powers likely to prove inadequate to
the task, especially if we discover any signs of sinking or col-
lapse, and before this proceeds to a dangerous extent, we
should apply the forceps if the head present, and if the breech,
adopt such measures as will be pointed out when treating
especially of that presentation.
The forceps might be introduced, properly applied and
locked, not with a view to immediate delivery, but to assist
during a pain, the efforts of the womb. In this manner de-
livery may be gradually effected and the head have time to
mould and accommodate itself to the passages, and these latter
gradually to dilate and thus more readily permit its transit.
In cases of unusual size simply of the head, the same meas-
ures as above will generally be found applicable. Here if the
powers of the womb prove inadequate, the forceps must be re-
sorted to before, and long enough before, the patient sinks into
collapse. We should remember, too, if the action of the womb
be violent, that there is great danger of the rupture of that
organ. If the forceps fail from advanced Ossification of the
cranial bones, or even from the size of the head being such
that we feel convinced it cannot pass, there is then no alter-
native but a resort to craniotomy. If, however, the extraordi-
9
130 PRACTICAL MIDWIFERY.
nary size of the head depend upon hydrocephalus, which may
mostly be detected by the openness of the sutures and its gen-
eral compressibility, if we do not or are not likely to succeed
with the forceps, or if the instrument be not adapted to the
case on account of the head being so much enlarged that it
does not enter the upper strait, we may discharge the con-
tained fluid by means of a trocar, and afterward extract.
Turning is advised by some in cases where there is a possibil-
ity of preserving the life of the child when an attempt with
the forceps has failed, and when the head has not descended so
far into the pelvis that it cannot be pushed up so as to allow
the feet to be brought down. The grounds upon which
preference for this operation rests, are elsewhere stated. It is,
however, generally doubtful whether turning will succeed if
the forceps do not, and if after performing version we fail to
extract the head, we ensure the death of the child as well as
increase the risks of the mother. In such case we are obliged
ultimately to resort to craniotomy, and we have placed the
head, as has been before remarked, in a position far less favor-
able to the performance of this operation than it was in before.
The operation is now not only more difficult to perform, but
its execution probably imperils the structures of the mother
considerably more than when the top of the head presents.
Enlargement of the abdomen through foetal or intra-uterine
ascites is of rare occurrence, and hydrothorax or enlargement
of the chest through dropsical effusion within its walls is said
to be still more so. To quote from Cazeaux, “The signs indi-
cative of dropsy of the chest, are a considerable enlargement
of the thorax, a widening of the intercostal spaces, and an evi-
dent fluctuation in these enlarged intervals. On the contrary
the extraordinary size of the belly, the distension of its walls
and the fluctuation detected there, characterize ascites.” This
is all simple enough, and yet when a foetus possessed of either
of these abnormalities, is crowded into the pelvis of the
mother, it may be difficult to ascertain the facts necessary to a
certain diagnosis. If, however, the descent of the head, while
the thorax or abdomen refuse to enter the pelvis, leads us to
suspect either of these diseased conditions in the child, we
DEVIATIONS FROM NORMAL LABOR. 131
should spare no pains to ascertain the truth. But let us hear
M. Cazeaux still further, for we can perhaps consult no better
authority. “The foetus being retained by the amplitude of
one or other of these cavities, is arrested in its progress
through the pelvis, and the accoucheur finds the excavation
filled up by a large fluctuating tumor. In some cases of ex-
treme distention of the abdomen, the walls of this cavity have
been found to yield, so that a great part of the tumor remained
above the superior strait, whilst the rest of the trunk gradu-
ally descended into the excavation; and when one portion of
the abdomen had reached the exterior, the liquid gravitated
towards this point, where the resistance was less, the portion
remaining internally progressively diminished in volume, and
the labor terminated naturally.” Some provision like the
foregoing will probably be found often to supply the needed
aid in such cases.
If, however, after giving the natural powers sufficient time,
and even aiding them by traction cautiously applied, we find
the child cannot be born, we are advised to puncture the
thorax or abdomen and discharge the fluid contained therein.
This should be done by means of a small trocar, and done
carefully, so as to give the child whatever chance for life its
diseased condition may have left to it. There are several
cases reported by M. Depaul in which an enormously distended
bladder simulated ascites, and he is of opinion that the latter
condition is often mistaken for the former, which he thinks is
very rare. Where distension of the bladder prevents delivery,
the puncture of this viscus will also be necessary, and should
be done as nearly as practicable according to the rules laid
down in works on Surgery for the performance of the opera-
tion upon the adult.
In cases of dropsical effusion into the cellular tissue, beneath
the chin and in front of the neck, such as the one I have above
detailed, I can think of no other or better management than
that adopted, namely, delivery with the forceps. In such
cases, where the head has come within reach, and unflexed,
especially if it be of large size, it would be, I apprehend, very
difficult by the sense of touch to ascertain the exact nature of
132 PRACTICAL MIDWIFERY.
the case, and even if made out, very hard to discharge the fluid
by means of an instrument. The plan adopted was successful
—the child is still living, and by far the brightest of the family.
The objection to the use of the forceps in this case was, that the
head being transverse and unflexed, one blade of the instru-
ment must necessarily lie over the eyebrows and nose, endan-
gering contusion of those parts. As the head did not undergo
flexion or rotation in its descent, it must have brought its
occipito-frontal or long diameter into correspondence with the
transverse, or short diameter of the lower strait. There was,
therefore, danger of the injurious compression of the intra-pel-
vic soft structures of the mother. Something of this kind pro-
bably did occur, for the patient suffered for some time with
pain in one of her lower limbs, which did not, however, set in
till some days after delivery. Otherwise she made a good re-
covery.
No general rule applicable to all varieties can be given for
the management of labors in cases of monstrosities. When the
monstrosity consists in a deficiency of the natural parts of the
foetus, it does not complicate the process, and therefore requires
no treatment different from normal labor. But where there
are redundant parts, the case may require a greatly modified
management. Even here, however, the child may be small, so
that it may be born even with two heads, by the natural
powers. If not, when one head is extruded, it may possibly be
turned out of the way while the other is brought down. If
this cannot be done, the one head may be removed by decapi-
tation, and the remainder of the child delivered either by the
natural forces, or with such aid as may best suit the case. It
is the mother's safety alone that is here to be taken into the
account, for such a monster is incapable of prolonging life, even
though delivered entire. Where two foetuses united are born
alive, as the Siamese twins, they are probably small, and pass
side by side.
The treatment of cases of plural births, so far as it differs
from normal labor, is for the most part very simple. If, upon
examination, we find the presenting child in such position that
it cannot be born through the natural forces alone, as soon as
DEVIATIONS FROM NORMAL LABOR. 133
*
the os uteri is sufficiently dilated we should render the assist-
ance necessary. If the shoulder for instance present, we may
perhaps succeed in correcting the mal-position by external and
internal manipulations conjoined, as elsewhere in this work
more particularly described. If the side or back of the child
present, turning will be necessary, to remove it out of the way
of the other. If the womb be not in vigorous action, it will
perhaps be better simply to turn, and leave the further, process
to the natural powers, stimulating the womb, however, with
Ergot in repeated doses at short intervals, till it responds in a
satisfactory manner. It should be a rule in plural labors never
to be forgotten, not to empty the womb suddenly, unless it be
in very vigorous action. If this be neglected there is great
danger from the over-distension and consequent atony of that
organ, of bringing on very dangerous hæmorrhage. Should this
accident occur from any cause whatever, it should be promptly
treated as directed in another place.
After the first child is born, if the womb do not very shortly
resume its action, we should use means to arouse it, as too long
delay—as we have already intimated—may be fatal to the
second child. Our first efforts toward this object may be simply
frictions with the hand over the region of the womb, a measure
which will often succeed in awaking that organ to renew its
efforts and finish its task. Should this fail we have the Ergot
to fall back upon. When the pains set in vigorously we may
rupture the membranes of the remaining sac, which will accel-
erate the birth of the foetus. Where there are two or more
foetuses present at once in the womb, usually each one has its
own placenta, independent of the other or the rest. We should
never, however, attempt to remove the placenta of the first
born until the birth of the other has taken place. To do so
would most likely be productive of very severe, if not fatal
haemorrhage, and sometimes cause the death of the unborn
child. It occasionally happens when one foetus presents by
the head and the other comes down by the feet, that the chin
or Occiput of the latter locks upon the corresponding, or at
least some part of the head of the former, so that neither can
pass. When this unfortunately occurs, we may try to push up
134 PRACTICAL MIDWIFERY.
the presenting head, and if we can succeed in doing so, we may
deliver the other by the feet. This manoeuvre failing, our only
remaining resource will be to separate the head of the one
whose feet have come down, and push it out of the way, so as
to permit the presenting head to come down. When this child
is born it will be our concern to deliver the decapitated head,
yet remaining in the womb. If the head be small and the pas-
sages well dilated, we may succeed in doing this with the un-
aided hand. But should we fail in this manner, we will pro-
bably find the following appliance enable us to succeed. A
piece of thin, well-dressed and soft calfskin, such as is usually
sold under the name of “whang leather,” of such a size that
the central portion, after it is prepared, will be sufficiently large
to surround the foetal head as a cap. With a knife cut out
from the border of what is designed to be left as the central
portion toward the margin of the whole piece, so as to give the
whole a star-like shape ; the rays, when it is finished, will be
straps emanating from the margin of the circular central part.
This, when well lubricated, can be carried up with the hand,
and a portion of the straps thrown over the head and drawn
down, while the others can be retained on the opposite side.
Now if all these straps be collected in one hand and gently
drawn, they will bring the central or uncut portion of the
leather to surround and enfold the foetal head. By drawing
upon the straps with a waving force, the head will be extracted
and so protected that its projecting bones will not wound the
tender tissues of the mother.
To prevent awkward and discreditable mistakes, we should,
in every case of labor, carefully examine the womb by external
pressure, after the birth of the child, to ascertain if there be
another still undelivered. This we may easily determine, un-
less it might be possible to mistake where the patient has a
great deal of adipose tissue upon the walls of the abdomen, and
the foetus be very small. The irregularity of surface presented
by a remaining child will readily distinguish it from the glob-
ular form of the contracted womb, which is usually felt shortly
after delivery.
The slight deviation from normal labor occasioned by the
DEVIATIONS FROM NORMAL LABOR. 135
death of the child some time previous, requires but little modi-
fication of treatment. If the collapsed condition of the head
cause delay in the dilatation of the os, if deemed necessary,
this may be hastened by the use of Barnes' dilators. If the
labor should prove so tedious that the patient’s strength is
likely to become exhausted, the forceps should be used or cra-
niotomy performed if better indicated, for here the mother's
safety is the only object in view—the child being manifestly of
no account.
DEWIATIONS FROM NORMAL LABOR ARISING FROM
UNFAVORABLE PRESENTATIONS OF THE FOETUS.
We have seen that in what we have selected as the normal
type of labor, not only is the head the presenting part, but
the vertex or top of the head is found lowest, and is the part
upon which the finger impinges in making the usual examina-
tion. This presentation is not only the most simple, the most
favorable to delivery by the natural powers alone, but it is by
far the most frequent. Under circumstances, however, favor-
able to such deviations, almost any part of the foetus may pre-
sent. But such cases are exceptions to the beautiful simplicity
whereby nature accomplishes her purposes in the process of
parturition.
Upon making a vaginal examination in a given case of labor,
we may satisfy ourselves that the foetus lies in an inverted po-
sition in the womb, that is, that the head is lowermost ; but
we cannot infer from this with certainty that the vertex will
present. Instead of the head entering the upper strait, flexed,
with the chin nearly approaching or resting upon the thorax,
it may depart therefrom at its entrance, or extension from
Some preexisting cause may, in exceptional cases, have taken
place prior to the commencement of labor. In either case, as
labor advances, the chin departs more and more from the chest,
and the Occiput is necessarily thrown further and further back-
ward and approaches nearer and nearer to the upper part of
the back or posterior plane of the foetus. This gives rise to
a) Presentation of the Face,—It is probable that nearly
136 PRACTICAL MIDWIFERY.
all face-presentations are originally presentations of the vertex.
That is, before the membranes are ruptured and the head at-
tempts to enter the strait, flexion already exists, and it is ready
to descend in the usual manner with the vertex in advance.
But from the direction of the propelling force, the shape of
the pelvis, or that of the head, the occiput encounters resist-
ance, while the forehead is free to move. The propelling force
continuing to act, is expended upon or communicated to the
longer arm of the cranial lever, which, obedient to the impulse,
moves in the direction of least resistance, carrying the chin
more and more remote from the thorax, and consequently leav-
ing the occiput still further behind it. It is manifest that the
more the head advances under these circumstances, the greater
will be the resistance with which the occiput will meet, and
consequently the more firmly it will be pressed upon the pos-
terior surface of the chest. As the atlanto-occipital articula-
tion in the foetus admits of much freer movement than in the
adult, this will bring the face nearly or directly downward,
constituting a face-presentation.
Similar to the foregoing is the explanation given by Dr.
Barnes. “A force,” says he, “which is generally unnoticed
in obstetrics, is friction, and if friction were uniform at all
points of the circumference of the head, it would be unim-
portant in a dynamic point of view to regard it. But it is
not always so. Friction at one point of the head may be so
much greater than elsewhere, that the head, at the point of
greatest resistance, is retarded, while at the opposite point the
head will advance to a greater extent, or resistance at one
point may quite arrest the head at that point. In either case
the head must change its position in relation to the pelvis.”
“Tet us then take the case where excess of friction bears
upon the occiput, directed to the left foramen-ovale. This
point will be more or less fixed, while the opposite point or
forehead, receiving the full impact of the force, propagated
through the spine to the atlanto-occipital hinge, will descend—
that is, the forehead will take the place of the vertex and be
the presenting part. If this process be continued, the head
rotating back more and more upon its transverse axis, the face
succeeds to the forehead.”
DEVIATIONS FROM NORMAL LABOR. 137
As the most successful management of face-presentations
depends upon our detecting them before the head descends so
far that they cannot be rectified, it is of the utmost import-
ance that we should be familiar with the characteristic symp-
toms by which they may be made out.
Before the membranes are ruptured the diagnosis is not
easy. The head is generally high, and if the membranes be
tense, it is not easy to reach the presenting part. As reversion
is not yet completed, if the presentation be reached at all, the
finger impinges upon the forehead, which may be mistaken
for the vertex. But if the membranes be lax or ruptured, the
diagnosis becomes more easy. By careful examination we can
detect the nose and eyes, the first a well-marked elevation
terminating abruptly, with two openings—the nares, the latter,
depressions surrounded by bony margins or rims, distinguish-
ing them sufficiently from anything else. The mouth may be
felt, characterized by the gums or solid alveolar process. This
will, one would suppose, sufficiently distinguish it from the
anus, the only opening for which it could be possibly mistaken.
Velpeau, however, tells us of a French professor who just after
making an examination of a patient in labor, and who snp-
posed he had introduced his finger into the mouth of the foetus,
pronounced the case to be a presentation of the face, and
boldly asserted the impossibility of his mistaking a breech-
presentation for a case of this sort, while, to the great amuse-
ment of his class, his finger was seen to be covered with
meconium. Careful reflection will, however, we think, prevent
such mistake—the opening of the mouth surrounded by solid
structures, the anus soft and probably resisting the introduc-
tion of the finger. The sensation of suction is said sometimes
to be felt upon introducing the finger into the mouth.
The diagnosis is, however, more difficult when the present-
ing part is crowded down into the pelvis in a more advanced
stage of labor. But it is then usually too late to do anything
effectively in correcting the mal-position. As it is then the
best we can do to wait and give nature fair play, we can take
time for fully considering the case without causing any detri-
ment to our patient. By careful and deliberate examination
138 PRACTICAL MIDWIFERY.
and due reflection upon the result, we shall be able to make
out the true state of the case in time enough to be ready to
render the necessary aid.
Cazeaux admits “two fundamental positions of this presen-
tation; in one of which the chin looks toward some point on
the right lateral half of the pelvis, the right mento-iliac ; and
in the other it is directed to one of the points on the left
lateral half; the left mento-iliac position; “and we may repeat,”
says he, “for the face what was said concerning the vertex-
presentations, namely, that there is no portion of the circum-
ference of the superior strait with which the chin may not be
in relation at the commencement of labor; nevertheless we
shall include all these shades of position in the three principal
varieties of each side; that is, for each fundamental one, we
have the anterior, the transverse and the posterior varieties.”
The opinions of authors vary considerably as to the difficulty
created by face-presentations, especially where the chin finally
turns backward in relation to the pelvis. Dr. W. Hunter, in
his MS. Lectures, as quoted by Dr. Meadows, remarks: “In
this case I do not turn the head around, in order to deliver,
but nineteen times in twenty leave it to itself to come as it
will.” To this Dr. Meadows adds, “The same opinion is ex-
pressed and the same practice adopted by most English author-
ities.” And further still the same author continues, “As a
general rule no treatment is required in the management of face-
presentations; for beyond a somewhat protracted first stage
and a little more pain to the mother, these cases mostly do
well.” On the contrary Dr. Barnes tells us that some of the
most difficult cases to which he has been called in consultation
were cases of presentation of the face. Of course very much
will depend upon the size of the child, especially of the head,
the shape of the latter, amplitude of the pelvis, etc.
If we be present before the face enters the superior strait
and detect this presentation, we should by all means seek to
correct it. We have already remarked that by far the larger
proportion, if not all these cases were most probably presenta-
tions of the vertex; that they have been changed by the ver-
tex or occiput meeting with resistance in its descent greater
DEVIATIONS FROM NORMAL LABOR. 139
than that encountered by the forehead, in consequence of which
the former was retarded or arrested in its progress, while the
latter, free to move, advanced and took the place of the ver-
tex. Now if we can reverse this state of things, we shall over-
come the difficulty. By introducing two fingers of the hand,
of which the palmar surface will most readily apply to the
forehead or the chin, according to the degree of extension
which has already taken place, and with the points of them
pushing it up, while, if practicable, two fingers of the other
hand, or a lever, are hooked over the Occiput, so as to draw it
down, we may restore flexion and thereby change a forehead
or face-presentation into one of the vertex. Here, by means
of the fingers, we more than counterbalance the resistance
which the occiput has encountered, by creating resistance to
the descent of the forehead, while we enable the occiput to
overcome that which detains it, by applying additional force.
If flexion be thus restored and maintained until the vertex
enters the upper strait, and if the action of the womb be
energetic, we may leave the labor to be completed by the
natural powers. Attempts to rectify the presentation in the
early stage of labor, have the approbation of some of the most
eminent accoucheurs. “If the practitioner be called early,”
says Dr. Hodge, “and recognize a face-presentation, after the
os uteri is dilated and before the presenting part has passed
this opening, the author thinks that in all cases it would be
best immediately to resort to version by the vertex. For under
the circumstances just mentioned, especially in multiparous
women, the operation can be easily and rapidly performed
without much suffering to the mother, and will effectually de-
liver the child and its parent from all the unpleasant incidents,
delays and even dangers of facial presentations.” “Now,” says
Dr. Robert Barnes, “if we can transpose the greatest friction
or resistance to the forehead, and still maintain the propelling
force, it is clear that the occiput must descend and that the
normal condition may be restored.” o
The author, however, last quoted, admits of cases where
such a fortunate result could not be reached. “In some,” says
he, “the face will not enter the brim,” and then asks, “What
140 PRACTICAL MIDWIFERY.
shall we do here?” The application of the forceps under
these circumstances he thinks attended with peculiar difficul-
ties, and advises turning by the feet or podalic version as hold-
ing out a better prospect to both mother and child.
It will often happen, however, that we do not reach the
patient in time to effect a rectification of the mal-presentation.
The face has already entered the pelvis and descended too far
to leave any hope of pushing up the chin and bringing down
the occiput, or in other words of producing flexion. An im-
portant question then is, what shall we do?
In by far the greater number of cases, the head in descend-
ing will so rotate as to bring the chin toward the symphysis
pubis, and ordinarily the natural powers after some delay and
the suffering of additional pain, will effect delivery. Should,
however, symptoms of approaching exhaustion manifest them-
selves the forceps should be used. The application of the in-
strument here does not materially differ from that in ordinary
cases. “When locked traction is at first directed downward,
to get the chin fairly under the pubic arch. Then the trac-
tion is directed gradually more and more forward and upward
so as to bring the vault of the cranium out of the pelvis. The
posterior part of the head puts the perineum greatly on the
stretch. It requires great care to extract. Give time for the
perineum to dilate. Extract gently.”—Barnes’ Obstetric Oper-
ations, p. 86.
As the position is so much more favorable when the chin
turns forward, although in obedience to the great mechanical
law we have elsewhere stated it generally does so, we should
carefully watch the descent, and if we suspect danger of its
turning backward (or if it do not in due time turn forward)
we should attempt to correct that tendency by a counteract-
ing resistance judiciously applied by means of the fingers or a
blade of the forceps—by interposing such resistance as will
direct it forwards. The fingers will answer best if there be
sufficient space, if not, a blade of the forceps.
Prof. Penrose details a case in the American Supplement to
the Obstetrical Journal of Great Britain and Ireland, in the
management of which he very successfully resorted to the
DEVIATIONS FROM NORMAL LABOR. 141
method here recommended. The expedient occurred to him
after he had twice unavailingly tried the forceps, as it had
done to me a considerable time ago. He simply applied and
held a blade of the forceps against the side of the child's face
which was turned backward. This furnished the resistance,
shunning which, under the powerful action of the womb, the
chin immediately turned under the symphysis pubis, and the
head was speedily delivered. It was an application of the law
“A body acted upon by a force and free to obey the impulse,
moves in the direction of that force, and when it encounters
resistance, in the line of least resistance.” The difficulty here
is that the face cannot reach the floor of the pelvis, otherwise
it would there encounter the resistance necessary to effect the
rotation of the chin. In cases where the chin spontaneously
turns forward “at the last moment,” the result is probably
owing to the presenting part having reached the floor of the
pelvis through the powerful action of the womb.
But if after all the chin turn backward or we are called to
a case so late that we had no opportunity to prevent this
unfortunate occurrence, what shall we then do 2 We are told
by some that even here the child may, and in a great propor-
tion of cases will be born by the natural powers. Others
again assert the contrary. The late Dr. C. D. Meigs, if we re-
member rightly, taught his classes that it cannot. Dr. Barnes
says: “The birth of a full grown living, or recently dead
child, with the forehead maintaining its direction forward, is
almost impossible.” In cases where the child is small and the
pelvis spacious, and especially when in conjunction with these
circumstances the uterine action is powerful and persistent, the
face is likely to be so far driven downward as to reach the floor
of the pelvis. When this occurs, it there meets with a resist-
ance competent, at least in some cases, to rotate the chin for-
ward, under the symphysis pubis. This favorable change hav-
ing taken place, the labor is usually terminated by the natural
powers. Under the opposite circumstances the child cannot be
born without the aid of art. These considerations probably
account for the great discrepancy of opinion upon this subject.
The forceps here, when the child is of ordinary size, is scarcely
142 PRACTICAL MIDWIFERY.
available, because, in drawing down the head, we draw down
also the shoulders and thorax, as it were alongside of it, and
greatly increase the compression.
Turning by the feet is usually impracticable when the head
is low; if it can be effected it ensures delivery, but generally
with the loss of the child and often mother too.
Some advise forcibly turning the chin around, by means of
the forceps, so as to bring it into relation with the symphysis
pubis. When it is fully turned backward, there is danger of
breaking the child’s neck by this operation, unless very care-
fully executed. It may possibly, however, be gradually coaxed
round without this accident, and if once turned the case may
be treated as one of anterior position of the chin originally.
When turning the chin around is impracticable, or for any
reason judged improper, and when after waiting, it does not
turn spontaneously, as it sometimes will do, even at the last
moment, it may be possible by elevating it and depressing the
perineum, to draw it over the latter. The forceps may be ad-
vantageously used in this operation. Careful stretching of the
perineum in the manner I have elsewhere indicated, may
also considerably contribute to our success. If this can be
accomplished, the lever may be applied to the occiput so as to
draw it downward and backward, thus restoring at least par-
tial flexion, by which means the head may be delivered.
Should all these expedients fail, as well as the resources of
nature, craniotomy may be resorted to, but with far less assur-
ance of easy delivery than when performed in cases of vertex
presentation. When it is deemed necessary to resort to this
operation, we should be careful to perform it in time, before
the mother's powers are so far exhausted as seriously to jeopard-
ize her life. Neglect in this matter we fear is too common, in
cases generally requiring such instrumental aid, and there is
reason to believe many mothers die either immediately from
shock, or later from want of power to recuperate from the ex-
treme prostration of long continued suffering. Craniotomy is
extremely repugnant to the physician, and attended with grave
responsibilities, especially if he be not well assured that the
child is already dead. Hence consultations are generally pro-
DEVIATIONS FROM NORMAL LABOR. 143
posed, which, in large towns and cities may not cause much
delay, but in rural districts require much time to arrange.
Hence, often by the time the parties are assembled, the patient
is beyond their combined skill to save. It should be remem-
bered the mother's interests are paramount to those of the
child, and if either must be sacrificed it should be the latter.
We would not, however, be understood to advocate precipi-
tancy. The condition of the patient should be carefully
watched, her former state of health taken into the account, and
her general powers of endurance fully considered. So long as
her strength holds out, and she manifests no signs of sinking,
let nature have fair play to do her best. But whenever sig-
nals of distress are hung out, then let the attendant be on the
alert. As such we may regard a quick and small pulse, coated
tongue, altered secretions of the mucous membranes, extreme
restlessness and manifestly sinking strength, while at the same
time there is subsidence of uterine action.
b) Presentation of the Back and Side,-While questioned
or denied by some, it is pretty generally admitted that under
certain circumstances the back of the foetus may present at
the entrance of the pelvis. When the child is of diminutive
size, this is most likely to occur, especially if favored by the
presence of a large quantity of fluid within the sac. If the
child, on the contrary, be large and the woman of less than
ordinary abdominal dimensions, it is not very easy to see how
it could assume this position.
The same remarks apply to the presentation of the side,
which does undoubtedly sometimes occur.
Indicative of the first of these abnormal presentations, we
will find it, upon examination, difficult to reach the presenting
part. If we succeed, however, in touching it, the finger can
detect the spinous processes in a line marking the presence and
course of the spine. On either side may be felt the insertion
of the ribs. In case of the side of the thorax presenting, we
have the ribs, which may be traced in their length around the
body. If it be the loins that offer to the touch, we may be
able still to discover in the vicinity some of the lumbar ver-
tebræ and the crest of the ilium.
144 PRACTICAL MIDWIFERY.
Although it is admitted that the above named parts may
present at the entrance of the upper strait, it is believed that
only very exceptionally they constitute a permanent presenta-
tion. If the foetus, through the abundance of the waters in
which it floats, or any special restlessness or activity, take up
such a posture, so long as it retains it, it is illy adapted to the
cavity of the womb in which it is contained, and, therefore,
produces abnormal pressure upon some portion of its walls.
This, through reflex action, would excite uterine contraction,
through which, according to the law we have cited when
speaking of the “Mechanism of Labor,” the foetus would be
obliged to adapt its position to the shape of the cavity in
which it is contained. It has been abundantly proven by ob-
servation, especially of the German obstetricians, as before
remarked, that the child often spontaneously changes its posi-
tion in the latter months of pregnancy. Even should this
favorable change not occur until the accession of labor, the
contractions of the womb in this process will be likely to
bring about a presentation of the vertex or the breech instead
of those parts of which we have just spoken.
If we be engaged to attend a patient in labor, and from any
peculiarity she may have noticed in her sensations or in the
shape of the abdomen, we have reason to suspect any of these
abnormal presentations, it will be well to ask permission to
make an external examination of her person, and if we have
reason to think anything may thereby be added to our knowl-
edge, one also per vaginam. When the womb is not too much
distended by fluid, or the walls of the abdomen not overloaded
with adipose tissue, we may, by skillful palpation, be able to sat-
isfy ourselves of the nature of the case. If we detect a crosswise
position of the foetus, we may administer Puls, which has been
advised with considerable confidence in its efficacy, and to
which we have before adverted. If a favorable change take
place, whether owing to the medicine or not, it is all very
well. But if we find; still carefully watching the patient, that
at the near approach of labor no favorable alteration has
occurred, we should attempt to change the position of the
child by external manipulations such as will be elsewhere
DEVIATIONS FROM NORMAL LABOR. 145
spoken of. If we succeed in this the patient should maintain
the strictest quietude till after delivery. But if when we are
called for the first to attend the case in labor, we find this
unfavorable state of things, we should then attempt to change
the presentation by bi-manual version—failing in this it re-
mains that we should turn by the feet.
c) Presentation of the Breech.-Presentation of the breech
is next in frequency to that of the head. It is much more
perilous to the child than the latter. There is considerable
discrepancy of opinion, however, as to the ratio of infantile
mortality when the breech presents. Dr. Churchill represents
it as nearly one in three, while Dr. Playfair, one of the latest
British authorities, thinks this entirely too high, and gives, as
his estimate, about one in eleven. Doubtless the proportion
of loss is smaller now than formerly, inasmuch as the manage-
ment of such cases has greatly improved. To the mother it is
generally believed there is no increased risk; but this can
hardly be correct, since labor is not unfrequently protracted,
and, therefore, the consequences of exhaustion proportionally
imminent.
The causes which determine the child to take up this posi-
tion in the womb, so that, contrary to what usually occurs,
the breech, at the time of labor, is found at the upper strait
instead of the head, are involved in obscurity. Various theo-
ries have been proposed to account for this anomaly in gesta-
tion; but to all of them insuperable objections may be offered.
In our present state of knowledge, therefore, it is most wise,
simply to accept the fact, especially as this will be sufficient
for all practical purposes.
It is important that we should, at an early stage of labor,
recognize a breech presentation when such exists. Before the
rupture of the membranes the diagnosis may be difficult, espe-
cially as we should be careful in our explorations, lest we
should prematurely discharge the waters, and thus lose the aid
of a very powerful agent in dilating the OS uteri. Such aid is
very important here, as the breech, both from its form and
want of solidity, has but little distending power when com-
pared with the head.
10
146 PRACTICAL MIDWIFERY.
***.
When the membranes are relaxed, in the absence of pain,
or when they have already ruptured, the exploring finger will
sooner or later impinge upon the point of the coccyx, and if
carried up in contact with this part, its solid, irregular posterior
surface will be felt. This may be regarded as diagnostic of a
breech-presentation—as no other part yields the same sensation
to the touch. Further exploration will reveal two soft pro-
tuberances, the buttocks of the child, which may be distin-
guished from the cheeks, the only parts for which they could
be readily mistaken, by the difference of the underlying bones
felt through the muscular structures, by the fissure between
them differing from anything found in the face, by the anus
in the centre of the fissure, a closed and puckered aperture,
resisting the introduction of the finger, at least in the living
child, and if the finger be forced within it, the absence of the
jaw-bones and gums, which, one would think, would prevent
the possibility of confounding it with the mouth. Palpation
upon the abdomen of the mother will sometimes enable us to
detect the head high up toward the ensiform cartilage, and
she will sometimes tell us of her suspicions, from the sensation
of a more than usually solid body pressing upon her stomach
during the latter period of gestation. The stethoscope may
also aid us in our diagnosis, as the sounds of the foetal heart
will be heard much higher up than in cases of presentation of
the head. The side of the mother upon which we hear the
pulsations most distinctly, determines that to which the back
of the child is turned, and enables us to decide upon its position
as well as its presentation. Thus, if the pulsations are most
distinctly heard anteriorly upon the left side, we may assume
that the back of the foetus is turned in that direction.
The breech, in the same manner as any other part of the
child, may present in several different positions. Thus the
back may be turned to the left side of the mother, and ante-
riorly, constituting what may be called the left sacro-anterior
position, which is by far the most frequent ; or it may be
turned to the right side anteriorly, the right sacro-anterior
position—while each of these has its reverse, and there may
exist intervening shades between them.
DEVIATIONS FROM NORMAL LABOR. 147
We have already spoken in a general way of the mechanism
of labor by the breech. As such labors, however, are not in-
frequent, say one in fifty, and require the utmost care and no
little skill to conduct them to a safe termination, at least as
regards the child, we will go somewhat more into detail upon
this subject.
Before labor comes on, the child, as it were, sits in the womb,
its head moderately flexed upon the thorax and its limbs upon
its anterior plane. Sometimes the limbs are merely flexed at
the hip-joints and lie extended their whole length upon the
anterior surface of the child, or they are again flexed at the
knees and the lower legs folded against the posterior surface
of its thighs. In the latter case, before the breech is forced
down, the lower legs may somewhat cross each other, as they
do in presentations of the head ; but, be this as it may, as the
breech descends they assume a position in front and parallel
with the sides of the child.
The breech enters the superior strait, impelled by the force
of the uterine contractions with its long diameter in corre-
spondence with the transverse or oblique diameter of the pel-
vis. It descends, but its descent is slow compared with that
of the head. As it lacks the solidity of that part, and espe-
cially if the child be small, it may not rotate so certainly as
does the head in its descent. As rotation in this case involves,
to some extent, the twisting of the body, and as the soft struc-
tures yield to compression from opposing parts in the inner
surface of the pelvis, rather than evade them, it may come
down without shunning such opposition to its descent as the
head would do, and thus not effecting complete rotation. Gen-
erally, when the child is of good size, one hip or the other,
according to the original position, will finally turn under the
pubic arch. In this rotation of the hips, however, if it take
place, the body and shoulders of the child do not participate.
When the membranes give way, the presenting parts, the
hips, are of such irregular conformation, that they do not close
the orifice by compression, but permit the waters wholly to
escape. The womb then clasps firmly the child, presses its
limbs closely to its trunk, as well as flexes its head upon its
148 PRACTICAL MIDWIFERY.
breast, and by this compression fits it the better for its transit
through the pelvic canal, but, at the same time, prevents the
upper parts from rotating in unison with that in advance.
When one hip takes its position under or near the arch of
the pubis, the other is thrown into the hollow of the Sacrum,
the anterior surface of which it traverses, and subsequently the
perineum, which it gradually distends. The dilatation of the
perineum, however, advances slowly under the distending
power of the breech, owing to the softness and compressibility
of the latter. In the case of primiparae this process may
occupy hours. The thinned edge of the perineum sometimes
falls into the fissure between the buttocks of the child, and
thus, for a time, arrests both movement and distension. Ulti-
mately, however, the posterior hip is born, and very shortly,
or simultaneously with it, the anterior. If the body have not
participated in the rotation of the hips, they then revolve
upon the long axis of the foetus, effecting a kind of restitution.
In the natural process the body then partially follows, and the
shoulders present at the upper strait, the long or bis-acromial
diameter corresponding with the transverse or oblique diameter
of the pelvis. As the shoulders descend they rotate with
rather more certainty than the hips, because by their greater
width they more completely fill the pelvis, and by their greater
solidity they are less liable to compression; and, therefore, not
accommodating themselves to resistance, they appreciate it, as
it were, and move in the direction in which it is least met.
The complete rotation of the breech is practically of less
moment than that of the shoulders. For it is manifest that if
the shoulders should come down to the lower strait in a trans-
verse position, the head, from its natural relation to them,
must offer at the upper strait with its occipito-frontal or prob-
ably its occipito-mental diameter in correspondence with the
antero-posterior diameter of the strait. There would in that
case be such a want of adaptation that the head could not de-
scend. The antero-posterior diameter of the superior strait
measures only four inches—the occipito-frontal diameter of the
child is also four inches—the occipito-mental five inches. But
if the shoulders rotate so as to bring the anterior one under
DEVIATIONS FROM NORMAL LABOR. 149
the arch of the pubis, then the head will present at the upper
strait with its occipito-frontal or occipito-mental diameter in
relation with the transverse diameter of the pelvis, 5} inches,
so that it can readily pass. The head thus engaging descends,
and finally rotates so as to bring its long diameter into accord
with the antero-posterior, the longest diameter of the lower
strait, and thus speedily follows the shoulders into the world.
The management of labors by the breech is very important,
in some cases very simple, in others very difficult. It is a
general rule not to interfere so long as the presenting part is
making suitable progress, unless the condition of the patient
absolutely require it. To exert force upon the breech by means
of the fingers or blunt hook fastened in the groin of the child,
is apt to draw away the head as it were from the embrace of the
womb and cause the chin to recede from the thorax, and carry
up the arms from the breast. Better wait with patience upon
the process of nature, minding as soon as the cord is within
reach to draw it a little downward, and if possible place it to
the side of the pelvis, where there appears to be the least danger
of pressure. If the patient suffer intensely, chloroform may be
administered, which will also conduce to relaxation of the
maternal parts. When the breech is born and the body as far
as the umbilicus, as the shoulders come down we should try to
secure the rotation of the anterior one under the arch of the
pubis, a position which it will generally spontaneously assume
in obedience to the general law already stated. When these
are born we should look after the head. This is the moment
of peril. Delay in the descent of the breech, unless through
compression of the cord, is usually unattended with danger,
but detention of the head beyond a very few moments, is very
apt to prove fatal to the child. When the labor is so far ad-
vanced that the head offers at the superior strait, it has nearly
left the womb, and is therefore almost out of reach of its ex-
pulsive power. It is well at this juncture to arouse the ener-
gies of the woman by exhorting her to bear down with all her
force. We should at the same time introduce two fingers of
the one hand, as soon as we can reach the face of the child, and
place one on either side of the nose, with which we can by
150 PRACTICAL MIDWIFERY.
pressure, flex and draw down the head, while we press upon the
occiput with two fingers of the other hand. By such manoeu-
vre the head will usually come down and the birth be safely
terminated.
If, however, the breech do not advance and the mother's
powers are manifestly failing, here, as always in like circum-
stances, it will be our duty to attend to her interests, regarding
those of the ehild as secondary. Dr. Barnes advises us in such
cases not to apply traction at the groin, but to bring down a
foot—the one nearest to the pubis, as in so doing we decom-
pose the wedge which the foetus represents, the breech forming
the apex, and the head, shoulders and flexed limbs the base.
Whether we should or should not make traction upon the foot
when brought down would depend upon the necessities of the
case. If the wedge thus decomposed and diminished in size
seem disposed to pass readily, we may leave the further de-
scent to the powers of nature, if they have not already become
exhausted—if they have we should deliver.
But after all the most important part is, so far at least as re-
gards the child, the delivery of the head quickly after it comes
to engage in the pelvis. If the simple manoeuvre already de-
scribed do not succeed, what shall we do, for there is no time for
delay ? Most writers advise us to resort at once to the forceps
—to have the instrument at hand and immediately introduce it,
and extract the head. This is probably easier said than done.
In the country, at least, we have seldom the assistance at hand
that would be required to apply the forceps with ease and ex-
pedition. The bystanders would require instruction, and while
we should be giving this, the child would perish. From my
own very limited experience in the use of the forceps in such
cases, I cannot but think it is a bungling, ill adapted appliance.
Various other expedients have been proposed by different ob-
stetricians. It will be remembered it is force we want to expel
the head, force which the womb is perhaps now no longer able
to supply. . If it can be rallied or rather assisted by the will of
the mother calling into aid the powers of the accessory muscles
it will be well; unfortunately, however, as before intimated
the head is nearly, if not entirely, beyond its reach. But
DEVIATIONS FROM NORMAL LABOR. 151
another expedient proposed by Prof. Penrose, of which I am
disposed to think very favorably, may be used in conjunction
with her efforts. The principle is to supply the vis a tergo
which the womb is supposed to be now no longer competent to
furnish. “Apply your hand or hands,” says he, “on the lower
part of the abdomen, or an assistant can make the pressure for
you, and press directly down upon the head : you can by this
proceeding apply any amount of vis a tergo, you can supplement
entirely the lost force of the uterus and the lost force of the
mother's efforts * * * * the rapid delivery of the head can
always be easily and quickly secured by the bearing down efforts
of the mother, aided or even replaced by the bearing down efforts
of the attendant.”—Obstet. Journ., Great Britain and Ireland,
Amer. Supplement.
We have not had occasion to test this method, but would
not hesitate to do so with great confidence in its prospect of
success if well executed. It would probably be advantageous
to place the patient upon her back, with her hips near the edge
of the bed. An assistant, or even an intelligent nurse might
be instructed beforehand, to lay her hands, one upon each side
of the womb, gently following it down as the body of the child
recedes until the moment when the head alone is felt, ready to
engage in the upper strait. Then at that instant a grasping,
downward, pressing, pushing movement should be made upon
the head through the fundus of the womb, and in the direction
that common sense would dictate as most effectual to extrude
the head. By assigning this duty to an assistant the ac-
coucheur would be left at liberty to manage the body of the
child, and might aid by moderate traction, for if the head be
pressed downward by an external force, there would be little
danger of extension taking place so as to interfere with its
speedy delivery.
We have thus dwelt upon the management of the after.com-
ing head, because it is important not only in cases of sponta-
neous breech presentation, but also in cases of artificial version
by the feet. In all these it is scarcely necessary to repeat what
may be readily inferred from what we have already said, that
prompt delivery of the head is essential to the safety of the
child.
152 PRACTICAL MIDWIFERY.
We have already spoken of direct traction as a means of de-
livering the after-coming head. We are usually restricted in
our application of this means, by a dread of breaking the child’s
neck. It is doubtless a good rule to use no more tractile force
than is necessary for the accomplishment of our purpose. But
from the experiments of Matthews Duncan (British Medical
Journal, Dec. 19, 1874, p. 763), it appears that the neck of a
dead child, at term, can sustain a weight of one hundred and
five pounds before the spinal column gives way. In the case
of the living infant, it is probable that muscular resistance
would enable it to sustain a still greater force. But how great
a force may be applied without doing serious injury, is still
another question. In desperate cases, however, where ordinary
force does not suffice, and where a few moments’ delay will un-
doubtedly sacrifice the life of the child, we will be justified in
increasing very considerably the amount beyond what we com-
monly use.
Heads as well as pelves may differ so much in shape, that it
is impossible, by any previous calculation, to determine exactly
where they will nip, and it is very difficult in the hurry and
excitement of the moment to discover what point is arrested,
and exactly where arrest has taken place. If we will bear in
mind, however, the general law laid down, and when the press-
ure of the assistant from above is for a moment relaxed, if we
will, by a wriggling movement, detach the head from its lock,
then applying force in a somewhat similar manner, according
to the illustration elsewhere given, viz., the drawing of a
buckle through a compressed terret, it will move in the direc-
tion of least resistance, and if the space be not entirely dispro-
portionate to its size, it will speedily be born.
It sometimes happensin presentations of the pelvic extremity
of the child, that the thighs depart from their close approxima-
tion to the abdomen, and the lower legs recede from the thighs,
giving rise to what is termed a presentation of the feet.
Again, the thighs may be extended, while the lower legs are
still more or less closely applied to their posterior surface.
This constitutes a presentation of the knees. These presenta-
tions assume different positions as true presentations of the
DEVIATIONS FROM NORMAL LABOR. 153
breech. It is unnecessary here to speak further of them, as
they are only varieties of that of the breech, and the same prin-
ciples we have already laid down equally apply to their man-
agement.
DEWIATED PRESENTATIONS OF THE HEAD
It occasionally happens, through obliquity of the uterus or
other causes, that the head, instead of presenting fairly at the
superior strait, rests upon the brim of the pelvis, and when
acted upon by energetic contractions of the womb, is, according
to the direction of the force, either restored to a normal pre-
sentation or is made to deviate still further therefrom. When
the former takes place the labor usually proceeds in the natural
manner; when the latter, a presentation of the shoulder is apt
to be the result. Such presentations, although generally be-
lieved to arise from deviations of the head, may, it is thought,
sometimes be original, and these are believed to be necessarily
associated with obliquity of the uterus. In a large proportion
of cases of shoulder presentation the arm prolapses, sometimes
also simultaneously, the umbilical cord. The descent of the
latter is generally, if not always fatal to the child, unless
speedily remedied by appropriate measures. When the arm
has come down, the hope of the presentation being corrected
by the natural powers alone, through what is termed “sponta-
neous version,” that is, a replacing of the head or even substi-
tuting the breech over the entrance into the cavity of the pel-
vis, is very small. The os humoris of the foetus, although lack-
ing the solidity of that of the adult, is sufficiently solid to act
as a pin, in fastening down the shoulder in its assumed position.
This may be illustrated by supposing a small piece of board
having a wooden pin inserted into it, laid upon another, perfo-
rated so as to let the pin pass through it. In such circum-
stances no ordinary force can move the small board sidewise,
for the pin passing through the other board prevents its motion.
But if we suppose the pin replaced by something more flexible,
as a piece of gum elastic of the same diameter, now although
the small board may be made to move sidewise, by forcing it
154 PRACTICAL MIDWIFERY.
to drag the gum elastic through the hole, it will require much
more force to produce the result than if the gum elastic pin
were not in the way of its movement. t
“In Nature we observe,” says Dr. Barnes, “two chief shoul-
der positions, and each of these has two varieties. In the first
position, the head lies in the left sacro-iliac hollow. In the
second position, the head lies in the right sacro-iliac hollow.
Now, in either position, either the right or the left shoulder
may present. Thus if the head is in the left ilium, the right
shoulder will descend when the child’s back is directed for-
ward; and the left shoulder will descend when the child’s belly
is directed forward. In the case of the second or right cephalo-
iliac position, the right shoulder will descend, when the child's
belly is turned forward, and the left shoulder when the child’s
back is turned forward.”
Although it cannot be denied that shoulder presentations
under favorable circumstances may be converted into presenta-
tions of the vertex, or even of the breech, such a fortunate
change is too improbable to be worthy of much reliance in
practice. It may do well enough for the doctor to sit expectant
by, to see what dame Nature unassisted may be able to accom-
plish, and if she succeed, to have it in his power to report a
wonderful case, and encourage some one else to pursue the same
course. But to do so is generally to do it at the risk of the
patient’s life. The shoulder will for the most part sink deeper
and deeper into the cavity of the pelvis, and become more and
more immovably fixed. The waters will gradually drain off
and the womb tightly embrace the foetus on all sides—insinuate
itself completely into its whole outline, and retain its hold even
in the absence of pain. Unable to overcome the opposing re-
sistance, the efforts of the uterus increase into fury, and if not
soon successfully aided, end only in rupture of the organ itself,
or in complete and often fatal exhaustion of the patient. We
remember two cases treated in this manner in which we were
finally called in consultation. In the first the membranes rup-
tured about one o'clock in the morning, and a presentation of
the shoulder with prolapse of the arm and cord immediately
manifested itself, attended also by very considerable flooding.
DEVIATIONS FROM NORMAL LABOR. T55
I was called about nine or ten o'clock the same morning. The
pains had entirely ceased, and the patient lay in an extremely
prostrated condition. From the size of the prolapsed arm,
there was reason to infer that that of the entire foetus was pro-
portionate, an inference afterwards fully confirmed. The death
of the child was, of course, considered as certain from the con-
dition of the cord, already for a long time pulseless and col-
lapsed; the only object in view, therefore, was to save the
mother. As the waters were almost wholly drained off, the
child closely embraced by the womb, and the shoulder forced
deep into the cavity of the pelvis, while a stout arm occupied
the vagina, cephalic version was out of the question, and podalic
version was likely to be very difficult. Under these circum-
stances I proposed to the attendant physician to deeply anaes-
thetize the patient with chloroform, and then endeavor to effect
turning by the feet, but that without this preliminary I did
not wish to attempt it. Objections were at first made to the
use of chloroform, as likely to increase the haemorrhage, as it is
said to do, but these were finally waived upon assurances that
it would not necessarily do so. The patient was then very tho-
roughly brought under the influence of the anaesthetic, and
turning and delivery effected with comparative ease; she did
not, so far as I could perceive, move a muscle during the whole
operation. The haemorrhage gradually yielded under the use
of Apoc. can. and Trillium pen., given in succession, and by
the afternoon it had entirely subsided. A good, but necessa-
rily, from the amount of haemorrhage, a somewhat slow reco-
very followed.
The second case alluded to above was not so fortunate. A
little before or shortly after the arrival of the attendant (1
o'clock, P.M.), the waters were discharged and the arm immedi-
ately prolapsed. A messenger was at once despatched for me
to see the case in consultation, but unfortunately I had just
gone several miles from home, in an opposite direction, and the
messenger did not follow me. The pains immediately became
strong, increasing still in force, till, as I was informed, from
5 P.M. onward till I arrived, they had reached a degree of agony
such as the attendant thought he had never before witnessed.
156 PRACTICAL MIDWIFERY.
Owing to my late reception of the message, it was not till 9
o'clock, P.M. I arrived at the bedside. The patient was of re-
markably short build, and upon examination I found the
shoulder so crowded down, that the hand could not be carried
up so as to reach the feet. I first placed her in the knee-and-
elbow posture, sustained by assistants, hoping that through the
influence of gravitation the shoulder would somewhat recede,
and make room for the hand to pass, but in this I was wholly
disappointed. The patient was then again laid down, and
chloroform administered to full anaesthesia. The relaxing
effect of this agent was such that upon a second attempt the
hand was readily introduced, a foot seized, and delivery effected
without any special difficulty. The child was of very large
size, but of course still-born. No appreciable haemorrhage fol-
lowed. The patient waked up as usual from the effects of the
anaesthetic, and we entertained the hope that with the proper
care she would do well. I remained about an hour after de-
livery, and having conferred with the attendant in another
room, as to the best mode of after-treatment, I was about put-
ting on my coat to retire, when suddenly summoned to the bed-
side, I found the patient dying. This seems to have been a case
of death from shock through extreme and protracted suffering.
She had, as I learned, taken a large amount of morphia, by
way of palliation, before my arrival.
In order to secure the best results in the management of
shoulder presentations, it is important we should recognize
them as early as possible. If this can be done before the mem-
branes have ruptured, we should endeavor to effect cephalic
version, as directed in the chapter on “Turning.” The neces-
sity for version by the feet should, as far as possible, be avoided;
in fact should be had recourse to only as a last resort. If the
child be of large size, and especially if the waters be discharged,
it may, perhaps, be said to be generally fatal to its life. Under
the same circumstances, too, it is very hazardous to the mother.
But however important it may be to recognize early a shoulder
presentation, if such exist, it is not always easy before the rup-
ture of the membranes. •
When upon a first examination the presentation cannot be
DEVIATIONS FROM NORMAL LABOR. 157
felt, while yet we are satisfied that the woman is really in labor,
we have reason to suspect there is something wrong, and should
be upon our guard and keep a vigilant lookout. I have, how-
ever, met with cases in which, at first, I could not touch the
presentation, but after an hour or so it came within reach, and
was as I desired. It is possible that in such cases the presen-
tation had been changed by the powers of the womb from a
faulty to a good one.
If the membranes, however be lax, or there be present but a
Small amount of the amniotic fluid, we may, by a careful ex-
amination, carrying up the finger as high as possible, even
allowing the hand partially to follow it into the vagina, when
this is practicable, be able to detect the shoulder presenting
at the superior strait. The signs, by which it may be recog-
nized, are the presence of the acromion process, the scapula,
the spine of the scapula, the axilla, and when they are access-
ible, the spinous processes of the vertebral column. We should
notice, too, the relative position of these parts by which we
may determine whether the foetus lies with its anterior aspect
toward the front of the mother, or the reverse. If we have
not been able to satisfy ourselves of the presentation prior to
the rupture of the membranes, we should immediately examine
when this takes place. And now, as often happens in shoulder-
presentations, if the arm prolapse, we must not jump to the
conclusion that the shoulder is present at the upper strait, for
the arm is sometimes extruded beside the head. The best
advice we can give the student or young practitioner, to enable
him to recognize the shoulder or any other part presenting, is
to familiarize his sense of touch with these parts in the born,
but quite newly born infant. Feel the shoulder in connection
with the neighboring regions,—also the knee, the elbow, the
hands, the feet. Repeat this until you know and remember
exactly what sensation these different parts communicate to
your sense of touch—until when you explore the shoulder you
will know it is not the elbow or the knee; when you lay hold
of the foot you will know it is not the hand. If once this ex-
perience is acquired, it will be useless to tell the student that
he may distinguish the foot from the hand because the former
has a great toe, the latter has not.
158 PRACTICAL MIDWIFERY.
Although, as we have intimated, slightly deviated presenta-
tions of the head may be, and perhaps generally are, corrected
by the natural powers alone, and even the shoulder, through
the same powers, may depart from the upper strait and the
vertex or breech take its place, we cannot always depend upon
this result, and if it should fail to take place, the longer we
delay, the more difficult will it be to avail ourselves of the re-
sources of art. These rectifications, by nature alone, probably
take place, for the most part, where the child is somewhat
below the normal size.
If then upon the rupture of the membranes, or better still,
before this occurrence, we detect the shoulder at the superior
strait, whether the arm be prolapsed or not, we should at once
endeavor to correct the presentation. The fingers of one hand
are introduced into the vagina, and an attempt made to push
up the shoulder, and, if successful in this, we should endeavor,
by the requisite manipulations, to coax the head to take its
place. These attempts may generally be greatly aided by the
other hand applied to the abdomen of the mother, and gentle
force exerted through its walls upon the other extremity of
the foetus in such a manner as common sense would suggest as
most likely to lead to the accomplishment of our purpose. To
give minute directions here, would be only to perplex, for if
the practitioner has not sufficient common sense to perceive
what forces he needs and in what direction to apply them, he
would be unable to follow advice given in detail. If we can
bring the head over the entrance into the pelvis and secure it
there until it engages in the superior strait, we may safely
entrust the labor to the natural powers.
If we be unable to succeed by this simple method in correct-
ing the faulty presentation, unless we are satisfied the child is
very small, and the powers of the woman very vigorous, we
should proceed at once, before the waters are wholly drained
off and the womb contracted firmly upon the child, to turn by
the feet. For minute instructions in the method of doing this
successfully, the student is referred to the chapter upon that
subject. (See Version or Turning).
I would only further remark that, as may be learnt from
DEVIATIONS FROM NORMAL LABOR. 159
the two cases given above, the previous administration of chlo-
roform affords immense advantages in the operation of turning
either by the head or by the feet. It should, when used as a
preliminary measure to this operation, unless there be manifest
counter-indications, be given until deep anaesthesia is produced.
Let it be administered cautiously and slowly, so as to induce
complete insensibility and that gradual and beautiful relaxa-
tion of the tissues which, when judiciously given, it can accom-
plish. If the chloroform even completely arrest the action of
the womb, which it does not often do, it will so much the more
contribute to our purpose. These assertions are not only fully
accordant with my own experience, but sustained by the vastly
greater experience of others—men of unquestioned eminence—
whose testimony ought to be received, one would think, with-
out cavil.
I have noticed in several cases where I have been called in
consultation, to one of which I have just adverted, where
morphia had been freely given by the previous attendant for
the relief of pain, that the effects of chloroform were not only
more speedily induced, but the insensibility was more profound,
and the relaxation of tissues more complete than where no
such antecedent measures had been adopted. Since I noticed
this phenomenon, I have learnt that M. Bernard has used mor-
phia previous to the administration of chloroform in his vivi-
sections, and the result was that his subjects became perfectly
passive and relaxed, opposing no resistance to his operations.
In cases where the waters have been long drained off and
the womb closely embraces the child, and where turning seems
still to be the proceedure most promising of good results, we
might take advantage of the fact above stated, and, half an
hour before we operate, administer a dose of morphia, either
by the mouth or by subcutaneous injection. This we would
follow by the administration of chloroform, to complete anaes-
thesia before we attempt to turn. I would, however, subjoin
the caution, that where great prostration exists, morphia should
not be given, as it probably greatly adds to the shock, and pro-
portionately increases the danger from that quarter. Under
these circumstances chloroform should be given with great
care, and its effects very carefully observed.
160 PRACTICAL MIDWIFERY.
CHAPTER X.
ACCIDENTS AND DISEASES INCIDENT TO
LABOR AND THE PUERPERAL STATE.
PROLAPSE OF THE CORD.
This is one of the most fatal accidents, so far as the safety of
the child is concerned, that occurs during labor. I need hardly
say that this fatality is owing to the compression of the cord,
arresting the circulation through its vessels, and thus causing
asphyxia. The length of time necessary to produce this effect
has been variously reckoned from two to ten minutes. The
former is probably a shorter time than is generally required to
cause the death of the infant, while the latter is, no doubt,
considerably longer.
I need not spend time in pointing out the diagnostic signs
by which prolapse is detected. When the cord is felt pro-
lapsed it is, or ought to be easily recognized—it is not easy to
imagine how it can be mistaken for anything else that may
occur, or anything else mistaken for it.
There are, however, a few cases upon record in which a coil
of intestine has been mistaken for the umbilical cord, and
which mistake led to the most disastrous consequences. Dr.
Tyler Smith, in his Annual Address to the Obstetrical Society
of London, reports the following: “A midwife attended the
patient, a very poor woman, during her labor, and she admit-
ted having given Ergot before the birth of the child. Mr.
Robinson was called at midnight to remove the placenta, going
as a matter of charity. On examining he found what seemed
to be a loop of funis in the vagina; passing his hand along it
and through what he supposed to be the OS uteri he felt a mass
of about the size of the placenta which he drew down. Find-
ing some difficulty, he divided the supposed funis in two
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 161
places, and then found to his horror that he had been dealing
with intestine. At the post-mortem and inquest it was shown
that a laceration existed at the upper part of the vagina,
through which the bowel had passed, and the placenta was
still in utero with the funis broken short off. The real facts
were, no doubt, that the laceration occurred during labor,
probably from the Ergot, that the midwife tried to remove the
placenta (there probably being spasmodic contraction of the
Os uteri in consequence of the Ergot), and in doing this tore
the umbilical cord from its attachment. This was not
mentioned to Mr. Robinson. The loop of intestine descended,
as it often does in such cases, through the rent. Mr. Robinson,
called at this peculiar juncture, fell into the trap.” The unfor-
tunate man was tried in a British court for homicide and con-
victed.
We hence see the importance, especially when aroused from
our midnight slumbers, of taking sufficient time to learn the
facts of the case and knowing precisely what we are going to
do, before we act. This especially applies when called to cases
which have been attended by ignorant midwives or ill-in-
structed, inexperienced physicians, especially such as deal hap-
hazard in enormous doses of Ergot. We should in such cases
most cautiously feel our way, distinguishing everything we
meet with, from everything else to which it bears resemblance,
and never operate until we are fully satisfied as to what we
are about to operate upon. We can hardly conceive, however,
of such a mistake being made and leading to such mal-practice
prior to the birth of the child. So long as the funis pulsates it
may be distinguished from intestine by its pulsations alone,
which are rapid and not synchronous with those of the mother.
When it has ceased to pulsate, as it usually has when long pro-
lapsed, we cannot avail ourselves of this characteristic. But
the peculiar sensation imparted by the cord, when slightly
compressed between the finger and thumb, would, I think, suf
ficiently distinguish it from anything else. The young practi-
tioner should familiarize himself with this sensation till he
cannot possibly be mistaken.
It is unnecessary to state the causes which have been assigned
11
162 PRACTICAL MIDWIFERY.
as giving rise to this accident, inasmuch as they are generally
irremediable in the case before us. Our business will be to ex-
hort to that vigilance and alertness which will enable us to de-
tect it immediately upon its occurrence, and adopt the best
means for its relief.
If we be convinced that the umbilical cord is presenting,
before the rupture of the membranes, we should watch the
case most assiduously, and make an examination immediately
after the waters break. We shall then probably find the cord
more or less prolapsed, and if so this will be the moment for
decided action.
Various expedients have been advised for remedying this
accident. Some direct us to carry up the cord with the fingers
and hook it upon the chin of the child when the head presents,
—others instruct us to hang the loop upon one of the limbs of
the foetus. Some again would simply place the prolapsed
portion within the womb and retain it there for a few subse- .
quent pains. Others advise us to turn or apply the forceps
according to the presentation, or the distance to which the pre-
senting part has sunk into the pelvis. The two latter expedients,
one or the other, may be successful or even necessary in some
cases, as, for instance, turning when the shoulder and arm pre-
sent. The other methods are apt to fail from the fact, that the
cord generally prolapses again and again, unless the pains be
sufficiently vigorous and the pelvis sufficiently wide to bring
the head rapidly down, so as to occupy the space to the exclu-
sion of the funis, and terminate the labor very speedily.
Dr. Thomas, of New York, in the year 1858 proposed a
method of treatment which he termed the postural method,
and which, in the large proportion of cases of this accident, is
likely to take the precedence of all other modes of treatment.
His plan consists in placing the woman upon her knees and
elbows, her face resting upon a pillow. The prolapsed cord is
then carried up into the womb with the fingers, and gravitation
then acting in an opposite direction, it does not again descend.
After retaining this posture for ten or fifteen minutes, that is
till after the occurrence of a few pains, the patient is suffered
to resume the usual obstetric position upon the left side. This
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 163
method is said to be very successful in saving the life of the
child, and avoids all risks to the mother such as she necessarily
incurs in the operation of turning, and even too hasty delivery
with the forceps. This practice has been introduced into
England with decided approbation. Dr. John Brunton, Sur-
geon-Accoucheur to the Royal Maternity Charity, details a
number of cases, in a late number of the Obstetrical Journal of
Great Britain and Ireland, in which the plan succeeded admi-
rably in his own practice, to which he adds several cases
equally successful from that of Dr. Wilson, Professor of Obstet-
rics in Anderson’s University, Glasgow.
If the presentation of the cord be recognized before the rup.
ture of the membranes, it would be well to try this method.
Should the membranes be slow to rupture spontaneously, the
waters might be discharged by artificial means, as soon as the
os uteri would be found sufficiently dilated. Thus the head
might engage in the upper strait and prevent prolapse.
ADHERENT PLACENTA,
This may, perhaps, strictly speaking, not be properly termed
an accident of labor, as it undoubtedly is a pre-existing condi-
tion. But it is during labor it first becomes known to the
obstetrician, and then first demands his attention. It seems
proper, therefore, to treat of it in this place. We have already
spoken of the delivery of the after-birth in normal labor, even
when undetached at the birth of the child and for some time
afterwards. But we have here reference to those cases, and
those cases only, wherein the placenta is not only retained
beyond the usual time, but abnormally or morbidly attached
to the surface of the womb, resisting the Ordinary attempts at
Separation.
We will not here stop to inquire into the causes of this un-
fortunate condition. No doubt they are varied. Some morbid
state of the surface of the womb, or of the placenta, or of both,
precedes and gives rise to this unnatural adhesion. This is,
perhaps, most generally inflammatory action from injuries or
other causes.
164 PRACTICAL MIDWIFERY.
It would seem that some women are peculiarly liable to this
accident. I knew a young lady several years ago who, in her
first labor, I was told, retained the placenta for several days,
as it had resisted the usual attempts at removal. It was, how-
ever, finally extruded “en masse,” and she recovered without
any specially untoward symptoms. At her next confinement
she experienced the same trouble. I was called to see her
nearly twenty-four hours after delivery. A young physician,
previous to this, had made unsuccessful efforts to extract the
placenta, and had abandoned the case as beyond his skill.
With great difficulty I succeeded in introducing the hand into
the womb, but the latter was so forcibly contracted, that I was
unable to use my hand satisfactorily, even by way of explora-
tion. I could only ascertain that the placenta seemed to be
firmly adherent in its whole extent, except a small portion of
its lower margin, which may have been detached in the pre-
vious attempts at removal. Having no reliable assistant to
keep the patient anaesthetized, and believing the operation im-
practicable without chloroform, I postponed further proceed-
ings until I could secure these advantages. It was late, and I
was under the necessity of returning home, over several miles
of road in the worst possible condition. My plan was to fully
anaesthetize the patient, dilate the OS uteri with the colpeuryn-
ter—we had not yet heard of Barnes' dilators—introduce the
hand and tenderly remove as much as possible of the placenta.
Unfortunately in my absence violent haemorrhage took place,
and another physician, who was much nearer, was called in.
I was also summoned, but when I arrived the patient was
pulseless and speechless, and as pale as a corpse. Haemorrhage
was still going on. The case being a desperate one—life nearly
extinct—the patient incapable of giving a single symptom or
answering the simplest question, I resorted at once to injection
of a weak solution of perchloride of iron. Haemorrhage almost
instantly ceased. I remained with the patient during the
night. Pulse gradually returned, and by the next day she had
considerably rallied, but still, I thought, too feeble to carry out
the plan above indicated. In my absence she began to show
signs of septicæmia, which did not yield to any remedies em-
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 165
ployed, and of which she died in the course of two or three
days. Pieces of the placenta picked off by the physician
who first visited her during the haemorrhage, were examined
by me and found to lack the usual structure of placenta, more
resembling in texture the fibrous muscular portions of beef,
an abnormality which I had surmised from my imperfect ex-
ploration.
There had been, as I understood in this case, but little
haemorrhage up to the time I first saw it, and this coincides
with the very extensive adhesion which I supposed to exist,
for it is manifest that the mouths of more vessels will be left
patulous if there be a pretty extensive separation of the pla-
cental mass, than under the opposite circumstances. The
uterus maintained its contraction when I last saw the patient
before the haemorrhage occurred ; that accident, therefore,
especially in so violent a form, was to me unexpected. Prob-
ably further separation of the placenta and relaxation of the
womb had simultaneously taken place. When I saw her after
the occurrence of the haemorrhage, the degree of contraction
of the os uteri was such and her exhaustion so extreme that I
could not then ascertain the then present condition of the pla-
Centa.
The intimate adhesion of the placenta, which we here con-
template, cannot be fully ascertained until we introduce the
hand and attempt to remove it. In order to effect this we
proceed, at first, as we would in the simpler forms of adhesion,
where, from inertia, we are sometimes obliged to assist nature,
namely, endeavor to find a detached portion somewhere around
the edge of the mass. If found, insert the points of the fingers
of the left hand under this, with the dorsal surface turned
toward the inner surface of the womb. Give the fingers a
swinging motion from side to side, thus gently separating the
placenta from the womb. I need hardly say the finger-nails
should be pared short and smoothed at the ends. In this
manner, as far as possible, detach all that can be easily de-
tached, until the more firmly adherent portion is, as it were,
isolated. Then spreading fingers so as to embrace the whole
mass, compress it toward, and so as to embrace, the still adher-
166 PRACTICAL MIDWIFERY.
ent portion. Then, with a wrenching movement and slight
pressure, turn the mass so as to cause it to separate. This
manoeuvre will probably bring away as much as can be
separated without risk of wounding the surface of the womb.
The hand, however, may be again introduced and the surface
examined, and if portions loose, or partially detached, be found
there, they can be removed. In this operation, and all similar
ones, the womb should be sustained and properly manipulated
by the outside hand.
In all such cases we should, for several days, be on the look-
out for post partum secondary hamorrhage, of which we will
fully speak further on.
It is still an undecided question how far we should proceed
in our efforts at the removal of morbidly adherent placentae.
On the one hand, if any considerable portion be left behind,
we run the risk of haemorrhage and septicæmia—on the other,
we may so wound the uterine structures as to give rise to fatal
inflammation of that organ. We should carefully consider
the specialities of the case, and accordingly take our risks.
Whichever of these we select, we should do all we possibly
can to prevent the anticipated evil by way of prophylaxis.
HEEMORREHAGE.
This is one of the most common, and not unfrequently one of
the most alarming accidents of labor which it is the lot of the
obstetrician to encounter. . Its occurrence is often sudden, and
it may be unexpected, and its violence sometimes so great as to
threaten the speedy extinction of life, or at least extreme pros-
tration, followed by a very tedious and unsatisfactory conva-
lescence.
This introductory statement will at once show how import-
ant it is that the young practitioner should be fully prepared
to meet such emergency with calmness and self possession,
which can be done only by his having at his command the re-
sources of our art, to be brought promptly into requisition, ac-
cording to the varying character of the cases with which he
may meet.
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 167
a) Ante-partum Accidental Haemorrhage.—We have
already spoken of the haemorrhage sometimes accidentally Oc-
curring during the course of pregnancy, as well as that antece-
dent and subsequent to abortion. We now propose to consider
the forms of the same accident which take place in connection
with labor, premature or at full term. By the former, as before
defined, we mean that which happens after the viability of the
foetus, but before the usual term ; by the latter, that occurring
at the close of normal gestation. In order to avoid as far as
possible repeating what the student has elsewhere learnt, we
assume that through works on anatomy he has become fully
acquainted with the structure of the parts concerned in repro-
duction, and from those upon physiology, the functions of the
various organs thus concerned. It will be necessary, therefore,
in this place only to remind him of the vascular connection be-
tween the placenta and the womb. Through the vessels of the
latter, blood is carried into the former, from the organism of
the mother, to perform the function, however that may be done,
necessary to the nourishment and growth of the foetus during
its intra-uterine life. These vessels are large in proportion to
the amount required for this purpose, and the afflux to the parts
is influenced by the constant demands of the growing child.
The quantity of blood therefore at all times circulating through
these vessels is very considerable. It will be thus apparent
that when they are severed, from any cause whatever, and re-
main patulous, haemorrhage must ensue. This sometimes hap-
pens in the course of labor otherwise normal, from a premature
detachment of a portion of the placenta. The ordinary means
provided by nature for the prevention of haemorrhage from the
open utero-placental vessels, is their closure by the contraction
of the womb ; but this cannot fully take place while the foetus
as well as its appendages, is still retained within its cavity.
When, however, the placenta is attached at a distance from the
os uteri, as it usually is, this form of haemorrhage is seldom
such as to be attended with serious consequences, or even to
cause alarm. If sufficiently copious to require attention we
may administer Apoc. cann., four grains of the first dec. tritu-
ration of the bark of the root, in four tablespoonfuls of water,
168 PRACTICAL MIDWIFERY.
giving a teaspoonful every few minutes. Trillium pen., a few
drops of the mother tincture, in a like quantity of water, to be
given as above. Per-sulphate of iron diluted with water will
probably answer a good purpose. Also Ergot may be thought
of, especially if the character of the pains correspond with the
pathogenesis of that drug. If these or other remedies, appa-
rently indicated, fail to arrest the flow, if the os uteri be pretty
fully dilated or dilatable, we may rupture the membranes and
discharge the liquor amnii. The womb, then, especially if in
vigorous action, will contract upon its contents, and thus at
least close the mouths of the bleeding vessels, and arrest or
modify the haemorrhage.
Another source of haemorrhage during labor, is the occasional
presence of a uterine polypus. This is a rare occurrence, but
should not on that account be passed without notice. Some
authors advise, when it can be brought within reach, to ligate
and remove it. The method of doing this will be found de-
scribed in works professedly upon uterine surgery. This ope-
ration, when performed during the puerperal condition, is not
without danger, and when the tumor does not interfere with
delivery, it is perhaps best to treat the haemorrhage as above,
and for the present let it alone.
Haemorrhage during labor may occasionally arise from ulcer-
ation of the os uteri. The distension to which this part of the
womb is subjected during the process of parturition, if ulcera-
tion has previously existed, almost necessarily ruptures the
small vessels traversing its surface, which of course pour out
their contents. Haemorrhage from this source is not likely to
be alarming—much less fatal. If detected, and thought worthy
of attention, perhaps the best method of holding it in check
would be to carry up a pledget of lint, moistened with a solu-
tion of Per-chloride or Per-sulphate of iron, into contact with
the os, and let it remain there till displaced by the force of the
womb. The strength of the solution may be properly regu-
lated by adding gradually to water the solution of the salt as
generally sold, until it produces a very decidedly styptic taste
when applied to the tongue.
Laceration of the OS uteri and vagina are also named as
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 169
sources of haemorrhage. Although the accident, when it oc-
curs, takes place during labor, the consequent haemorrhage is
not likely to manifest itself till that process has been com-
pleted. When it happens, it will probably be most effectually
controlled by the application of a styptic, as above directed.
b.) Placenta Praevia—Unavoidable Haemorrhage.-But
by far the most important source of haemorrhage during labor
is the implantation of the placenta wholly or partially over the
os internum or cervix uteri. This is called “placenta praevia,”
and, in the opinion of some, always gives rise to haemorrhage of
a more or less alarming character, and from this supposed cer-
tainty of its occurrence, it has usually been termed “unavoid-
able haemorrhage.”
“Although a haemorrhage,” says Cazeaux, “is usually con-
ceded to be inevitable under such circumstances, yet it may not
appear even during the labor; and the dilatation of the os uteri
may be effected without the loss of a drop of blood. This ab-
sence of discharge is doubtless a rare circumstance; but its au-
thenticity at the present day, is well established by numerous
cases; authors only differing as to the explanation given of it.”
So rare indeed, however, is such exemption, that it should not
in the least influence our precautions in practice.
In cases of placenta praevia, the haemorrhage usually mani-
fests itself a few weeks before the close of gestation. On its
first appearance it is not always violent; perhaps not generally
so. If the patient keep quiet it usually subsides spontaneously,
but is apt to recur again and again, up to the time of delivery.
When we are called to a case of flooding, toward the close of
gestation, and are not able to trace the accident to any violence,
such as a fall, lifting heavy weights, or any kind of over-exer-
tion, we have reason to suspect the existence of placenta praevia.
Our suspicions will be confirmed, if a second occurrence take
place in like manner, without any assignable cause. If an ex-
amination be now made, and the os uteri be sufficiently patu-
lous to admit the point of the finger, a spongy mass will be felt
overlying it.
The theory formerly entertained to explain these precursory
haemorrhages was the following. It was thought that the Os
170 PRACTICAL MIDWIFERY.
internum began to dilate some time before labor, preparatory
to that process, and as the placenta, firmly attached to the
lower segment of the womb, could not stretch, so as to accom-
modate itself to the altered condition of the seat of its attach-
ment, its connection with the womb was gradually severed, and
consequently the utero-placental vessels ruptured, and hence
they poured out their contents. This theory is now by the
more advanced authors regarded as untenable, inasmuch as it
is believed that dilatation begins at the os externum and ad-
vances upwards, and not the reverse of this, which the theory
contemplates.
In his work on Obstetric Operations, Dr. Barnes gives us a
diagram representing the womb as divided into three zones, as
he terms them. The upper he calls the fundal zone—the mid-
dle, the meridional zone—and the lower the cervical zone.
When the placenta is seated upon the latter, haemorrhage must
ensue prior to labor, because, as he affirms, this region does not
dilate in proportion to the growing demands of that organ, and
during labor, because this portion of the womb must dilate, re-
cede from the os, its centre, and fall back in all directions, to
afford an opening for the child to pass, and hence, as it recedes,
must detach itself from the placenta in sità upon it, and, of
course, open the uterine vessels, over which the latter had been
superimposed. In this process, however, the cervical zone, as
it recedes towards the middle, or meridional Zone, and is, as it
were, lost in it, closes its own vessels, and thereby arrests haº-
morrhage from their mouths.
The theory of Dr. Barnes to account for the first accessions
of haemorrhage, it seems to me, is liable to objections. Perhaps
all we are justified in saying confidently of these early attacks
is, that they are owing to partial separations of the placenta
from its attachment to the internal surface of the womb, caus-
ing an opening to a greater or less extent of the utero-placen-
tal vessels, which consequently pour out their contents. What
causes this severance is not so plain. Possibly, as the placenta
is here implanted upon a less congenial soil than it would have
found in the higher regions of the womb, its attachment may
be less firm, and therefore more liable to be disturbed by slight
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 171
causes. Thus unfavorably situated it may possibly undergo
changes itself, in the latter months of pregnancy, increasing the
instability of its hold upon the uterine surface. Under these .
circumstances, slight forces may effect separation more or less
extensive. It is now well ascertained, as we have stated in the
chapter upon the Signs of Pregnancy, that the womb, during
gestation, is constantly subject to contractions at short inter-
vals. Even these, under favoring circumstances, may cause
utero-placental separation, and give rise to haemorrhage. But
whatever doubts we may have of the correctness of Dr. Barnes'
theory of the precursory haemorrhages in cases of placenta
praevia, his explanation of the cause of that during labor is en-
tirely satisfactory, and seems unquestionable.
Fortunately placenta praevia rarely occurs, but when met
with constitutes a very dangerous complication of labor. Its
infrequency of occurrence itself, furnishes a reason why the
practitioner should thoroughly acquaint himself with every-
thing necessary to its successful management.
Various methods have been from time to time proposed for
the treatment of this accident, most of which it must be con-
fessed have been very unsuccessful. A large proportion of the
infants have been lost, and not a few of the mothers.
We were told by the older authors, that when called to a
case of placenta praevia, we should moderate the attendant
haemorrhage by cold applications, or if necessary hold it in
check for a time, by the use of the tampon, until the OS uteri
is sufficiently dilated, or in urgent cases even hasten its dila-
tation by moderate force, pass up the hand peeling off the pla-
centa on one side, rupture the membranes as far up as possible,
seize a foot, turn and deliver. This method, now perhaps
pretty generally abandoned, at least as to its indiscriminate
application, is open to many objections, and its want of success
proved it practically to be a very bad one. The OS uteri, not-
withstanding the haemorrhage, is not unfrequently slow to di-
late, being, as it were, sealed up by the superimposed placenta.
Hence, while waiting for the completion of this process, the
patient may perish from the loss of blood. Again, turning by
the old method subjects the child to considerable risk, and the
172 PRACTICAL MIDWIFERY.
shock from suddenly emptying the womb may very likely
prove fatal to the mother, already reduced to the lowest grade
of prostration, through great and repeated losses of blood.
TJnder such circumstances the womb should never be suddenly
emptied.
Another method, first proposed I believe by Dr. Radford,
was to insert a finger into the os uteri and peel off the placenta
entirely from its attachment to the womb. It was said that the
haemorrhage then ceased, and the labor might be allowed its
own time for completion. This was a step in the right direc.
tion; for, although all was not done that was intended, that, at
least, was often done which was required. That is, although
it was intended to remove the entire placenta, this was really
not effected; for, as Dr. Barnes has shown, the finger could
not reach the entire insertion of the placenta. It was, how-
ever, detached from the lower segment or zone of the womb,
and this, as we shall see, was all that was necessary to arrest
the haemorrhage.
It should be remembered that no single method of treatment
is applicable to all cases with which we may meet. Having
familiarized ourselves with the great principles upon which all
rational and safe practice must be founded, we should modify
our treatment according to the dictates of science and common
Sense, so as to suit each individual case.
When consulted for haemorrhage, prior to the actual com-
mencement of labor, we may use such measures as are else-
where laid down to arrest it temporarily. Perfect rest in a
Cool room, Apoc. can., Trillium pend., Viburnum, Erigeron
can., Thlaspi bursa-pastoris, selected according to symptoms, are
likely to answer our purpose. We should watch the case
closely, and if the patient seem seriously endangered from re-
peated losses of blood, we should conscientiously consider the
propriety of inducing premature labor. If this be decided
upon, we may find that introducing and inflating, or filling
with water, the colpeurynter, carried up to the os uteri, may
be the means not only of temporarily arresting haemorrhage,
if such be present, but of bringing on efficient labor pains.
Should this simple measure not succeed in accomplishing our
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 173
purpose, we should adopt such means as are pointed out in our
chapter upon the induction of premature labor, that may be
found suited to the case.
In attending a case, whether of induced or spontaneous
labor, if the OS uteri do not dilate we may use Barnes’ dilators
One after the other in succession. When the os uteri is suffi-
ciently dilated to admit of the operation, if haemorrhage is still
going on, we should puncture the membrane through the pla-
centa with a male catheter, and slowly draw off the liquor
amnii. This will especially be proper if we have fully satis-
fied ourselves that the head presents—if otherwise, and podalic
version of the child seem likely to be demanded, the measure
may be more questionable. When the waters are discharged
the womb will probably contract more vigorously, and forcing
down the head upon the placenta, will apply it as a compress
upon the bleeding vessels. If the pains be not sufficiently vig-
orous, give Ergot in small doses, repeated at very short inter-
vals, so as to be able to control its effects. If haemorrhage, how-
ever, still continue, introduce the finger and detach the pla-
centa all around, as far as it can be reached. This will remove
an obstacle to the full dilatation of the os uteri, and favor the
retrocession of the lower segment of the womb, and enable it to
fall back upon the meridional region. . We have seen that in
So doing its patulous vessels are closed, and haemorrhage conse-
queutly ceases. If the action of the womb be now energetic,
either spontaneously or in response to Ergot, and the presenta-
tion normal, the labor may be left to the natural powers to ter-
minate. If, however, flooding still continue, it might be well
to inject, by means of a flexible gum catheter, attached to a
Davidson's syringe, a warm, slightly styptic solution of persul-
phate of iron, between the detached portion of the placenta and
the uterine surface.
In most cases where the above measures are resorted to, the
haemorrhage will cease, and there will be no need of haste.
But if flooding still continue, and we cannot excite the womb
to the requisite action—or if there be an abnormal presentation,
we must render such aid as may be required according to the
principles elsewhere laid down. Turning should be avoided,
174 PRACTICAL MIDWIFERY.
if possible, or if indispensable, should be executed by the bi-
polar method, if that be applicable. The forceps, recommended
by some, is objectionable on account of the difficulty of applica-
tion in such cases, and the loss of blood likely to take place
during the operation; but notwithstanding this, there may be
instances where the use of this instrument is indispensable.
I have no doubt there are cases of placenta praevia which may
be safely managed, in reference at least to the mother, without
further interference than to secure the dilatation of the os
uteri, where nature fails, unaided, to effect this, and to keep up
the vigorous action of the womb when this fails. Nor do I
think such management always imperils the life of the child
beyond its usual risks in such a state of things. At all events,
the life of the child is here a secondary consideration, as it is
likely to be born feeble and anaemic, and therefore not very
likely to pass through the usual perils of infancy.
Many years ago I had the sad misfortune to lose a very in-
teresting young woman, in her third or fourth labor, in conse-
quence of the complication now under notice. She had suffered
repeated haemorrhages before I was called finally for her relief.
Following the directions of the then best authorities, I turned
and delivered the child alive and with the utmost ease. Al-
though, at the time, I thought the patient's pulse fully justi-
fied the measure, she collapsed, and I found it impossible to
rally her, so that she died apparently from shock within an hour.
From what I noticed about the moment I commenced the ope-
ration, I afterwards thought, had I let her alone, she would
have delivered herself without my interference.
Some years afterwards, a case came under my treatment
which I had no doubt was one of placenta praevia, although I
had not made a vaginal examination. I had prescribed for
haemorrhage, occurring perhaps a month before her expected
confinement, for which she could assign no cause. She was re-
quested to let me know, if any, even the slightest recurrence
should take place. Her husband called on me, perhaps two
weeks after, to say that his wife had been flooding since the day
before; that she had no pains (which I afterwards found to be
incorrect), that the abdominal enlargement had so much sub-
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 175
sided since the former haemorrhage, that she thought she must
have been mistaken as to her condition.
As I was about to leave home, I gave him Apoc. can. pretty
strong, to be taken at short intervals, and if the haemorrhage did
not shortly cease, he should by all means let me know. I sat
up till after midnight, expecting and prepared to treat a case
of placenta praevia. I was called up by 1 o'clock, A. M., by a
messenger, who could tell me nothing of the case, but on my
arrival I found the child had been still-born, before the messen-
ger had been dispatched; from appearance had probably been
dead since the former flooding. I found the membranes rup-
tured just at their junction with the placenta. The secundines
had been expelled with the child.
The patient told me that not finding the medicine relieve the
flooding, she had taken the doses in rapid succession, each of
which seemed to increase her pains, till the whole contents of
the womb were at once extruded.” She made a good recovery.
We need scarcely add that when the child and the after-
birth are delivered, we should be careful to secure firm and
persistent contraction. Give Bell. if symptoms of cerebral
congestion ensue.
POST-PARTUMI HAEMIORREIAGE.
Haemorrhage may occur immediately after the birth of the
child, and before the delivery of the secundines, even where
there has been nothing abnormal in the implantation of the
placenta. This is generally owing to the presence of the after-
birth, by which the womb is prevented from contracting, so as
to close the mouths of the bleeding vessels. The placenta may
be wholly or partially detached from the uterine surface. In
either case, there are vessels patulous and pouring out their
contents. They will continue to do so till the womb contracts
and closes their open mouths, or these latter are temporarily
plugged by coagula formed within them. This latter may hap-
* When in such cases, there is unreasonable delay in the passage of the
head through the pelvis, the forceps may perhaps be available—at least
should be thought of.
176 PRACTICAL MIDWIFERY.
pen through partial stagnation of the circulation brought on
by decrease of the heart's action through loss of blood. The
arrest from this cause is, however, usually only temporary, so
long as uterine contraction has not been fully effected. As
soon as the heart rallies, and the circulation resumes in any
considerable degree its force, the clots opposing a barrier to
haemorrhage are liable to give way, and alarming flooding
again to set in.
In this state of things, we should as soon as possible empty
the womb of its remaining contents. We need not here repeat
the instructions elsewhere given for the delivery of the after-
birth. It is, however, particularly important in this case, to
second the tractile efforts of the hand within the internal
organs, by the other hand placed over the womb externally,
exerting a bearing down force, not only for the purpose of facili-
tating delivery, but to induce the womb to contract as its con-
tents recede. This external pressure should be maintained for
Some time, until it is ascertained that there is no disposition to
relaxation.
When the secundines are delivered and uterine contraction
Secured, haemorrhage usually ceases permanently. This will
not, however, always be the case. Sometimes, the womb again
relaxes, and the flooding recurs with great violence. It is
therefore important that the accoucheur should remain for
Some time with his patient, and before he leaves give particu-
lar instructions to the nurse how to proceed, in case such an
unfortunate occurrence should take place in his absence.
If the womb do not contract when the after-birth is removed
and flooding still continue, and if the usual compressing ma-
nipulations do not succeed, or if danger be imminent, it is ad-
vised to carry one hand up the vagina and elevate the lower
segment of the womb, while the other hand applied externally
forces down the fundus, so as to bring together the upper and
lower regions of that organ, thus closing its cavity, and conse-
quently the open mouths of the vessels. Where there is a dis-
position to relaxation of the womb after it has contracted, most
writers advise the application of a compress over that organ,
secured by a binder.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 177
Dr. Hyatt, of North Carolina, claims to have frequently
arrested post-partum haemorrhage, either before or after the
delivery of the secundines, in the following simple manner.
“An india-rubber balloon, which may be bought at any toy-
shop, is tied over the end of a Davidson-syringe nozzle and
passed into the cavity of the flaccid uterus. It is then distended
by warm or cold water; by this means we bring pressure to
bear directly upon the mouths of the bleeding vessels, which
effectually seals them, and renders further haemorrhage impos-
sible.” If water be used in the above operation, we would by
all means advise to use it warm, as we cannot but think that
cold applications to the interior of the uterus shortly after de-
livery are, to say the least, extremely hazardous; not so much
as regards immediate consequences, as those more remote. Ac-
cording to very respectable testimony,” the injection of water
as warm as can well be borne (110°) into the uterus, is itself
ONE OF THE MOST EFFICIENT MEANS of arresting haemorrhage.
In this latter operation, the pipe of the syringe should be
carried up within the womb till near the fundus.
It appears from an article published in the Archives de
Tokologie, for May, 1876, that Dr. Chassagny had resorted to an
expedient for the arrest of haemorrhage essentially the same as
that of Dr. Hyatt given above; the latter gentleman, however,
claims priority in its use.
If the above expedient be resorted to, we would suggest that
after the india-rubber is sufficiently distended, the bulb of the
syringe be detached and the finger of the accoucheur gently
applied to the end of the tube, so that the water may be retained
and gradually escape as the womb contracts.
Flooding will occasionally set in violently, as above inti-
mated, some time after the delivery of the after-birth, even
when the womb has seemed to be well contracted. Of course
* Dr. Athill and others. Dr. A., in a paper read before the Obstetrical
Society of Dublin, details some interesting and successful experiments with
the above expedient in the Rotunda Hospital of that city. He says he was
induced “to try it in consequence of a letter written by Dr. Whitwell of
San Francisco to Dr. Foley, of Boston, who is at present studying in this
hospital.”
12
178 PRACTICAL MIDWIFERY.
relaxation in such cases has again taken place. Such an event,
alternate contraction and relaxation, is believed, sometimes at
least, to be foreshadowed by the character of the pains during
labor. When the uterine contractions set in suddenly, soon
attain their height, and then quickly subside, we may look for
a want of permanent contraction after the parturient process is
ended. In such cases we should endeavor to forestall this un-
fortunate circumstance, by the administration of remedies
during labor. I have found small doses of Ergot given toward
the close of labor, generally secure speedy and permanent con-
traction, and at the same time greatly diminish subsequent suf-
fering from after-pains. We need hardly repeat the injunction
that when the prognostic indication just mentioned is encoun-
tered during labor, the attendant should be specially watchful
of the case, and remain as long as possible with his patient
after her delivery.
Another premonition of flooding, to which we have before
called attention, is an unusual quickness of the pulse. When
this is observed to continue after the excitement of labor has
somewhat subsided, we should be upon the look-out for flood-
ing and provide accordingly. I met with this symptom once
in a young woman after the birth of her first child, and sus-
pecting haemorrhage, I remained in the house for an unusual
length of time, but finding no abnormal discharge, I was just
about to leave, when I was suddenly summoned to the bedside
of the patient. Perhaps the most alarming haemorrhage I have
ever witnessed, followed. It yielded at the time, to the meas-
ures employed, and the womb seemed to contract in a normal
manner. The following night, however, I was again sum-
moned on account of its recurrence in a very violent form. It
again yielded, but the patient some days afterward seemed to
be affected by septicæmic poisoning, and appeared likely to
make a very bad recovery. After using several remedies with
negative results, I gave Ars. alb., 2d dec., with excellent effect.
Unusual quickness of the pulse, with some haemorrhage, and
symptoms of shock should lead us to suspect laceration of the
perineum. <\.
Post partum flooding may generally be attributed to want of
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 179
complete and persistent contraction of the womb. This, as we
have intimated, is sometimes due to mechanical obstruction,
such as retained placenta, in whole or in part, and even clots
formed within the uterine cavity may have the same effect.
But this deficiency of contractile power may be owing to one
or more, of several remote causes, having primarily no relation
to that just stated. Sometimes it may be traced to pre-existing
disease, giving rise to general debility, of which the womb, as
other organs, partakes. Again it may be owing to exhaustion
of the uterine power, from severe and protracted labor. It may,
moreover, be caused by a too rapid delivery, a too sudden emp-
tying of the uterus, so that its walls cannot follow up the re-
ceding contents. Besides very sudden delivery is usually at-
tended by more or less of shock, in which the womb, in com-
mon with the whole organism partakes. When want of con-
traction follows the administration of chloroform, it is pretty
uniformly laid to the charge of that agent, and haemorrhage,
in the opinion of some who have never used it, is almost an un-
failing result. We will, hereafter, express our opinion upon
this subject, and need not anticipate in this place. The action
of the causes we have just referred to, sometimes give rise to a
mechanical one, which, in its turn, tends to increase and pro-
long the haemorrhagic condition. When the womb fails to
contract, immediately after the extrusion of the after-birth, the
blood, pouring into its cavity, forms clots, which in turn inter-
fere with its complete closure, until it acquires sufficient force
to expel them as foreign bodies.
Generally, in regard to the evils attending childbirth, it is
better, if we can, to forestall and prevent them, than to suffer
them to become developed, even though we should be success-
ful in relieving them. Much may be done in this way in re-
gard to post-partum haemorrhage.
It is a good rule, as we have already said in the chapter on
the Management of Labor, and here repeat for the sake of em-
phasizing it—it is a good rule, when the head of the child is
born, to have an assistant, well instructed in the duty, to place
the hand over the uterine tumor, and with firm pressure, to
follow down the receding body as it passes into the world.
180 PRACTICAL MIDWIFERY.
Nor should the hold be relaxed even when the body is born,
but firm pressure maintained until the accoucheur himself is
free to take charge. This simple expedient itself, we have
thought, does much to secure contraction of the womb, the
early expulsion of the Secundines, and subsequent immunity
from haemorrhage.
But while we regard firm and persistent contractions of the
womb the great prophylactic against haemorrhage, and the only
reliable means of its permanent arrest, when it has taken place,
the homoeopathic obstetrician is by no means restricted to me-
chanical manipulations to produce this condition. On the con-
trary, there may be existing at the time, a morbid condition of
the uterus which may completely baffle all such efforts, and
yield only to a well selected remedy truly homoeopathic to that
condition. The young practitioner should therefore thoroughly
study the pathogenesis of all remedies likely to be available
under these trying circumstances. This he should do, not at
the bedside of the patient, and from a book carried in his
pocket, to be used if necessity require; but in his private
study, and previously and thoroughly—and then we have no
objection to the book in his pocket as a reminder.
There is, perhaps, no situation in which the young obstetric
practitioner can be placed, more trying, than to have in charge,
without the aid of older counsel, a case of violent uterine hae-
morrhage. On the one hand he feels his own reputation at
risk—on the other the life of his patient. Fortunately, how-
ever, these cases do not so often result fatally, through their
immediate consequences, as one would expect. Perhaps the
secondary effects are, upon the whole, more to be dreaded than
the primary. But we reiterate, let the young practitioner al-
ways be prepared to do the utmost to speedily arrest an unna-
tural effusion of blood.
The following are a few of the remedies particularly deserv-
ing attention in post-partum haemorrhage, viz.: Apoc. can.,
Bell., Crocus, Ipecac., China, Secale, Trillium, Ergeron. There
are still others’worthy of study in this relation. We have,
however, I believe, never gone beyond this list in the use of
medicines, and have as yet lost no lives. In violent cases we
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 181
have almost always resorted to medication in conjunction with
the mechanical measures just recommended.
When there is good reason to believe that clots have accu-
mulated in the uterus, so as to prevent its contraction, efforts
should be made to procure their expulsion. If firm pressure
upon the organ do not effect this object, we may try Puls., and
if this do not succeed, perhaps Ergot will answer our purpose.
These remedies, however, should not be given at random : the
one or the other must be selected according to the circum-
stances of the case, and which it would be useless for us to
imagine and then depict—it must be taken as it occurs. If
Ergot be given, it must be given in repeated doses of such
strength as will ensure vigorous contraction, or else satisfy us
that it is incapable of reaching the case.
When the womb, from its size, as felt through the abdominal
walls, is believed to contain a large amount of coagulated
blood, while yet the os and vagina are sufficiently dilated or
dilatable, we are advised to introduce the hand and turn out
the clots. This expedient may be necessary if haemorrhage is
still going on, and we have reason to believe that the measures
we have already laid down may not succeed sufficiently soon
in effecting their expulsion. It must be remembered that co-
agulated blood, if present in large amount, must be removed,
if we would secure safe contraction of the womb. It has been
advised to raise and seat the patient upon the chamber-vessel
to effect this object, and we have known this measure to suc-
ceed. If haemorrhage continue after the expulsion of the clots,
we may try the injection of warm water.
Should we meet with a case of violent haemorrhage which
should resist such of the foregoing expedients as might be se-
lected, and, indeed, any others we might adopt, and seemed to
be progressing toward a fatal termination so rapidly that some-
thing more effectual must be done or the life of the patient be
lost, an important question arises, shall we or shall we not use
an injection of a solution of the per-chloride or per-sulphate of
iron 7
I am fully aware that Homoeopathic physicians entertain
strong prejudices against such measures, and I may truly add,
182 PRACTICAL MIDWIFERY.
I am myself one of that number. Some very positively affirm
that they have met with no cases that did not yield to homoeo-
pathic remedies, and I readily concede that they have been
very fortunate. I will, moreover, add that I myself have met
with very few. But yet every one who has had an extended
experience must admit that cases do occur wherein a fatal result
is so alarmingly imminent, that it is evident something must
be efficiently done in a few moments, or the case will be lost.
The patient is unable to give her subjective symptoms—can
answer no questions—nay is absolutely speechless and almost
pulseless, while flooding is still going on. Under these un-
favorable circumstances, and ordinarily no little trepidation,
whatever remedies may be really available, the physician has
a very poor chance to select. Unfortunately we are sometimes
compelled, as the best we can do, to choose between two evils,
and it is certainly the part of wisdom to choose the less.
A solution of the perchloride of iron of very moderate
strength, injected into the womb, has, in all cases reported,
so far as my researches extend, immediately arrested haemor-
rhage. This arrest, so far as I have noticed, has been perma-
ment. In the very few cases in which I have resorted to this
measure, such has certainly been the result. A very important
question then arises, namely, are the ordinary or necessary
consequences of the practice, such as to determine its rejection
in every case of flooding, however violent or hopeless?
The haemostatic action of the remedy is probably two-fold.
By its irritating property it stimulates the womb to contract,
and by its power as a styptic it coagulates the blood within
the mouths of the bleeding vessels, and constringes the con-
gested capillaries from which blood may be welling out into
the cavity of the womb. From these two actions of the drug
arise whatever dangers may necessarily follow its use. We
will, for a moment, examine them. In the first place, as an
irritant acting upon the internal surface of the womb, highly
congested, and in a state of exalted nervous impressibility, it
must be confessed there is some reason to dread serious inflam-
mation (endometritis). Practically, however, if we may de-
pend upon the reports of those most frequently resorting to
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 183
such injections, this does not often happen. Again, through
the same property of the per-chloride, there is danger to be ap-
prehended from another quarter. The injected fluid may pos-
sibly, through the Fallopian tubes, find its way into the peri-
toneal cavity, and excite severe, if not fatal, peritonitis. This
risk may, however, be in a great measure avoided by using
but little force in throwing up the fluid and providing for its
easy return through the vagina. Its constringing power,
moreover, probably sets up a barrier to its entrance. Through
the styptic properties of the drug, danger may be apprehended
from the size and quality of the coagula formed within the
womb. Whatever amount of blood may be present there,
when the solution of the perchloride is injected, if this latter
be in sufficient quantity and of sufficient strength, will be co-
agulated and form very solid clots. The uterus, weakened by
the loss of blood from the general system, may be unable, at
least for a considerable time, to expel these from its cavity.
Their solidity, and perhaps adherence, may oppose an addi-
tional obstacle to this result. Hence a ground of apprehension
of septicaemia from their decomposition. The danger, how-
ever, from this source is probably not so great as might be
supposed. The decomposition of the clots is most likely de-
layed by the very agent that produced them, the per-chloride
itself, at least to some extent, acting as an anti-septic. Besides
injections will arrest haemorrhage effectually, when of a far
less degree of concentration, than those generally employed, and
thus their danger, whatever it may be, may be lessened, both in
regard to their irritating properties, and their tendency to form
solid clots, by extreme coagulation of the fibrine of the blood.
So far as I have resorted to this measure for arresting flooding,
I have used a solution merely of sufficient strength to produce
a decidedly styptic impression when applied to the tongue, and
yet the flow was instantaneously arrested.
The propriety of using injections of perchloride or per-sul-
phate of iron, has been very fully discussed by the different
obstetrical societies of Great Britain. The weight of authority
in these learned bodies, seems to be in favor of its employment,
but rather as a last resort than as an ordinary expedient. From
184 PRACTICAL MIDWIFERY.
a very limited experience with it, fortunately so, it is certainly
only as such I would have recourse to it. But as “drowning
men catch at a straw,” I would rather employ it with all its
risks, whatever they may be, than to be obliged in a few mo-
ments to lay my hand upon a pallid corpse. I would only add
that the per-sulphate is perhaps, in most respects, preferable to
the per-chloride, and is probably homoeopathic to haemorrhage.
Finally, there is one other condition of haemorrhage to which
I think the foregoing expedient may be applicable, but these
too only when other means have failed, and death seems slowly
but surely advancing to seize his prey. Violent and exhaust-
ing flooding has already occurred, prostrating the patient to
the lowest condition compatible with the continuance of life.
We have given remedies which seemed to check the flow, but
still there is from hour to hour and from day to day a con-
tinued drain, which nothing seems to arrest, and which is
manifestly extinguishing the little spark of life which yet re-
mains. In such cases, we should carefully examine both with
the finger, and if necessary with the speculum, to ascertain if
possible whence the haemorrhage proceeds. It will likely be
found to be from some laceration or abrasion, or it may be from
a growth. If the latter, its removal at the time may be attended
with too great risk to attempt, and in either case the injection
as above will most probably, at least temporarily arrest the
flow, gain time, and enable the patient to rally.
There is a form of haemorrhage differing in no essential char-
acteristic from those we have just considered, except that its
occurrence is not announced by the usual unmistakable signs.
The blood accumulates in the womb sometimes in large amount,
but does not flow out by the vagina, and therefore the accident
may not be detected until even dangerous effusion has taken
place. This has been called, not with very great propriety,
internal harmorrhage, simply because it is not attended by the
usual external manifestations, while strictly speaking, all
uterine haemorrage is internal. º
It is important that the accoucheur should early detect this
secret process, since owing to the expansibility of the womb
just after delivery, a vast amount of blood may accumulate
within its cavity.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 185
After the child is born and the after-birth removed, or even
before this latter is accomplished, if the pulse be found quick,
the womb but little or not at all contracted, or on the contrary
it may be rather enlarged, if upon examination no external
haemorrhage or very little appears, if no laceration of the pe.
rineum be detected (if such exist there will be haemorrhage), if
the patient manifest signs of shock, suffers from difficulty of
respiration and is thirsty, we have reason to believe that in-
ternal haemorrhage is going on. The indication is to remove
the accumulation within the womb and compel it to contract.
We have already given in detail the means to be employed for
effecting contraction, and if we can secure this, we secure at
the same time the expulsion of the blood contained within.
IBut if we cannot induce the womb to contract and expel its
contents without unnecessarily wasting precious time, it is
proper we should introduce the hand and turn out the clots,
and then renew our efforts to secure contraction. We need not
hesitate to turn out the blood, whatever may be its quantity,
for it is already thrown out of the circulation, and can there-
fore do nothing toward sustaining life. On the other hand, by
its presence it prevents contraction, and thereby invites still fur-
ther loss. If great exhaustion have taken place, use stimulants
very cautiously. The subsequent treatment of such cases dif.
fers in no important respect from that already given, only we
should be especially watchful to keep up permanent contraction.
It occasionally happens, that shortly after delivery, even
where no premonitions have been noticed, a frightful haemor-
rhage sets in, rapidly undermining the vital powers, and not
unfrequently terminating in sudden and unexpected death. I
have not myself been so unfortunate as to meet with a case of
this kind, but have repeatedly known them to occur. Such
cases are always attended with extreme danger, from the sud-
denness and violence of the onset, from the perturbation they
usually excite in the attendant and friends of the patient, as
well as too often the absence of the appliances necessary suc-
cessfully to meet the urgent indications.
A method of arresting uterine haemorrhage has lately been
proposed, which I think, when it is available, would answer
186 PRACTICAL MIDWIFERY.
well in cases such as above described. I am sorry I am unable
to give the name of the individual by whom it was first prac-
ticed and recommended to the profession. It consists in apply-
ing pressure upon the aorta upon the principle of the tourni-
quet. This is effected in several different ways, according to the
requirements of the case in hand. If the woman, for instance,
be of relaxed muscular fibre, attenuated abdominal walls, and
the internal viscera easily movable, the womb and bowels may
be partially pushed aside, and the points of the fingers thrust
deep into the tissues until they press upon the great aorta with
sufficient force to arrest the haemorrhage. Their position and
pressure should be thus maintained till there is no longer dis-
position to recurrence. When the womb cannot be easily turned
aside, and where it presents considerable solidity, it may, like
the pad of the tourniquet, be pressed upon the artery by force
applied externally. Again, pressure may be exerted upon the
vessel through the posterior wall of the uterus by the hand in-
troduced into that organ. Manipulations performed by one
hand in the rectum, and the other applied externally, or within
the womb, have also been recommended. *
The advantages of this method, when applicable, are the
celerity with which it may be applied and the promptness of
its effects. It requires nothing but what is always at hand.
These advantages are very important, as the cases we have in
view admit of no delay. A short time spent in looking up
appliances, and life is extinct. However strong our confidence
in well selected medicaments, there is no time for them to act,
scarcely enough to administer them.
On the other hand, where there is extreme tenderness of the
abdominal walls, as there not unfrequently is, the patient
would scarcely bear the requisite amount of pressure to be
effective. Again when the abdominal parietes are very thick,
either from heavy and dense muscular fibre, or the presence of
much adipose tissue, or when the omentum is loaded with fat,
it will not be easy to make sufficient pressure upon the vessel
to answer our purpose.
I need hardly add that the point selected in the course of
the aorta, to which to apply pressure, should be sufficiently
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 187
high to arrest the current in the direction of the womb, nor
need I say that the method, if successfully executed, will have
a doubly beneficial effect, first, by arresting the unneeded flow
to the womb, and, secondly, by sending an additional amount
of blood to the brain, which is, perhaps, already suffering from
anaemia.
A very interesting paper will be found upon this subject in
the Obstetrical Journal of Great Britain and Ireland, Vol. VI.,
No. 11, p. 704, by G. de Gorrequer Griffith, L.R.C.P.
d) Post Partum Secondary Haemorrhage.—It has long
been a matter of surprise to me that obstetrical writers have
devoted so little space to the subject indicated by the above
title. Its importance certainly merits more attention than has
thus far been accorded to it. Of all the writers, to whose
works I have had access, Dr. Barnes, in his “Obstetric Opera-
tions,” does it most justice, and here, as everywhere, is very
instructive. Under the head of “Secondary Puerperal Haemor-
rhage,” however, he treats of several forms which have not
their origin within the uterine cavity, as, for instance, those
arising from laceration or abrasion of the cervix, laceration of
the vagina, perineum, etc. It is our present design, however,
to speak only of haemorrhage having its source in the internal
surface of the womb, and such as occurs not earlier after de-
livery than the second or third day, and may take place at a
much later period. & -
This form of haemorrhage is peculiarly dangerous from at-
tendant circumstances, and from the pathological condition
upon which it often depends. When haemorrhage occurs
shortly after birth, some symptoms usually herald its approach,
“Coming events cast their shadows before,”
and the prudent accoucheur remains with his patient, provided
with the best means at his disposal, to ward off approaching
danger. Not so, however, when secondary hamorrhage takes
place. Its occurrence, perhaps, is not anticipated; the patient
is alone with the nurse or the members of her family, it may
be unsuspectingly enjoying quiet sleep, so necessary to her res-
toration, when waking suddenly, she finds herself immersed
188 PRACTIC AI, MIDWIFERY.
in a pool of her own blood. The doctor is hastily sent for,
but he lives miles away, and is, perhaps, not at home when
the messenger arrives. Thus, before anything is efficiently
done, the patient has become exanguious and pulseless, and if
of a feeble constitution, may have sunk below the rallying
point.
Another source of peculiar danger is found in the liability
of the blood-clots resulting from the haemorrhage to become
putrid within the womb, and thus give rise to septicaemia, often
in its worst form. It has seemed to me that the womb has less
power to expel foreign bodies after secondary hamorrhage,
such as we here contemplate, than after that which may occur
shortly subsequent to delivery. The blood-vessels, too, being
so thoroughly depleted of their normal contents, the more
readily absorb any fluid within their reach, be it noxious or
otherwise.
There are also morbid conditions sometimes co-existent with
this form of haemorrhage, which may indeed have contributed
to its occurrence, and which, at least, add to its danger. There
may, for instance, have been pre-existing circumscribed inflam-
mation of the internal surface of the womb. It may have
constituted a factor in the production of haemorrhage; but be
this as it may, when it has taken place, it very considerably
augments the danger of its results. The patient then not only
suffers exhaustion from the loss of blood, but from the depress-
ing, consuming effects of local inflammation. The citadel of
life is thus assaulted at different points, and, in consequence,
is, too often, doomed to fall.
If, moreover, it be true, as some have supposed, that second-
ary hamorrhage sometimes has its origin in a peculiar dyscra-
sia of the blood itself, in consequence of which it is thinned in
its consistence, or its coagulability is diminished, or both, for
they are likely to be associated, it is manifest that the arrest
of the flow by Nature's usual method would be more difficult,
and the consequent danger of the result increased. The im-
paired state of health, too, necessarily concomitant with such
a dyscrasia of the blood, would render the patient far less
likely to rally from the extreme exhaustion of profuse haemor-
rhage.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 189
Fortunately cases of secondary post partum hamorrhage are
comparatively rare, for it mostly depends upon causes which
the careful practitioner may avoid. We will at present under-
take to enumerate but a few of the more prominent of these,
and subsequently endeavor to indicate, as far as we can, both
prophylaxis and remedy.
Among the most fruitful sources of this form of haemorrhage
may be mentioned, portions of the placenta or even membranes
left behind within the womb. If these portions be detached
and escape the hand of the operator, so as to be retained, they
are, perhaps, less likely to produce this disastrous result than
if left undetached. In the former case they merely act as a for-
eign body, and as such may indeed produce irritation upon the
internal surface of the womb, and, consequently, invite an un-
wonted afflux of blood to the part and thus encourage haemor-
rhage. But in the latter they furnish an outlet by which the
vessels of the womb pour out their contents into the cavity of
that organ. Besides, if any considerable portion of the pla.
centa remain, by its bulk it prevents the uniform contraction
of the womb, and, consequently, the perfect closure of the
mouths of the maternal vessels, so essential to safety from
haemorrhage.
When speaking of Adhesion of the Placenta, we have re-
ferred to the difficulty occasionally encountered in our attempts
to remove the entire mass, and of the great risk of haemorrhage
where we fail to effect this. We need not here repeat what
we have said, but will speak only of the treatment of the
haemorrhage which, sooner or later, is likely to occur in these
unfortunate cases.
And here I would refer the reader to the remedies spoken of
when treating of haemorrhage in a former chapter of this work.
These remedies are available also here. But secondary hamor-
rhage from the cause we are now speaking of, generally occurs,
as we have already said, in our absence, and often to an extent,
before we reach the bedside of the patient, that she is unable
to give the subjective symptoms of her case. The flow perhaps
still continues, and it is manifest, unless soon arrested, the pa-
tient's life must be sacrificed. In such case I would not hesi-
190 PRACTICAL MIDWIFERY.
tate to inject, as an extreme resort, the perchloride or persul-
phate of iron, diluted very considerably below the degree of
concentration used by Dr. Barnes, or as I have elsewhere said,
just strong enough to produce a decidedly styptic impression
when applied to the tongue.
Another cause of secondary post partum haemorrhage we
would notice, is the retention of blood-clots within the uterine
cavity. From various causes it sometimes happens that the
uterus does not firmly contract after delivery, and blood still
oozing from the patulous mouths of the vessels, forms a coagu-
lum which the deficient powers of that organ are unable to ex-
pel. This coagulum may increase in size by continued accre-
tions, and thus in turn prevent the further contraction of the
womb, and the firm closure of the mouths of its vessels, and in
the meanwhile acting as a foreign body produce irritation.
This will cause an increased flow of blood to the womb, while
under its distending force, the imperfect closure of the vessels
may give way and more or less alarming haemorrhage ensue.
To forestall and prevent the accident from this source, we
should, of course, by a resort to the means elsewhere pointed
out, secure perfect contraction of the womb before leaving the
patient after delivery, and from time to time see that such con-
traction is maintained. When clots are suspected to exist in
the womb shortly after delivery, and which that organ seems
unable to expel, obstetrical writers, as we have before said, ad-
vise us to introduce the hand and turn them out. This could
not be done, however, when secondary post partum haemorrhage
occurs, inasmuch as the OS uteri would then be closed, so as not
to admit the hand without violence. But even then, Secale
may so stimulate the womb, as to secure the action necessary
to expel any clots it may have retained for want of vigor.
Mental emotions sometimes give rise to secondary haemor-
rhage. This is brought about indirectly through their influ-
ence upon the heart. We may suppose, in such cases, that the
mouths of the maternal vessels are not yet firmly closed, and
when from fright or other emotion, the heart is excited to un-
wonted action, the increased impetus given to the blood causes
it to break through the imperfect barriers, at the mouths of the
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 191
uterine vessels, opposing its exit. Common sense prescribes as
the best prophylaxis against accidents from this cause, that the
patient, especially if she be of a nervous temperament, should
be scrupulously secluded from all sources of emotion or excite-
ment.
Derangement of innervation, which controls the contractile
powers of the womb, giving rise to irregular, unsymmetrical
contraction of that organ after delivery, constitutes another
source of secondary hamorrhage. The womb, when its power
is intact, usually assumes a globular form—on the other hand,
when impaired in the manner referred to, the form assumed
may be cylindrical or otherwise abnormal. Such contraction,
but an imperfect safeguard against haemorrhage even at the
first, is apt to relax in a few days, and may be followed by pro-
fuse flooding. To correct this defective contraction, and
thereby forestall its consequences, we would have confidence in
minute doses of Ergot, if the difficulty have not been caused by
abuse of that drug.
Another derangement of innervation or nervous function
giving rise to secondary hamorrhage, may yet be mentioned.
It is that in consequence of which an equilibrium of the circu-
lation is no longer maintained. There is undue afflux of blood,
first to one organ or part, then to another. The womb is liable
in its turn to become the seat of this afflux, and the conse-
quence sometimes is profuse, and even fatal haemorrhage.
The following case will illustrate this rather rare phenome-
non. It occurred perhaps more than twenty years ago. A
young woman of low stature, primipara, was in labor for at
least three days, owing at first to deficiency of uterine contrac-
tions, and afterwards, in the second stage, to the unusually
large size of the child. She was delivered without instrumental
interference, and made a reasonably good recovery up to the
tenth day, when, according to custom, she began to sit up out
of bed. Her mother then, unfortunately gave her some rice
pudding at her dinner, prepared with milk—the latter an ar-
ticle which had always disagreed with her. This imprudence
brought on violent cholera morbus, and the irritation extended
to the womb—already susceptible from its contused condition
192 PRACTICAL MIDWIFERY.
in consequence of an unusually hard and protracted labor. The
vomiting and diarrhoea subsided under treatment, but in the
course of two or three days her face at one time would become
so congested as to be almost of a purple color—then the lungs
would be so oppressed as to cause extreme dyspnoea, while the
face would become pale. Finally the afflux of blood was deter-
mined to the womb, followed by a haemorrhage which at once
brought her to death’s door. This occurred in the night; I
was not present, but an experienced physician and his son, who
had been called to my aid, were with her. She expired the
following evening,
We have before observed that the physician, especially in
the country, is seldom present during the most violent stage of
the haemorrhage of which we speak. Should he be, and the
same accompanying symptoms present themselves as in the
haemorrhage occurring just after delivery, the remedies indi-
cated in the one case, as we have before said, would be also
proper in the other. But in the majority of cases we should
simply witness the violent gush of blood and the rapid sinking
of the vital powers, demanding the immediate arrest of the
flow, if we would save the life of our patient, or prevent her
sinking into that depth of prostration from which too often
there is no return. Here the various expedients for producing
contraction of the womb, if that be found relaxed, as is mostly
the case, immediately suggest themselves, and most of them
need not interfere with the most skilful medication simultane-
ously carried on. It is an excellent plan for country practition-
ers to instruct a nurse or other woman, in every neighborhood,
within the bounds of his practice, how to use the more simple
of these expedients, such as kneading and compression of the
womb by means of the hand or by pad and binder, or even the
introduction of the tampon. By so doing the temporary arrest
of the haemorrhage would often be secured, the ruinous loss of
blood prevented, and I verily believe lives, in many instances,
saved, which are now lost for want of such knowledge.
If the physician be present, other means failing, he may
have recourse to the introduction and inflation of the gum
elastic toy balloon elsewhere spoken of. It may be remarked
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 193
here, that we cannot expect in these cases, so much from appli-
ances calculated to promote uterine contraction, as in haemor-
rhages occurring earlier after delivery, as the contractile power
of the womb at this late period and under existing circum-
stances may generally be supposed to be very deficient.
Before closing my remarks on haemorrhage, do I owe an
apology for having so largely recommended mechanical, chem-
ical and physiological appliances? If so, it has ever been my
wish “to give a reason for the faith that is in me,” such as
ought to be sufficient to satisfy every candid mind. Some, I
know, profess to treat successfully all haemorrhages by simple
medication—by remedies, perhaps, of the forty or hundred
thousandth dilution. As I wish publicly to question no man’s
assertion, although there is, perhaps, no truth better established
than that such assertions are sometimes incorrect, I would
simply say that all are not equally skillful in selecting remedies
and, of course, not equally successful in their employment. I
have already spoken of the difficulty, in many instances, in
ascertaining symptoms such as would guide us in the correct
selection of a remedy if, in the case before us, uch there be.
I readily admit that a diseased condition may be an important
factor in haemorrhage; but when this is the case, that disease
is, perhaps, mostly of a chronic character, and not likely to
respond to a remedy with sufficient promptness to save the
patient’s life. This should be the great object of the physician's
aim, no matter by what means attained.
If called to a man whose femoral artery had been severed
and his life blood flowing rapidly away, the idea of medication
would probably hardly occur to us. Common sense would
suggest other means of arrest. The case of a woman flooding
after labor is not so unlike to this, as not to suggest similar
means of relief.
I must say, however, that by far the larger number of
haemorrhages I have encountered, have ceased after medical
treatment and the simpler adjuvant means, and when I am
convinced that medicine alone will answer in every case, I
will be among the first to use it to the exclusion of all other
II) ea IlS.
13
194 PRACTICAL MIDWIFERY.
LACERATION OF THE PERINEUM.
This, although not reckoned amongst the more dangerous
accidents of parturition, should nevertheless be guarded against
with the utmost assiduity, on account of the distressing con-
sequences it sometimes entails. It is, however, not without
danger, as, in its worst forms at least, it exposes an extensive
raw surface to the action of the discharges, and, by absorption,
may give rise to fatal septicæmia.
In order to prevent this accident, when that is possible, we
should, in the first place, inquire into the causes usually con-
cerned in producing so unfortunate a result. Of these authors
have enumerated the following as the principal, viz.:
1. Neglect to support the part while the head is passing.
2. Injudicious or improperly directed support, which is re-
garded by most as worse than no support at all.
3. Rigidity of the perineum, on account of which it fails to
yield under the pressure of the head. This is most likely to
occur in primiparae, and especially those somewhat advanced in
life when they give birth to their first child.
4. Extreme uterine action propelling the head violently
against the perineum, without giving it sufficient time to
yield.
5. Large size of the head of the child requiring extreme
distension before it can pass the outlet.
6. Fatty degeneration of the muscular structures composing
the organ in question.
7. The sudden extension of the limbs of the patient from
their usual flexed position, just as the head is held within and
about to pass the vulva.
8. Misdirection of the head from defective formation of the
parts, whereby, instead of being propelled forward toward the
outlet, it takes a direction backward toward the coccyx, thus
spending its force upon the posterior part of the perineum.
In reviewing the alleged causes of the accident under con-
sideration, we are compelled to say, in regard to the first, that
we doubt extremely whether support of the perineum be neces-
sary, except possibly in very rare and they, perhaps, unrecog-
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 195
nizable cases, and whether in nearly all it does not tend to
bring about the very accident it was intended to prevent.
When we contemplate the wonderful provision the Creator
has made for carrying the process of parturition through its
earlier stages, we can hardly suppose he has left it so defect-
ively provided for at its close, as so much to need our bung-
ling aid, that it cannot be safely completed without it. But
throwing aside the argument from analogy, if we, for a moment,
reflect upon the manner in which lacerations usually take place,
we will, I think, equally arrive at the conclusion that support
can do nothing to prevent them—nay, may even favor them,
by interfering with the normal yielding of the tissues. Lacer-
ations usually commence at the posterior commissure, and are
caused by the wedge force of the head, which tends to sepa-
rate laterally the labia. When the rupture begins at the com-
missure, it runs backwards under the influence of this lateral
force, following the raphe or a line near and parallel to it. But
this force is not acting in a direction opposed to that of press-
ure or support, and, therefore, capable of being controlled or
modified by it, but in a line across or at right angles to that
of the support, and, therefore, entirely beyond its power to
hold in check. I can conceive of no form of laceration, except,
perhaps, the central, that could be prevented by perineal sup-
port, as usually advised. I should, perhaps, say that we are
directed by authors generally, to lay the ends of the fingers
upon or near the point of the coccyx and let the whole length
of the palm lie in a forward direction upon the perineum.
This method of support may, to some extent, counteract cen-
tral laceration, that is, where the head perforates the perineum
midway between the posterior commissure and the anus; but
this form of the accident is extremely rare. Even this might
be more effectually prevented by other means.
When there is extreme distension of the perineum and labia,
the outlet refusing to dilate with sufficient rapidity to let the
head pass, while the child is propelled by a powerful “vis a
tergo” from the energetic action of the womb, I am inclined
to think something might be done to prevent laceration, by
applying both hands, so as, with gentle firmness, to embrace
196 PRACTICAL MIDWIFERY.
the tumor formed by the head, as covered by the structures of
the mother, a little way back from the circle formed by the
distended labia, and drawing the structures somewhat forward.
The hands, thus applied, would act as a hoop or band to Sup-
port the endangered tissues. Dr. Goodell advises us, where
we apprehend laceration, to insert a finger of the left hand
into the anus, to draw the tissues forward, while several fingers
of the right hand are firmly applied in front of the head, to
retard its advance. We need hardly say this would be most
repugnant to patient and physician.
It must, however, be admitted that authors are, as yet,
divided upon the necessity or utility of perineal support dur-
ing the last throes of labor. The older writers generally
strongly advocate its use, and even among the most recent
ones there are those who still insist upon its importance. Dr.
Thomas More Madden, of Dublin, in a paper contained in the
May number, 1872, of the American Journal of Obstetries (on
Lacerations of the Perineum, Sphincter Ani, etc.), has tabu-
lated a series of cases which had come under his observation—
a large proportion of which he attributes to neglect of the
perineum, and, of course, maintains the utility of its support.
On the other hand, Leishman, in his work on the “Mechanism
of Parturition,” denounces it. The latter claims that the acci-
dent has not happened in his hands more frequently than in
the hands of others of greater experience and ability than him-
self, who uniformly resort to perineal support. Dr. Grailey
Hewitt, a high authority, contends that not only is the prac-
tice quite unnecessary, but very often it is absolutely mischiev-
ous. Dr. Meadows, a quite late writer, in his “Manual of
Midwifery,” says: “My own opinion is, that when the head
has had fair time gradually to stretch the perineum and sur-
rounding structures, there is no need whatever for this, to say
the least, most unpleasant proceeding.” He admits, however,
that in the opposite state of things support may be of use.
But while we would reject the neglect of support as a fre-
Quent cause of lacerations, and propose a very simple preventive
for those arising from that which is termed injudicious, namely,
to omit support altogether, rigidity of the perineum as a fruit-
ful source of the accident, deserves more serious attention.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 197
It was the custom of the older allopathic physicians in such
cases to resort to blood-letting, tartar emetic, and the like.
These remedies are objectionable, if for no other reason, because
they reduce the strength of the patient, and thus disqualify
her for her important functions, to say nothing of the extreme
discomfort which they produce. In other words, although
these may to some extent relax the perineum and diminish its
resistance, they at the same time lessen the uterine power in a
perhaps still greater ratio, and although the danger of lacera-
tion may be reduced, the length and discomfort of the labor are
likely to be greatly increased. The use of lobelia, which has
been more recently recommended, if pushed to the point of
nausea, comes under the same category and is open to the same
objections. If it be found to produce relaxation short of its
nauseating and debilitating effects, as I believe some assert that
it does, it may prove a very useful remedy in this state of
things. I have used the tincture of Gelseminum as I thought
with favorable results, but my experience with it has not been
sufficiently extended to enable me to speak positively in its
favor. Warm sitz-baths are likely to do good, and as I cannot
conceive of any bad results likely to follow their use, unless in
cases where they might encourage haemorrhage, they might be
resorted to when more powerful means are not available. In-
unction with lard and prolonged rubbing, as advised by Dr.
Clay, may be tried. * >
When, however, the uterine action is very moderate, or even
defective, no harm, so long as this state of things exists, can
result from rigidity of the perineum. Under the moderate ac-
tion of the womb it is likely sooner or later to yield. When
the head comes to rest upon this structure, and the rather feeble
action of the uterus seems unable to overcome its resistance, I
would recommend the manipulation I have fully described
when speaking of “Retarded Labor.”
But it is when rigidity of the perineum co-exists with violent
uterine action, that we are to expect danger of laceration of the
perineum and surrounding structures. Here, fortunately, we
have one of the most efficient and reliable of remedies for the
correction of both these evils. Singly, so far as danger to the
198 PRACTICAL MIDWIFERY.
perineum is concerned, they are not much to be dreaded—com-
bined they should always excite our apprehensions. The re-
medy to which I refer is chloroform. This, if judiciously and
understandingly administered, not only moderates eaccessive ute-
rine action, but softens and relaxes all the maternal structures
which are concerned in parturition, the perineum included.
One of the great advantages of chloroform is that it holds in
check reflex action, just at the moment when the parts are most
in danger of laceration. Who has not noticed that, in sensi-
...tive women, when the head is just ready to emerge, the sensa-
tion caused by its pressure calls forth such violent, involuntary
efforts, that it must pass, though all opposing structures should
be driven before it. Chloroform saves all this. Under its in-
fluence we have observed the head to be retained for some mo-
ments, even within the embrace of the distended labia, the pa--
tient being wholly unconscious of its presence there. In order,
however, to secure such results, it is necessary that the effects
of the chloroform be deepened toward the close of labor to al-
most complete anaesthesia. This may be done, we think, in all
suitable cases, with almost entire immunity from danger.
Whether there be any homoeopathic remedy capable of miti-
gating the excessive pains of labor, I am not, from any experi-
ence of my own, able to decide. I know it is claimed that there
are such, but whether they succeed in the hour of trial is quite
another matter. If the severity of the pains arise from a dis-
eased condition, then it is probable such remedies may be found.
If, for instance, as M. Beau professes to believe, the pains of
labor are, for the most part, a lumbo-abdominal neuralgia, I
would expect some relief from the arsenite of copper. Yet we
must not confound the pain with the action of the uterus.
They usually co-exist, but are not the same thing—they are
separable. It is possible for the most energetic action to go
on, while there is comparatively little pain—the remedy there-
fore which may control the pain does not necessarily diminish
the violent contractions of the womb.
The preventive measures we have already detailed apply also
to those cases where there is danger of laceration from other
causes, which we enumerated at the outsetting, but have not
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 199
considered seriatim in the course of this chapter. If the head,
from malformation, be directed backward upon the perineum,
assistance may be afforded by proper manipulation tending to
carry it forward toward the outlet.
Again to prevent the accident from sudden extension of the
limbs when the head is about to emerge, an assistant should
take hold of and firmly support and elevate the upper knee
(the right), and in the absence of such aid, a large roll of some-
thing light and soft should be placed between the limbs.
But supposing after all our precautions, or before our arrival
at the bedside of the patient, laceration may have taken place,
what is then to be done? This is certainly a most important
question, and before answering it, we must take into account
the extent of the injury.
Prof. Tarnier, the annotator of Cazeaux, divides these lacer-
ations into three grades, incomplete, central and complete.
“They are incomplete, when beginning from the vulva they do
not involve the sphincter of the anus; central when the rupture
occurs between the vulva and anus, without involving either
of these openings; complete when the vulva, perineum and
sphincter ani are torn, together with the recto-vaginal partition
to a greater or less height.” Prof. Tarnier maintains that in
both the incomplete and central varieties of the accident, it is
best to abstain from all operations as not only unnecessary, but
possibly injurious. Dr. Madden, of the Dublin Lying-in Hos-
pital, advises quilled sutures of silver wire or carbolized catgut
to be introduced immediately after the accident has occurred,
and to be removed in forty-eight hours. This is his practice
in all forms of serious rupture. He insists much upon the
early removal of the sutures, and believes that adhesion has
generally taken place in that short time. According to Prof.
Tarnier even complete laceration will often heal without oper-
ation, but in such cases there can be no doubt but Dr. Madden’s
course is the most prudent, unless the condition of the patient’s
health should make it advisable to postpone the operation.
When the sphincter ani is not involved, and we decide to omit
the sutures, the knees should be kept in close proximity either
by the will of the patient or secured by a bandage. A small
200 PRACTICAL MIDWIFERY.
compress saturated with a solution of tincture of calendula, or
carbolic acid, when the discharges smell badly, should be firmly
applied to the wound, and retained by means of a T bandage,
care being taken that the compress should not be so large as to
wedge the parts asunder. The most strict regard to cleanliness
should be observed. The patient should not be allowed to
walk about till the healing process is completed, or nearly so.
There is reason to believe that this accident often occurs to
considerable extent, when it is either not detected by the at-
tendant, or if known to exist the patient is not informed.
These cases, if such there be, recover spontaneously more or
less perfectly.
When attending a case of labor, if the uterine action have
been very intense, the perineum rigid, the head somewhat sud-
denly extruded, and shortly after the child is born the patient
manifests symptoms of severe shock, such as an extremely
quick and feeble pulse, dyspnoea, a sensation of sinking, etc.,
there is reason to apprehend that an accident of this kind may
have happened, even though it may not before have been de-
tected. Careful examination should at once be instituted, and
if rupture have taken place, such measures should be promptly
adopted as the nature and extent of the injury may seem to
demand.
In the first place we should resort to means to relieve the
patient from the shock of injury. If there be haemorrhage
from the wound or womb, we should use means to arrest it as
speedily as possible. For uterine post-partum haemorrhage we
have as remedies, Apocynum cannabinum, Trillium pendulum,
Erigeron and others whose special indications should be care-
fully recalled.
For that occurring from the laceration, the best remedy will
be to bring the edges of the wound together, and secure them
in contact by a compress, retained by a suitable bandage. The
compress should not cover the outlet, otherwise the usual dis-
charge from the womb will be prevented and accumulation
take place. For the extreme prostration, camphor may be
given by olfaction, or if it be very alarming, stimulants, as wine
or brandy, may be administered, being careful to avoid excess-
ive reaction.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 201
TOXAEMIC PUERPERAL DISEASE.
Within this term we include all those forms of puerperal
disease which, in the present state of our knowledge, we re-
gard as arising from an agent acting upon and changing the
character of the blood of the patient; whether this agent may
have had its origin in septic matter generated within her tis-
sues or be derived from without ; and, in the latter case, with-
out regard to its particular source.
During labor there are doubtless few, if any, cases in which
the parts concerned entirely escape injury. They are subject
to contusions, abrasions and lacerations, some or all of which
would doubtless very generally be found if the necessary ex-
aminations were made. They sometimes, as we all know, take
place to a very serious extent. These injuries are liable to be
followed in the puerperal woman, as in others, by traumatic
inflammation. Under favorable circumstances, however, this
may pursue a mild course and reach a fortunate termination,
differing in no essential particular from that arising from
wounds in general. As this affection does not fall within the
limits of the subject which will now engage our attention, we
will take no further notice of it. We will only here remark
that all abrasions and lacerations—all breach of continuity of
surface whatever, afford an open door for the entrance of septic
matter, which may be brought into contact with them, until
they are protected by the reparative process.
But the course of inflammation occurring in the puerperal
woman is, unfortunately, not uniformly favorable. It is not
always followed by speedy subsidence and healthy repair of
the injury. It frequently assumes a much more serious char-
acter. From the prostrated, adynamic condition, which often
follows labor, sometimes even precedes it, inflammation, result-
ing from injury, may assume a low grade, tending to sloughing
and the discharge of a putrid, sanious fluid (itself, perhaps, the
result of a previously acting blood poison), which, by absorp-
tion, is capable of still further contaminating the blood and
thus giving rise to all the alarming phenomena and too often
fatal consequences of toxaemic disease. Nor is this the only
202 PRACTICAL MIDWIFERY.
Source of blood poison originating within the organs of the
woman. On the contrary, blood clots retained within the
womb or vagina, portions of the placenta, or even the lochial
discharge, when putrid, may act in a similar manner.
There seem to be two factors necessary to the production of
toxaemic puerperal disease. The one is found in the peculiar
susceptibility of the puerperal woman;–the other in some
agent capable of acting, at least in her present condition, as a
blood poison. Wherein this susceptibility consists, has by no
means been demonstrated to the satisfaction of all. Some
have supposed that it has its origin simply in the prostration
succeeding labor. If, by prostration, be meant merely the re-
duction of nervous or muscular power which follows all ordi-
nary cases of labor, the theory is inadequate to an explanation
of the phenomenon. But may we not suppose that when any
cause, of whatever nature, so reduces the vital forces so that
the catalytic action concerned in carrying on the processes of
life is, for the time being, held in abeyance, that of the mor-
bific agent, namely the blood poison, gains the ascendency and
developes the disease in question, especially as the condition
of the blood, peculiar to pregnancy and the puerperal state,
abounding in albumen, may render it more liable to its action.
It is probably this latter circumstance which so modifies the
operation of the morbific agent as to produce what we recog-
nize as puerperal toxaemic disease.
Some maintain that it is through breaches of continuity in
the tissues of the woman alone that septic poison can be ad-
mitted, at least in sufficient amount to produce disease. But
as blood poison in other cases can gain admission by other
avenues, so as to produce its full effect, perhaps we are not as
yet prepared to deny the possibility of this happening in the
case of the parturient woman.
When the vital powers of puerperal women remain in suffi-
cient vigor after labor to rapidly repair injuries sustained dur-
ing that process, before or by the time septic matter is formed,
an efficient barrier is set up against it, and absorption, to any
considerable extent, at least, is prevented. In the opposite
state of things, however, septic matter may be taken up, but
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 203
even then, unless in overpowering quantity, serious disease may
not result. The powers of the organism may still exist in suf-
ficient force to resist and ultimately expel the blood poison.
But if, through the action of some one or more of the ordinary
debilitating causes, including mental emotions, atmospheric
and telluric influences, etc., the activity of the catalytic force
concerned in carrying on the vital processes of the system, be
so reduced that it is no longer capable of holding in check the
similar force which the blood-poison tends to exert, then the
latter becomes predominant and disease triumphs over healthy
vitality, the blood is “touched corruptibly,” and all the phe-
nomena of toxaemic disease are developed.
Billroth, I believe, claims to have demonstrated that absorp-
tion cannot be effected by wounds, except in a recent state, or
when the fluid to be absorbed has the power of dissolving their
protective covering, so as to present a fresh surface. Be this as
it may, it is certain that absorption to the extent of producing
serious disease does not always take place when putrid matter
is contained within the genital organs of the woman. We
often meet with cases where blood-clots are expelled from the
womb in a state of decomposition, as evidenced by their odor,
and when the lochia is highly offensive, and yet there is but
little, if any, departure from normal convalescence. Even re-
tained placenta is sometimes thrown off in a very putrid con-
dition, and yet the patient afterwards makes a reasonably good
recovery.
But when the placenta is for some time retained, or when
bloodclots undergo putrefaction within the womb, toxaemia, in
Some of its forms, not unfrequently results. This is especially
liable to happen when exhausting haemorrhage has taken place,
as it often does when any portion of the placenta remains un-
detached within the womb. The danger of this result is here
increased by twofold causes. In the first place, the vessels
being emptied of their normal contents, fluids within reach of
the absorbents are greedily taken up. At the same time the
powers of the system to resist the deleterious action of morbific
agents are greatly depressed, through the debilitating effects
upon vital action by the loss of blood.
204 PRACTICAL MIDWIFERY.
But the agent employed in the production of toxaemia does
not always originate within the patient herself. On the con-
trary it is often derived from other sources. It may be intro-
duced into her organism by contact, through the physician or
nurse. When the attendant has had in charge a patient labor-
ing under this disease, especially if he have had occasion to
make vaginal examinations, he may readily convey the poison
to another by his hands. It would seem that this effect may
be produced where the utmost care has been taken to cleanse
the hands, and even to throw off the clothes worn when in the
presence of a patient suffering from toxaemic disease. The case
of Dr. Rutter, of Philadelphia, is often cited, whose practice,
notwithstanding the utmost precautions on his part, was so
constantly followed by the disease, that he retired for weeks
into the country, but, upon his return, met with a repetition
of the same disasters.”
The contagion of certain other diseases is believed by many
to be capable of producing puerperal toxaemia in the lying-in
woman. Such is that of malignant erysipelas, typhus and ty-
phoid fevers. So frequently is what is usually termed child-
bed fever encountered during an epidemic of erysipelas, that
they are by some considered essentially the same disease, only
modified by different circumstances. Such conclusion we think
hardly sustained by general observation. It would seem that
puerperal women may have attacks of genuine erysipelas, in
which all the distinctive symptoms of that disease are fully de-
veloped, unaccompanied by the peculiar symptoms of puerperal
toxaemia, and without the fatality of that disease. The same
may be said of scarlet fever.
It would seem, nevertheless, pretty certain that the conta-
gious emanations, whatever they may be, from malignant ery-
sipelas, are capable of producing the disease under considera-
tion, in those who may be in a condition favorable to that re-
sult. Indeed, the disease known as malignant erysipelas, may
be but a form of what is termed pyaemia, and which is but a
* I have seen it stated that Dr. Rutter suffered from ozoena, and it was
surmised that this might have been the source of the trouble.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 205
modification of toxaemic disease, and therefore more nearly re-
lated to puerperal toxaemia than to ordinary erysipelas.
It cannot be denied that the same morbific agent may pro-
duce different morbid phenomena in different individuals, ac-
cording to their peculiar susceptibilities. Several persons, for
instance, are caught out in a drenching shower. Their suscep-
tibilities to disease are different, we are unable to say why or
wherein this difference consists. One perhaps suffers, in conse-
qence, from acute bronchitis, one from pneumonia, one from
diarrhoea, another from dysentery, another from neuralgia,
another from rheumatism, and some perhaps escape uninjured.
Here the morbific agent is the same, the subjects apparently
similar, but the results very different. We observe something
like this also in the proving of our drugs, in the different
symptoms evolved by different provers.
An epidemic of puerperal fever lately occurring in the Phila-
delphia Hospital has been reported, which could not be attri-
buted to the contagion of erysipelas, for no case of that disease
had for some time previous been in any of the wards, but
which is said to have manifested the tendency to produce ery-
sipelas in those not liable to puerperal fever. It is from this
apparent relationship between the two diseases, namely, erysip-
elas and puerperal toxaemia, that, as before intimated, some
have supposed the latter to be merely a modified form of the
former. This relationship has, however, been strenuously de-
nied by others; and it is but proper to say that preconceived
theories may have led to incorrect observations or false deduc-
tions. The truth probably is, that any morbific agent capable
of acting as a blood-poison, may give rise to the phenomena
constituting puerperal toxaemia, in one whose peculiar condi-
tion, or, so to speak, present temporary idiosyncrasy, disposes
her to take on that kind of diseased action.
The poison of typhus and typhoid fevers have also been
named amongst the causes capable of producing the disease of
which we are now speaking. If so, it must be owing to the
peculiar susceptibility of the patient. Within the last eighteen
months I attended a well marked and severe case of typhoid
fever in a man whose wife, when he was at the worst stage of
206 PRACTICAL MIDWIFERY.
his sickness, gave birth to a child in the same room in which
he lay, and remained there during her confinement. The room
was by no means well ventilated, and I feared for the result.
She was, however, in an unusually short time out of bed, and
engaged again in her attentions to her husband. Her conva-
lescence was perfect, and so far as I know, without a single un-
toward symptom. Some weeks afterwards she exhibited, in a
very marked degree, the usual precursory symptoms of typhoid
fever, and I felt almost certain she would go down with that
disease. I gave her immediately Baptisia tinc., as a prophylac-
tic, and to my surprise, in the course of a very few days she
was entirely well. In this case we may believe that the im-
pression was made upon her system by the poison, either during
the puerperal state or before her confinement, for when she left
her bed her husband was already convalescent.
The precise nature of the change wrought in the circulating
fluid in puerperal toxaemia, through the agency of the blood
poison, has not yet, so far as I know, been precisely deter-
mined. “In many respects,” says Dr. Meadows, “it resembles
that found in severe cases of typhoid fever. There is a de-
crease in the number of red blood cells, and an increase in the
white cells, the fibrine is also increased, at least at first, but the
solids generally are diminished. The extractive matter is in-
creased, as is also the amount of lactic acid and fat. Moreover,
, there are also traces of bile-pigment, and Mr. Moore says that he
discovered a ‘black precipitate' in the blood of a person who
had died of this disease, and that there was “a peculiarly offen-
sive odor arising from it.’”
The foregoing is probably but an imperfect account of the
change which takes place in the blood, under the influence of
the poison, rendering it not only unfit for the support of life, but
causing it to produce destruction of tissue, or at least to suffer
it to take place, almost in any part of the organism to which it
circulates, and even in some instances to extinguish the vital
spark before any appreciable organic lesion has supervened.
Nor can we suppose that it is merely the quantity of poison
absorbed by the blood that, by its admixture, renders that fluid
unfit to perform its normal functions. The amount primarily
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 207
absorbed is often no doubt exceedingly small. But in these
cases “a little leaven leaveneth the whole lump.” The precise
manner in which this is effected has not as yet been demon-
strated to the satisfaction of all. Some have supposed the
process to be similar to, if not identical with fermentation.
Hence they have been encouraged to use as antidotes to blood-
poisoning, those agents which are known to prevent or arrest
that process. For instance, sulphurous acid prevents fermen-
tation, at least for a considerable time, in freshly prepared
cider. Iſence the sulphites have been used to prevent or arrest
the ravages of blood poison. But whatever hopes artificial ex-
periments may have held out, these have been disappointed so
far as I know, when these agents have been employed in
clinical cases.
It is a well established fact in chemistry that certain sub-
stances, by their mere presence, disturb the stability of com-
pounds, and cause their elements to enter into new combinations,
while these substances themselves undergo no change. “When
a mixture of oxygen and hydrogen is exposed to the action of
spongy platinum, the gases combine to form water; when alco-
hol is dropped on platinum black, under exposure to air, the
alcohol is oxydated and converted into acetic acid.” In these
cases the platinum itself undergoes no change, but determines
changes in the condition of the substances with which it is in
contact. This peculiar action or modification of force, as yet
unexplained, has been called Catalysis, from the Greek words,
zara downwards, and Ava, I loosen. As yet we employ this
term as we do a or y in algebra, to denote an unknown quantity.
IBut whatever may be the nature of this action, it seems to me
probable that that of the poison upon the blood may be similar
to, if not identical with it; that through its catalytic power,
it may cause such changes in the constitution of the blood that
it remains no longer the vital fluid, conveying life and health
and nutriment to every part, but becomes a lethal agent, set-
ting up disease even in the very channels through which it cir-
culates, and producing disorganizations and death in all the
parts to which it is conveyed, and which, in its healthy state,
it had built up and supported.
208 PRACTICAL MIDWIFERY.
If this view be correct, we think it furnishes a satisfactory
explanation of the astounding fact that toxaemic puerperal dis-
ease may originate from contact of the hands of the physician
with the genital organs of the patient, even when the former
are supposed to have been thoroughly cleansed. A single atom
of septic matter may so act upon the secretions as to convert
them into poison to be taken up by the absorbents, and ulti-
mately corrupt the whole mass of blood. Strange as this may
seem, it is scarcely more so than that a single spark carelessly
dropped in the dried grass of the prairie, should kindle a fire
capable of spreading over and devastating vast regions of
country.
Without regard to the source whence the toxaemic poison
may be derived, the resulting disease differs greatly in different
subjects, in its symptoms, course and pathological lesions. In
one case, the uterus will appear to have been almost exclu-
sively the seat of diseased action; in others, and more fre-
quently it will be found to have invaded other organs, as the
peritoneum, Fallopian tubes, broad ligaments and ovaries.
Distant organs, as the lungs and liver, may be and not unfre-
quently are involved in the morbid process. All this goes to
demonstrate the all-pervading nature of the poison, whose dele-
terious action may be traced wherever the contaminated fluid
circulates. The pathological lesions differ not only in their lo-
cality, but also in their kind. In one case may be found only the
vestiges apparently of ordinary inflammation, while in another
will be detected purulent deposits. From some difference in
the symptoms of the disease in different cases during its course,
and in pathological lesions detected after death, some writers
have supposed several distinct toxaemic puerperal diseases to
exist, to which the terms Septicæmia, pygemia and puerperal
fever have been respectively applied. In the present state of
our knowledge, however, it seems to me probable that these
varieties are mainly owing to differences of idiosyncrasy, for
the time being, in the patient, or other inappreciable circum-
stances, which modify the result. The opposite opinion has
not, as yet at least, been demonstrated with anything like sat-
isfactory clearness, as it is yet as far as ever from meeting with
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 209
general acceptance. We have, therefore, as announced at the
commencement of this chapter, preferred to treat of this Protean
disease under a generic term, including all the varieties, rather
than as several distinct affections. This is the more allowable,
because in Homoeopathic practice we select the remedy accord-
ing to the symptoms which present themselves, and not accord-
ing to any arbitrary nosological classification or name, nor yet
according to any supposed local pathological lesions which may
exist, but which generally cannot be demonstrated till remedial
measures are no longer of any avail.
As the sources of toxaemic disease are so varied, and the pa-
thological lesions discovered after death so different, it is rea-
sonable to suppose that the symptoms which announce its ap-
proach and characterize its course will be equally diverse. It
will be well, therefore, before we proceed to speak of treatment,
to give such a general view of these, as will at least enable the
practitioner to anticipate the coming storm, or when it has ac-
tually arrived, to appreciate its extent, violence and probable
results.
Of the various lesions found after death, the following pro-
portions are given by Dr. Simpson: “Of 500 fatal cases of puer-
peral fever, recent inflammatory changes were noted in the
interior of the uterus in 372 cases; in the veins of the uterus,
349; in the peritoneum, 321; in the lungs and pleura, 202;
in the lymphatics, 129; in the ovaries, 78; in the cellular
tissues and muscles, 46; in veins other than uterine, 40; in the
brain and its membranes, 23; in the spleen, 21; in the vagina
and pudenda, 19; in the bones and joints, 18; in the kidneys,
17; in the stomach and bowels, 13; in the pericardium, 12;
in the mamma, 7 ; in the Fallopian tubes, 5; in the bladder, 4;
in the parotid gland and heart substance, 3 each ; in the endo-
cardium, 2.; and in the iris, tonsils, larynx and trachea, 1
each.”
In cases in which the peritoneum is first or mainly invaded
in the onset of the disease, the patient complains of unusual
soreness in the lower abdominal region, and tenderness under
pressure. This is usually accompanied by pain more or less
intense, and of a continuous character. This latter circum-
14
210 PRACTIC AI, MIDWIFERY.
stance will serve to distinguish from the after pains, which are
intermittent. Those of “false peritonitis' are perhaps gene-
rally still more acute, and are ameliorated by occupying the
patient’s attention. These pains go on, however, increasing in
severity, and are greatly aggravated by motion and by tension
of the abdominal muscles. To avoid the latter the patient as-
sumes the dorsal position, with the limbs drawn up. There is
said to be a peculiar pain about the umbilicus, with a sensation
as if it were drawn inwards. General constitutional disturb-
ance soon follows; there are distinct rigors, greatly increased
pulse, varying from 120 to 160 beats per minute, small and
wiry. The skin becomes hot and dry, the breathing short, the
abdominal muscles taking but little part in the process of res-
piration. The tongue becomes dry and coated, red at the tip,
but brown further back. The abdomen is often tympanitic,
and as the disease advances, swollen from effusion of fluid
within the peritoneal sac. There are nausea and vomiting of
mucus or bile, and sometimes of a dark fluid resembling coffee
grounds, and even of foecal matter. The lochia may be unaf.
fected, diminished, or even increased. The bowels are some-
times constipated, or there may be even profuse diarrhoea. The
urine is thick, scanty, and high colored.
In fatal cases, low muttering delirium sometimes sets in, the
expression of the features is anxious, the pulse becomes still
more frequent and sometimes scarcely perceptible, till death,
from exhaustion, closes the scene.
When the uterus is first involved, that organ is found to be
enlarged and extremely tender under pressure. The symptoms
are said usually to set in shortly after delivery, but we believe
we remember one case wherein they did not at least become
strongly pronounced till several days afterwards. There are
severe rigors, accompanied by intense headache, general con-
stitutional disturbance of a highly inflammatory character.
Lochia usually suppressed. The inflammatory action often
extends to the peritoneum, and the symptoms become modified
accordingly.
When the uterine appendages are primarily involved, the
pain and tenderness will be more circumscribed, and its seat
will indicate the particular organ invaded.
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 211
When the veins of the uterus are inflamed, constituting what
is termed uterine phlebitis, the onset is sudden and usually oc-
curs a few hours after delivery. Here, again, there are rigors,
followed by headache, suppression of the lochia and milk,
fever, thirst, dry brown tongue, vomiting, etc.
The foregoing description will furnish a general outline of
the disease. Different cases will be found to vary considerably
in their symptoms, and different epidemics So much so, as almost
to seem to be distinct diseases. This variation may depend
upon modifications of the morbific agent acting as a blood
poison, or upon some distinctive peculiarity inherent in differ-
ent patients. An epidemic recently occurred in a Philadelphia
hospital, in which a remarkable indifference on the part of the
patients as to their condition and prospects characterized the
disease.
But whatever shades of difference we may observe, there will
still be manifest a general family resemblance that will enable
us to decide as to the real nature of the case before us. We
must not forget, however, that the protean form of the disease
itself, admonishes us of the necessity of individualizing each
particular case, as it is presented to us; that we must not ex-
pect to find any specific of universal applicability, nor even
certainly suited to any considerable number of consecutive
cases. Still, however, in any given epidemic, a remedy which
we find efficacious in the outsetting of the disease, is likely to
prove generally useful throughout its course.
Before speaking of the details of treatment which is too
often unavailing in this terrible disease, we will endeavor to
point out such measures as are generally successful in its pre-
vention. Prophylaxis, where practicable, is always better than
cure, and especially so in case of the malady which now en-
gages our attention, which too often has progressed so far, or
assumed such a degree of virulence before we are called in, as
to baffle all our efforts.
We have already intimated that liability to this disease pro-
bably consists in depressed vitality. If this view be correct,
then an important prophylactic measure will be to see after our
patient before her confinement, and adopt such measures, if ne-
212 PRACTICAL MIDWIFERY.
cessary, as will bring her up to that period in the best possible
state of health. She should be in a condition which we term
vigorous, all the vital functions actively performed, and even
the mind in the best possible tone, active and cheerful. This
object will be more or less attainable in different cases, and
alas! in some not attainable at all. I need not attempt to enu-
merate the various means adapted to the object just stated.
They will be suggested to the intelligent physician by the va-
rious circumstances of his patients, and valuable hints, I trust,
be found in this and other works upon midwifery.
Before confinement, the physician should at least assist and
advise in the selection of the lying-in room, so that as far as
possible it may be well adapted to ventilation, proper and uni-
form temperature, etc. As we have elsewhere advised, it will
be well, as a general practice, where tedious labor is antici-
pated from rigidity of the Soft structures, to require the patient
to take Actea racemosa or Macrotin, for some days before
labor, or such other remedies as he may think indicated, for
the purpose of relaxation,
When labor comes on it should be conducted upon principles
already laid down, so as to avoid, as far as possible, all unneces-
sary extreme suffering, abrasions, lacerations, contusions and
mechanical injuries of every kind. Extreme exhaustion should
by all means be avoided by timely resort to such means of
assistance as the principles of our art require. After delivery,
firm and persistent contraction of the womb should be secured,
so as to expel blood-clots, or leave no room for their accumula-
tion. I have thought Ergot, given in small doses in the course
of labor, promoted this object. Dr. Goodell advises placing
the patient frequently over the chamber-vessel, after delivery,
as an efficient means for the expulsion of clots, to which I have
elsewhere adverted.
When the patient is properly put to bed after delivery, as be:
fore advised, a few drops of the tincture of Arnica, diffused in a
tumbler of water, should be administered in teaspoonful doses,
once in two hours, and if contusions are manifest externally, a
stronger preparation should be applied. Dr. Zwingenberg,
translated by Dr. Lilienthal, in the Hahnemannian Monthly, for
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 213
July, 1875, asserts that it is his uniform practice to prescribe
Arnica internally and externally, to women immediately after
delivery, and since he has adopted this mode of treatment, says
he has met with no cases of puerperal fever. The translator
avers that this has also been his experience, and I would add,
it has been mine. The Arnica probably tends to this result by
accelerating the healing of wounded structures before septic
matter is formed, and thus presenting a barrier to its absorp-
tion when it is produced, and probably too, as a powerful
homoeopathic antiseptic.
After what we have already said, it would seem hardly neces-
sary to warn the practitioner to avoid communicating the dis-
ease through any careless neglect of precautions on his part.
If he have been so unfortunate as to have had a case of the dis-
ease, especially if his duties have required him to bring his
hands in contact with the person, and more particularly with
the discharges of the patient, he had better, if possible, for the
time being turn over his obstetric practice to another. The
same precaution would be proper if he have had recently a bad
case of erysipelas. But if this cannot be done, the utmost care
should be taken to disinfect his hands, his person and his
clothing, or rather to entirely change the latter. Dr. Wynn
Williams speaks very highly of iodine as a disinfecting agent,
in reference to septicæmia—he uses it for cleansing the hands
with great confidence—for disinfecting the clothing—for wash-
ing out the genital organs, etc. He affirms he has never had a
case of puerperal fever since adopting its use, which he has ex-
tended over a space of twenty years. Possibly bromine would
be equally or more efficacious.
Toxaemic puerperal disease frequently occurs, especially in
large cities, in epidemic form. Of the nature of the epidemic
influence we have no certain knowledge. It is truly “the pes-
tilence that walketh in darkness.” Of the part it plays in the
production of the disease, we are equally ignorant. Possibly,
after all, it may act only as a predisposing cause, by reducing
the vital force below the standard necessary successfully to re-
sist the encroachment of the blood-poison ; the latter, derived
from some of the ordinary sources, serving, under these favor-
214 PRACTICAL MIDWIFERY.
ing circumstances, as the proximate or exciting cause of the
disease. If this be so, although direct prophylactic measures
may be unavailing against the action of the epidemic influence
itself, those we have already proposed may still, to some ex-
tent, prevent its ultimate effects.
But a most important question here presents itself—can we
by the specific action of a remedy administered, forestall that of
the blood-poison, and thereby prevent this terrible disease from
becoming developed 3 Have we or have we not, medicinal an-
tidotes to the morbific agent which in this as in other zymotic
diseases, so often works destruction in despite of all our reme-
dial measures? It has long seemed to me that a vast field of
research, in reference to this class of diseases, lies before us,
holding out the most tempting rewards to the successful ex-
plorer.
It is plain to every one that when the blood becomes so con-
taminated, so changed in its constitution and character as no
longer to be adequate to the support of life, death is inevitable.
To forestall and prevent this consummation should therefore
be the great object of the physician, if he would save life. So
far as we know, however, we cannot arrest this lethal process
by throwing into the circulation an agent which is capable of
seizing and destroying germs of blood poison, or of causing the
elimination of the altered blood corpuscles, while it leaves be-
hind the still unchanged portion to perform its function in sus-
taining life. Such power of selection in any medicinal agent
is not to be expected. If we would therefore accomplish the
object above stated, we must look for something that will act
upon an entirely different principle.
Far-sighted men seem to discern a dawning light in this di-
rection. At a meeting of the London Obstetrical Society, held
April 7th, 1875, Dr. Richardson, in concluding his remarks,
holds the following noble and suggestive language: “My im-
pression is,” says he, “that in the course of time we shall ar-
rive at the discovery of certain agents which will immediately
stop the action of septicæmous poison by their direct physical
effect upon the blood, and their influence in holding oxygen
in combination with the blood. I have recently referred in
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 215
another society to the effect of quinine in this respect, but that
is a bungling crude method of dealing with an agent that will
act in such proportions as the ten thousandth or the hundred
thousandth part of a grain, so as to produce disturbance within
the organism. So, dealing with this matter of antiseptics, I
should say that if antiseptics, as they are called, that is bodies
which prevent putrefaction, are advanced as a means of curing
these particular diseases arising from septicæmous poisons, their
action is not because they are antiseptics (because other agents
which are not antiseptics possess a similar property), but for
the simple reason that they act upon a given prinčiple, and
many of them act altogether in accord physically, and I might
almost add chemically in neutralizing the specific action of
these poisonous agents; I mean antiseptics do not act by de-
stroying germs or organic forms, but they act definitely by in-
terfering with the poisonous action of the septicaemous material
which produces the fatal disease. I predict that in ten years
hence, in this society, we shall see a means of preventing these
diseases from Septicæmous poisonings as clearly as we now see
the means of producing them by the introduction of these
poisons in the form of inoculated matter in small-pox by
vaccination.”
Looking back, we find in the Medical Ecaminer for Novem-
ber, 1848, a reference to quinine as a prophylactic of puerperal
fever. Several experiments with that drug are given, from
which it would seem that the opinion advanced by the writer
is not at least altogether unfounded. Dr. Goodell, in detailing
his treatment of lying-in patients, which he claims to have
been unusually successful, and remarkable for its exemptian
from childbed fever, when that disease was prevailing around
him, speaks prominently of using quinine as a prophylactic,
but explains its efficacy upon a principle different from that
which I have in view and wish to elucidate.
Recent observations made upon the action of quinine, would
lead us, I think, to the conclusion that it produces changes in
the constitution of the blood. The disease resulting from the
protracted use of this drug, usually called cinchonism, seems to
be in reality a blood disease, and has, as an essential element,
216 PRACTICAL MIDWIFERY.
an altered condition of that fluid. This effect, too, appears to
be produced independent of any change which the quinine
itself undergoes; for the latter seems to be eliminated by the
emunctories, unchanged and in about the same quantity that
had been taken. Now, if these statements be correct, it would
appear that whatever change the quinine may effect upon the
blood, is effected not by adding any portion or element of itself
to that fluid, nor by abstracting any principle by way of com-
bination with itself from it, but simply by catalysis or action
of presence, through which force its constitution is altered, its
elements" more or less extensively entering into new arrange-
mentS.
Now, if septicaemous poisons act upon the blood by catalysis,
as we have attempted to show is probably their mode of action,
then there may be, and probably is, a similarity between the
latter and that of quinine, and consequently the one is anti-
dotal of and Homoeopathic to the other.
If we be thus far correct, we would go still further, and say
that according to the principle just stated, the whole class of
remedies which act by catalysis upon the blood lie before us
from which we may hopefully select for the prevention and
even cure of toxaemic puerperal disease, as well as zymotic dis-
eases generally. Similarity of catalytic action between the
remedy and the morbific agent is equivalent to antagonism ;
the one suspends or sets aside the action of the other. Probably,
too, the greater the similarity in the particular mode of the
catalytic action of the rémedy and the morbific agent, the more
certainly effectual will the remedy be. Further, too, it may
possibly be found that high attenuations of the remedy, if well
selected, will most certainly arrest and hold in check the changes
in the blood set up by the lethal agent, which acts often in a
highly attenuated form. Of this, however, I do not speak from
any experience, but simply the analogy of the case.
The power of the catalytic force of one agent to arrest or
suspend that of another, is recognized by Prof. Dalton in his
work on Human Physiology. In answering the question “How
it is that the gastric juice which digests so readily all albumi-
nous substances should not destroy the walls of the stomach itself,
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 217
which are composed of similar material,” he gives the following
reply. “The true explanation, however, we believe, lies in this—
that the process of digestion is not a simple solution, but a
catalytic transformation of the elementary substances, produced
by contact with the pepsine of the gastric juice. We know
that all the organic substances in the living tissues are con-
stantly undergoing, in the process of nutrition, a series of cata-
lytic changes, which are characteristic of the vital operations,
and which are determined by the organized materials with
which they are in contact, and by all the other conditions
present in the living organism. These changes therefore of
nutrition, of secretion, etc., necessarily exclude for the time all
other catalyses, and take the precedence of them. In the same
way, any dead organic matter exposed to warmth, air and moist-
ure, putrefies, but if immersed in gastric juice, at the same tem-
perature, the putrefactive changes are stopped or altogether
prevented, because the catalytic actions, excited by the gastric
juice, take precedence of those which constitute putrefaction.
Eor a similar reason, the organic ingredients of the gastric
juice, which acts readily on dead animal matter, has no effect
on the living tissues of the stomach, because they are already
subject to other catalytic influences, which exclude those of
digestion as well as those of putrefaction.”
I fondly hope that further researches upon the action of reme-
dies by catalysis upon the blood, will enable us to forestall and
prevent the developement of the dreaded disease which now
engages our attention. Every woman in child-bed we may re-
gard as possibly liable to an attack, and especially so if cases
have recently occurred in the same vicinity. We have thus,
so to speak, the “probabilities” signalled to usin advance, that
we may look out for, and provide against the coming storm.
Nor is it only as prophylactic agents I anticipate much from
the class of remedies known as antiseptics, which will probably
generally be found to act by catalysis upon the blood. They
will, most likely, constitute our best curative agents, when the
disease is developed, by arresting the process which rapidly
tends to render the blood unfit for the support of life. Short
of this point and before irreparable lesions have taken place,
218 PRACTICAL MIDWIFERY.
they will doubtless often save the patient—beyond it, no reme-
dial measures of course will avail.
But while it is our first duty to employ all suitable means to
prevent the accession of toxaemic puerperal disease, indeed all
puerperal disease, it is no less incumbent upon us closely to
watch the patient, from day to day, so that should an attack
unfortunately occur, we may have an opportunity of treating
it in its earliest stage. To this end we should not only visit
the patient as often as may be necessary, but strictly enjoin
upon her to inform us immediately when any symptoms arise
different from those of ordinary convalescence.
Lest we should seem to require the practitioner to enter into
this fearful contest in armor to which he is not accustomed,
before closing we will endeavor to give him as well, the treat-
ment which has at least the sanction of some authority—how
generally successful we are unable to say.
When the attack sets in with highly inflammatory symp-
toms, such as high fever following a severe chill, full bounding
pulse, etc., Aconite should be given in repeated doses, and of
sufficient strength to allay the fever and reduce the pulse. A
few drops of the strong tincture in a tumbler of water, a tea-
spoonful every hour, or for awhile even more frequently, till
Some improvement in these symptoms takes place, or another
remedy seems demanded. Some advise the high attenuations
of Aconite, a dose every half hour or fifteen minutes, till im-
provement, then suspend its use. In some instances Veratrum
viride may be preferable; the symptoms, of course, must deter-
mine the choice.
If the disease be ushered in by a severe chill, with disposi-
tion to its periodical recurrence, I would advise Sulphate of
quinine, 1st dec., 1 gr., to be repeated, at least for some time,
every hour, or even at shorter intervals. When there is severe
congestive pain in the head, especially if accompanied by a vio-
lent bearing down sensation in the uterine region, Belladonna
should be given. If there be evidence of rapid change taking
place in the blood, from the catalytic force of the blood poison,
Arsen. a., 3d dec. should be given and persevered in. This
condition may be recognized by the great tendency to prostra-
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 219
tion, fetor of the breath, sordes upon the teeth, disposition to
passive haemorrhage, etc. When there is extreme prostration,
muttering delirium, grasping at flocks, involuntary stools, etc.,
Chin. ars., 1st cent., is recommended by Dr. Baehr. In this condi-
tion Crotalus may also be thought of also Muriatic ac. Rhus
tox. may be useful where there is a disposition to epistaxis, pains
characteristic of the drug, and a low typhoid condition. Some-
times it may be well to compare the symptoms of Ergot with
those of the case before us. When we are called to see the
case early, before the actiqn of the blood poison has gained
much headway, I would have considerable confidence in Bap-
tisia, which might, if thought best, be alternated with some
other remedy, which we should think more specifically indi-
cated. Indeed I would strongly advise Baptisia to be given
from the beginning, in doses equivalent to one drop of the
mother tincture, at intervals, such as the urgency of the case
would seem to demand. Baptisia is more specially indicated
when the uterine discharges are foetid. Where there is consi-
derable tympanitis, eructations, fetid diarrhoea, diminished se-
cretion of urine, tendency to passive haemorrhage, especially
from the bowels, Terebinthina will often be found an excellent
remedy. The “spirits” of turpentine may be given upon
sugar or in emulsion, in doses equivalent to one, two or three
drop doses, at first every hour or two hours, afterward length-
eming intervals according to the usual conditions prescribed.
The same remedy may at the same time be externally applied
to the abdominal region by means of stupes.
It has been stated in the Scientific American, that Drs. Berg-
man and Schmiedeberg have claimed that they have succeeded
in isolating the poison generated by the putrefactive process of
animal matter, in the form of what they denominate the sul-
phate of sepsin. If this be so, this article will probably be
found of great value in treating the more malignant forms of
puerperal toxaemic disease.
So hopeful am I of the success of those remedies that act
directly upon the blood, in the prevention and cure of this
dreadful disease, that I would strongly recommend the perse-
vering use of not only those already named, but of others of the
220 PRACTICAL MIDWIFERY.
same class; not indeed given indiscriminately, but carefully
selected as may be, with our present imperfect knowledge of
their true pathogenetic effects. Nor would I administer them
exclusively by the mouth; but when there was reason to be-
lieve that the absorbent powers of the alimentary canal were
impaired, I would give them by inhalation, and even by sub-
cutaneous injection.
So general is the outlook of thoughtful men in the direction
I have above indicated, for a more reliable means of treating
puerperal and zymotic diseases generally, that I cannot think
their hopes will prove altogether fallacious. No one, however,
has, as yet, so far as I have known, fully comprehended the
great principle—the homoeopathic principle involved; and if that
which we have above stated be the correct one, we are not as
yet in possession of the exact kind of pathogenetic and patho-
logical knowledge necessary to apply it always with the great-
est possible certainty and success. But let us, by means of the
microscope and chemical analysis, ascertain the precise nature
of the changes wrought upon the blood by any given disease,
and also of those produced by our remedies, and if this can be
done, we have then, in military phrase, the key to the whole
position. We do not, of course, mean to say that other symp-
toms, both subjective and objective may not be called in to our
aid to the same end.
PUERPERAL CONWULSIONS.
This term should, in strict propriety, be used to denote such
forms of convulsions only, in the production of which the puer-
peral state is an essential factor. Under it, however, are gene-
rally included by writers upon obstetrics, all convulsions which
befall the parturient woman, shortly before, during, or imme-
diately after labor, however these may vary in their symptoms
or differ as to the causes from which they arise. Using the
term as a generic one, they distinguish the different forms by
specific names. Hence we have Hysterical Puerperal Convul-
sions, Apoplectic Puerperal Convulsions, and Epileptic Puer-
peral Convulsions, meaning by the last Eclampsia or Puerperal
Convulsions, properly so called.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 221
The cause of this disease has been a subject of laborious in-
vestigation, but notwithstanding the labor expended in the re-
search, no opinion has as yet been advanced acceptable to all.
The case is still “subjudice,” and likely for some time at least
so to remain.
It would seem, however, that one essential element in the
production of eclampsia, or true puerperal convulsions, is that
peculiar state of the nervous system of the woman, sometimes
at least, induced by utero-gestation. Such condition does not,
however, in all cases follow pregnancy, else when the same
proximate causes come into play, all puerperal women would
be attacked with eclampsia, which we know is not so. For in-
stance, one will be thrown into violent convulsions when the
head strongly presses upon, or is in the act of passing the cervix
uteri, while another during that process experiences no par-
ticular inconvenience. Nor does this difference depend wholly
upon an original or radical difference of constitution or organi-
zation; for the same woman may suffer from convulsions during
one labor, while in another, apparently in the same circum-
stances, she will be exempt.
It seems probable, however, that women of a naturally irri-
table nervous system, are more likely to acquire during preg-
nancy this susceptibility to eclampsia than those of an opposite
organization.
When this peculiar irritability exists, any cause producing a
strong impression upon the nervous system, either central or
peripheral, may give rise to convulsions. Thus, perhaps, over-
distension of the uterus by the presence of twins, or an abnor-
mal amount of liquor amnii, pressure of the foetal head upon
the os uteri, over-distension of the bladder with urine, or of
the rectum with faeces, congestion of the brain from the blood
being forced upon it by the efforts of labor, or its return inter-
fered with from any cause whatever. Even strong mental
emotions may cause a sudden invasion of convulsions.
Much has of late been said about urea retained in the blood
through disordered function of the kidneys, as a cause of puer-
peral convulsions. This state of things has been inferred from
the presence of albumen in the urine, for when this is detected,
222 |PRACTICAL MIDWIFERY.
it is said that upon analysis that fluid is found to contain less
than the normal quantity of urea, while at the same time the
blood contains more. Associated with an albuminous urine,
will often coexist oedema of the feet, lower limbs, arms and
face of the patient. These symptoms were supposed to fore-
shadow an attack of eclampsia, upon the occurrence of labor.
Although convulsions, according to the experience of obstetri-
cians not unfrequently occur when albuminous urine has been
previously detected, and there has been Oedematous swelling of
the feet, face etc., of the patient, yet this does by no means al-
ways happen. I remember the case of a woman who engaged
me to attend her in confinement just one day before labor set
in, whose feet were so swollen as to bulge over the tops of her
shoes, which she then wore much larger than her usual size, while
her face and arms were equally odematous. She had a tedious
labor, and was ultimately delivered with the forceps, the head
being taken at the upper strait, and yet no convulsions super-
vened. I had not an opportunity to examine the urine, and
cannot therefore say whether it contained albumen or not, but
it is most likely it did. It should be remarked, however, that
in this case, being apprehensive of an attack of eclampsia, and
noticing at one time during the course of the labor some twitch-
ing of the muscles of the face, which I thought rather ominous,
I gave her a few doses of the tincture of Gelseminum, and soon
these convulsive movements ceased, and shortly were, for the
time, forgotten. Another case, however, perhaps still more to
the point, was that of a woman who sent me a message that she
desired to see me, without stating her object. Living at some
distance, and not supposing the matter of much importance, I
did not see her until some time afterwards. She then told me
she had been very much swollen in her limbs and face, but that
the swelling had passed away spontaneously. I was called
upon to attend her in labor, but could not reach her until the
child was born. There had been no convulsions, nor so far as
I could learn, even the remotest indication of their approach.
Convulsions of the severest character often occur when the
urine has been for some time before labor daily examined, and
not a trace of albumen detected, and when there had been no
Oedematous swelling of the limbs or face of the patient.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 223
If, however, albumen be not present before the eclampsic
attack, especially if this be severe or prolonged, it is apt to ap-
pear in the urine shortly afterwards. From these facts, it
seems not unlikely that the two phenomena, viz., eclampsic
convulsions, and the appearance of albumen in the urine, and
an abnormal amount of urea in the blood are effects, the off-
spring of a common cause, rather than that they sustain to
each other the relation of cause and effect. It has been thought
that the same morbific agent which induces convulsions may
also derange the functions of the kidneys, giving rise to the
appearance of albumen in the urine, and at the same time par-
tially arresting the elimination of urea from the blood.
Frankenhäuser, of Jena, has published a work referred to by
Dr. Barker, entitled “On the Nerves of the Uterus,” illustrated
by plates, in which he claims to have demonstrated a direct
connection between the nerves of the uterus and the renal gan-
glia. From this discovery he infers that the condition of the
kidneys, often associated with convulsions, is merely sympa-
thetic with the irritation of the uterus. “He believes that the
sudden occurrence of the eclampsic attack, following all exter-
nal sources of irritation (as pressure of the foetal head upon the
cervix, digital examinations, etc.), and from emotional causes,
goes to prove that the nervous system, and not the vascular
System, is the starting point of puerperal convulsions, and that
the changes observed in the kidneys of women dying from con-
vulsions, are too trivial and transitory, to indicate a long con-
tinued congestion ; and further, in confirmation of these views,
are to be added the undeniable cases of convulsions when no
albuminuria has existed.” A similar idea was promulgated by
Dr. Tyler Smith, namely, “that the albuminuria may depend
upon sympathetic irritation of the kidneys by the gravid ute-
rus, similar to the irritation of the salivary glands, the mam-
mae, the thyroid, etc., and not upon mere pressure * (Dr. Bar-
ker's Puerperal Diseases).
Still it may be true that the abnormal amount of urea said
to be contained in the blood, cotemporaneously with the exist-
ence of albumen in the urine, may be a factor in the production
of puerperal convulsions. Whatever irritates the brain, and
224 PRACTICAL MIDWIFERY.
through it the spinal cord, may contribute to such result: for
it is maintained that upon whatever point the irritation may
primarily act, its action must be communicated to the spinal
cord before convulsions can take place.
Although the puerperal condition must be regarded as an
essential element in the production of eclampsia, there is never-
theless a vast difference in the liability of puerperal women to
this fearful accident. A very large proportion of the cases oc-
curring are those of primiparae. In women in their first gesta-
tion we may suppose there exists a more exalted sensibility of
the nervous system than in such as have borne several children.
There are also sources of irritation which in future pregnancies
are much less powerful. For instance, in the case of primiparae
the abdominal walls resist more strongly the distending force
of the womb. The same perhaps may be said in regard to the
walls of the uterus itself—that this organ accommodates itself
in a less friendly way, to the necessities of its new condition,
than it will do in future pregnancies. Statistics seem to show
that young unmarried girls are peculiarly liable to puerperal
convulsions. In their case, in addition to the causes just enu-
merated, the moral emotions come into play. A sense of shame,
degradation, and sometimes the loss of all once held dear—a
compulsory descent from respectability it may be, to prospec-
tive ruin, adds fearfully to their risks.
It is thought by some that women of minute stature are more
liable to convulsions than those of larger size. If this be true,
and we have met with no confirmation of it in our own expe-
rience, it is accounted for upon the same principles we have
laid down in the case of first pregnancies. Some again have
supposed that epileptic patients are more subject to eclampsic
seizures than others. On the contrary, however, statistics seem
to show that in such patients, pregnancy often arrests for the
time epileptic paroxysms, which again recur and assume their
accustomed regularity after delivery. It is probable, however,
that women who from early life, through the influence of slight
causes, are thrown into convulsions, not epileptic, but mani-
festly of a purely nervous character, will be more subject to
puerperal convulsions than others, whose nervous systems are
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 225
naturally less impressible. It has, moreover, been said that
women who have once suffered from this malady are likely to
experience a recurrence of it in their subsequent labors. This
may be so in regard to the class of patients we have last no-
ticed, but, generally, it probably does not hold good. We know
a lady now resident in the city of Baltimore, the mother of se-
veral children, whose first labor was ushered in by severe con-
vulsions, which continued in less and less frequently recurring
paroxysms for several days. Her second labor was attended by
the same complication, but subsequent ones were normal.
Puerperal convulsions of the severest form are sometimes
ushered in suddenly without any premonitory symptoms. Dr.
Lilienthal records the case of a lady far advanced in preg-
nancy (Hahnemannian Monthly), who, very shortly before her
seizure, walked to the door with some friends about leaving
her house, and was suddenly attacked by what proved to be
fatal eclampsia. Sometimes the attendant, while taking his
ease, and unanxiously waiting upon the progress of what he
regards as a natural labor, is suddenly called by the nurse to
the bedside, to witness the unmistakable commencement of
severe convulsions. In this, however, as in other affairs of life,
very often
“Coming events cast their shadows before,”
and precursory symptoms manifest themselves, which should
always put the accoucheur upon his guard. These are given in
such faithful and minute detail by Dr. Barker, in his recently
published Lectures on “Puerperal Diseases,” that I cannot do
better than to transfer his description to these pages. “The
first and most frequent of these symptoms is headache, some-
times dull and continuous, and in other cases throbbing and
recurrent. It is occasionally intermittent for days or weeks,
until a few hours before the attack, when it becomes constant.
It is frequently attended with vertigo, on making any move-
ment of the head.” º
“The symptom next in frequency and still more significant
of danger, is impairment of vision. This, like the headache, is
frequently temporary at first, afterward becoming permanent.
15
226 PRACTICAL MIDWIFERY.
In some the sight, which had previously been good, appears to
be suddenly lost.” *
“In connection with either or both of the symptoms I have
just described, I should mention odema, particularly of the
face, coexisting with Oedema of the extremities. It occasion-
ally happens that this symptom exists alone, and even this in
so slight a degree as not to be observed, unless carefully sought
for, when the two other symptoms are wholly absent. Under
these circumstances, it becomes an imperative duty to carefully
and frequently examine the urine and test it for albumen.”
“Whether albumen be or be not found in the urine, or even
when the other symptoms I have just described are absent, if a
pregnant or parturient woman suddenly complains of sparks
before her eyes, or dimness of sight, or ringing in her ears, or
difficulty in articulation, or suddenly becomes nervous, irritable,
and complains of a severe pain in the head, the danger from con-
vulsions is imminent.”
Although any of these symptoms appearing in a patient near
the time of confinement, or indeed at any period in the course
of utero-gestation, should put us upon our guard, we have
known most of them to exist, either singly or in groups, and
eventually to pass away spontaneously without the superven-
tion of convulsions. Those detailed in the last paragraph of
the extract we have made, may I think justly be regarded as
by far the most threatening.
Puerperal convulsions may take place before, during, or after
labor. We remember the case of an unmarried girl who had a
fatal attack about her seventh month. She had endeavored to
conceal her pregnancy, and did not give any account of the
prodromic symptoms she might have experienced. The con-
vulsions first manifested themselves early in the morning, and
the mother spoke of her as having been up in the night and
showing signs of strange bewilderment. She, I believe, never
spoke from the commencement of the attack.
The description of the onset of the paroxysm is so graphi-
cally given by the author from whom I have just quoted, that
I trust I shall be excused for making a further quotation from
his work just named.
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 227
The patient “becomes pale, with a fixed expression of her
countenance, and a general immobility of her whole system.
This lasts but a moment, when the eyelids begin to twinkle,
the eyeballs to turn in their sockets, under the upper lid, so
that only the white of the eye is seen; the angles of the mouth
are drawn, producing a horrid grimace, which Baron Dubois
has aptly compared to the countenance of the satyrs of the
fable. The angle of the mouth being drawn up on one side,
the face turns to the same shoulder; then the muscles of the
face begin rapidly to contract, and this contraction almost im-
mediately extends to the muscles of the trunk and the extremi-
ties. The neck swells, the jugular veins stand out prominently,
and the carotids beat violently. The fists are doubled, gene-
rally with the thumb of one or both hands compressed in the
palm by the fingers. Sometimes one arm is raised as if in an
attitude to ward off a blow. The muscles of the throat and
larynx strongly contract and cause a momentary suspension of
respiration; the face is intensely congested, and of a purple
hue. This condition of tonic convulsion does not continue,
ordinarily, more than twenty or thirty seconds, when it is fol-
lowed by the clonic convulsive movements. Rapid, jerking
movements of the muscles of the face, body and extremities
now succeed the muscular rigidity. A short, noisy, broken
inspiration, with stertorous expiration, is attended with the
escape from the mouth of a white foam, sometimes bloody from
lacerations of the tongue. The patient can neither feel, see
nor hear. The circulation is soon influenced by the respiratory
troubles. The spasmodic contraction of the diaphragm and
the other thoracic muscles interrupt decarbonization and oxy-
genation; the pulse which was at first hard and strong, now
becomes rapid and feeble, capillary circulation is arrested, which
causes a purple hue, particularly noticeable on the hands. To-
ward the end of the paroxysm, all these symptoms progres-
sively disappear. The spasmodic movements of the muscles
become less frequent and less violent until they entirely cease,
the respiration and circulation become regular, the superficial
congestions disappear, and the surface recovers its natural
color. This period of clonic convulsions lasts from two or three
228 PRACTICAL MIDWIFERY.
minutes to twenty. The tonic convulsions are really much
more dangerous to life, and when patients die in the convul-
sion, it is in this period, the death being probably due to
asphyxia.”
The Prognosis of eclampsia is always uncertain, at least in
the severer forms of the malady. Although comparatively a
rare occurrence, it is not only one of the most alarming, but
also one of the most fatal that attend pregnancy or the puer-
peral state. It may terminate in complete recovery, the pa-
tient having no recollection of what has transpired, or it may
give rise to other diseases, such as puerperal mania, paralysis
of members, idiocy, loss of memory, amaurosis, etc., or it may
terminate in death, either directly during tonic spasm, perhaps
as above stated through asphyxia, or, as more frequently hap-
pens, during the soporose stage, induced through oppression of
the brain, by congestion or effusion. Fatal haemorrhage has
been known to succeed convulsions, through paralysis of the
womb preventing its firm contraction. A favorable termina-
tion may be expected when the paroxysms become more distant
and less severe, when a good degree of consciousness is restored
between them, when there seems to be but little cerebral op-
pression, or if this have existed, when it is manifestly subsid-
ing. On the contrary, short and imperfect intervals between
paroxysms of great severity, deep unconsciousness between the
convulsions, stertorous breathing, and other indications point-
ing to great cerebral oppression, portend a fatal issue. The
prognosis will be specially unfavorable, if the attack has hap-
pened before delivery, and there has been no amelioration as
regards the frequency and severity of the paroxysms after that
has been accomplished.
Such being the nature of this formidable malady, its success-
ful treatment is manifestly a subject of great importance. We
will, however, premise before going further, that here, as in
many other cases with which the physician meets, prevention
is, sometimes, easier than cure. When at all practicable, there-
fore, it should at least be attempted. If we succeed in prevent-
ing the occurrence of the malady, we of course avoid the uncer-
tainties always attendant upon treatment when it has once
taken place.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 229
When our services are engaged beforehand for attendance
upon a patient in confinement, we should always call upon her
and ascertain exactly the state of her health. And although
convulsions and albuminuria by no means seem to be insepara-
bly connected, yet the existence of albumen in the urine is
Sometimes a symptom of that derangement of vital function
which appears to be a factor in the production of eclampsia.
It will be well, therefore, to test the urine of the patient, espe-
cially if there be swelling of the feet, arms and face, or, indeed,
of either. This oedematous swelling is believed to be often
associated with albuminous urine. The remedy upon which I
have most relied in correcting this condition, especially if the
swelling be prominent, is Arsen. alb., say thrice daily. If the
urine be very scanty, Apis mel. may be given, either in alter-
nation with the Arsenic or alone. If the patient complain of
pain and burning, after voiding her urine, Equisetum hiemale
will probably be of service. Where the albumen is very abun-
dant, perhaps Merc. corr. will be found useful. Phosphor. may
be thought of, if other symptoms be present pointing to it.
Where there may be anticipated difficulty from unyielding
structures, and especially if there be choreic twitchings, I would
by all means give the tincture of the Actea rac., say six drops
in water, thrice daily, for ten or fourteen days before expected
confinement. When the patient complains of fullness and pain
in the head, especially on stooping, Bellad. should be given—if
the pain be greatly aggravated by motion, Glonoine should be
thought of. If nervousness and wakefulness are troublesome,
these should be treated as before directed (see chapter on Dis-
orders of Pregnancy). In short, whatever derangement of
health we may find in the patient, it should be carefully treated
according to the symptoms. As far as possible every source of
irritation, whether material or moral should be removed.
Anxiety and despondency should be counteracted by present-
ing encouragement drawn from the proper sources, and the pa-
tient should be led to feel that whosesoever sympathy she may
lack, she has fully that of her attendant. To bring the patient
up to the time of trial in good health and a cheerful state of
mind, has a wonderfully prophylactic effect, not only as regards
230 PRACTIC AI, MIDWIFERY.
the calamity under consideration, but others also. Even the
“unfortunate’” should share our sympathy. We should re-
member that while far from condoning their crime, we are
called upon, not to sit in judgment upon their conduct, but to
relieve their sufferings, and save their lives, that they may go
their way and sin no more. We should call to mind the ex-
ample of Him who was infinitely purer than the best of us,
whose withering rebuke dispersed the bloodthirsty conscience-
stricken crowd—“Let him that is without sin among you, cast
the first stone at her.”
But it will sometimes lie beyond our power to use prophy-
lactic measures to avert convulsions. As we have already said,
they will sometimes suddenly manifest themselves without
premonition, and without suspicion, on our part or perhaps even
that of the patient, of their approach. Or we may be called,
or at least reach the bedside after they have fairly begun. All
we can then do is to resort to remedial measures, such as our
knowledge and skill may suggest.
In the first place, if we are present when the attack sets in,
our duty is to secure the patient as far as possible from injuring
herself during her spasms. Something should, if possible, be
placed and kept between her teeth, in order to prevent her from
biting her tongue. A piece of cork will perhaps answer best,
if present—if not, a very solid roll of linen or muslin. She
should be so restrained as to prevent her from bruising her
limbs by violent movements, but not held so firmly as to en-
tirely prevent mobility. We should, if possible, ascertain the
focus of irritation which has given rise to the spasms. We
should endeavor to discover whether the bowel may not be
overloaded with faecal matter, or the bladder distended with
urine. The former, if it exist, should be immediately relieved
by injections of tepid water, and the latter by the introduction
of the catheter, as soon at least as this can be done.
Most persons in their ordinary condition and health, experi-
ence little or no inconvenience from either of these causes, un-
less in extreme cases, or very long continued; but we must bear
in mind the very greatly increased impressibility of the ner-
vous system of the puerperal woman.
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 231
Should any other source of irritation be discovered, whether
material or moral, it should at once, as far as possible, be ob-
viated. Even the presence of persons in the chamber toward
whom the patient may be supposed to entertain any feeling of
antipathy, should not be permitted. Our motto here should be,
emphatically, “Tolle causam.”
If labor have already set in, we should examine the condi-
tion of the os uteri, and if there be sufficient dilatation to jus-
tify the procedure, and especially if there be reason to believe
that the convulsions are dependent upon irritation of the womb
from the presence of the foetus, we should deliver either by
means of the forceps, or by turning, according as the one or the
other of these resources may be most plainly indicated. If the
head be already engaged in the upper strait, or have descended
into the cavity of the pelvis—especially if the os be well di-
lated, the forceps will come into play, but on the contrary, if
the head be high and the os imperfectly dilated, turning will
be the proper resort. It may, perhaps, be stated generally,
that when convulsions occur during labor, to empty the womb
as speedily as can be done with safety, is one of the first indica-
tions to be fulfilled. Till this is done remedies are not likely
to succeed, but nevertheless should be diligently used. It fre-
quently happens, however, that the mouth of the womb is most
rigidly contracted, and obstinately refuses to yield to the ordi-
nary resources of nature, and too often also those of art. We
must not, then, rudely lacerate this organ for the sake of effect-
ing speedy delivery, but resort to such other measures for the
present as may best serve to mitigate the spasms, and ultimately
secure dilatation. If there seem to be symptoms indicating
congestion, especially of the head, Bellad, may be given, pro-
vided the patient can be induced to swallow. Pellets or
powders may be thrown far back into the mouth, if she con-
tinue too unconscious to take them in the usual manner. This
remedy very often corresponds to the most prominent symp-
toms of eclampsia, and that it has “moreover a special affinity
to the condition of a parturient female, is not only shown by
our Materia Medica, in spite of the incoherent arrangement
of its symptoms, but may likewise be learned from any recog-
nized toxicological treatise.”
232 PRACTICAL MIDWIFERY.
Gelseminum is a remedy of great promise in the treatment
of puerperal convulsions. Its pathogenesis can be best learnt
in Hale's New Remedies, also in Burt’s Characteristic Materia
Medica. From the effects of this remedy I myself have wit-
nessed, I know of none in which I would place greater confi-
dence. I would give it in drop doses of the mother tincture,
repeated according to urgency. Dr. Hempel speaks very favor-
ably of Bromide of Potassium in large doses. I have had no
experience with this drug; but would be disposed to try it
should others, with which I am more familiar, disappoint me.
Where there is rigidity of the os uteri, I would place consid-
erable reliance upon Actaea racemosa; not only from its relax-
ing effects upon that organ, but on account of its curative
powers over chorea, a spasmodic affection sometimes arising
from irritation of the womb. By all means try it where the OS
wieri is very rigid. Hydrate of chloral is very highly spoken
of by allopathic authors, and should not, on that account, be
rejected.
But a great difficulty, in administering medicines satisfac-
torily by the mouth, arises from the spasmodic nature of the
disease, and, in severe cases, from deep and long continued un-
consciousness. Where this opposes an insuperable barrier, they
may be given by enema, or, perhaps better, by subcutaneous
injection.
In cases where the paroxysms are severe, return frequently,
where we are anxiously desirous of emptying the womb, but
the os is undilated and undilatable, and especially where other
remedies, carefully selected, have been of little or no avail,
Chloroform affords us an admirable resource. When properly
managed, it not only controls reflex action and holds in abey-
ance the convulsive attacks, but it proves the very best agent
for relaxing the os and thereby rendering delivery not only
practicable, but safe. As it is administered by inhalation, its
salutory effects are independent of the consciousness of the
patient, so long as she still respires. The inhalation should
be conducted carefully and in the manner I have elsewhere
advised (see chapter XII); but, at the same time, with suffi-
cient boldness, to produce the anaesthetic effects of the agent.
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 233
Its administration should be suspended when the paroxysm
comes on, till this has subsided and the patient has taken in
sufficient fresh air to relieve the asphyxia.
I am aware I subject myself, at least with some, who, per-
haps, claim to cure all cases by other means, to the charge of
departing from Homoeopathic practice in this advice. In the
first place I am not so certain that it is a departure from sound
Homoeopathy. I am strongly inclined to believe that Chloro-
form exercises a specific curative power over, at least, some
forms of convulsions. Its action upon the nerves of sensation
is certainly similar to that of the morbific agent, inasmuch as
both produce anaesthesia. Chloroform is also said to have
caused convulsions. I well remember a case which, I admit,
is not wholly conclusive, as the conclusion is reached only
through analogy; but which is certainly strongly suggestive.
It happened in the very early days of the use of chloroform
as an anaesthetic, as some then thought, and still think, as a
lethal agent. A young male cat had been dropped upon my
premises, I suppose, perhaps, because he was regarded as an
incurable invalid. He was subject to what appeared to be
very severe epileptic convulsions of frequent recurrence. His
paroxysms were ushered in by the most piteous howling, and
then violent clonic spasms, followed by tonic, which in a few
seconds closed the fit. When his paroxysm ceased, he walked
slowly away, and seemed to feel very badly. He had become
much emaciated. It occurred to me I would kill him with
Chloroform, which, from the high reputation of the drug in
that direction, I thought would be an easy performance. I
took the opportunity when he was in a severe paroxysm, and
administered the chloroform upon a sponge and without stint.
The convulsions soon ceased and the patient lay still, as if in
death. He soon, however, showed by his movements that he
was not dead. I repeated the process—and that again and
again, until I became convinced that however well adapted to
homicide, chloroform is not the best agent for felicide. I
therefore dismissed the patient to die at his leisure. But, to
my astonishment, I never saw the cat have another paroxysm
of convulsions—I believe he had none, and he soon took on
234 PRACTICAL MIDWIFERY.
flesh, and became apparently perfectly healthy, and remained
so about my premises for several years.
The objection, too, that the amount of Chloroform required,
and that if successfully used, is commonly given, is at vari-
ance with the ordinary course of Homoeopathic practice, I
consider of no weight. If it be even fully settled that some
remedies, such as Arsenic., Silicea, Sulphur, etc., act best in
high attenuations, it is certainly bad logic, in our present state
of knowledge, to conclude that the same is true of all other
medicinal agents. The utility of Chloroform, given as directed
above, is, I think, fully established by the experience of others.
Our Allopathic brethren claim to have reduced their mortality
through its agency about fifty per cent. We are hardly justi-
fied, I think, in the conclusion that this difference is owing to
the substitution of chloroform in the place of more homicidal
IOlea,SUI TëS.
The following case, treated but a few months since, I think
of sufficient interest to justify me in the recital.
I was called upon to attend in labor a young lady in her
first confinement, whom I had known before to be of exceed-
ingly nervous temperament, and subject to spinal irritation.
She lived at a distance of several miles, so that, although en-
gaged some time before her labor, I did not see her, but re-
quested particularly by letter that if any oedematous swelling
of her person should occur, I might be informed of it. I was
assured there was none.
When I first reached her bedside she complained of severe
headache, and seemed to be very nervous. I gave her some
remedy, I think Coffea. Shortly after I heard no more of pain
in the head; but as labor advanced, and she began to suffer
severely, she begged of me to give her chloroform. Her re-
quest was granted, and she passed very handsomely under the
influence of the anaesthetic. The womb continued in very vig-
orous action, although she was wholly insensible to pain, and
toward the close of labor its powerful contractions were almost
continuous, as if under the influence of Ergot, although none
had been given. The labor terminated rather sooner than I
had expected, and the child, constitutionally a feeble one, was
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 235
still-born, either, I presume, from premature detachment of
the placenta or compression of the cord. The patient waked
up as usual and made no particular complaint. I saw her next
day toward evening, and found she had been suffering through
a considerable part of the day from intense pain in the hèad.
I left Bell. with a strict injunction to let me know if anything
more unfavorable should occur.
I was waked about two o'clock the following night by a
messenger, who could only inform me that the patient was
“much worse; ” but could not tell in what particular way. I
went with him a distance of about nine miles, and the night
being rainy and exceedingly dark, a good deal of time was
spent on the road. When I arrived I found the patient had
been in frightful convulsions since about nine o'clock—it was
now about four in the morning. The paroxyms recurred about
every twenty minutes—the pulse, which had been the evening
before full and remarkably slow, had now become very small
and quick.
After some preliminary measures, I commenced administer-
ing chloroform in the intervals of the paroxysms, by inhala-
tion, and as soon as I was able to effect it, threw up one drachm
of the same in water as an enema. This was retained, how-
ever, but a short time. Simultaneously with these measures,
I commenced giving by teaspoonful doses a solution of six to
ten drops of Veratrum viride in a tumbler say two-thirds full
of water, every fifteen or twenty minutes. In the intervals of
her seizures, the patient, although entirely unconscious, swal-
lowed any liquid put into her mouth with a spoon.
After commencing this treatment, the next recurrence was
at an interval of one hour—then two hours—then three hours,
which was the final one. I visited the patient next morning,
and found her doing well, but utterly oblivious of all that had
happened the day before ; had at first forgotten about her late
confinement, and had even expressed some uncertainty about
her marriage. She, however, fully regained her faculties,
which were very good, and made a satisfactory recovery.
Upon my return from my last visit to this patient (Sunday), I
was informed that two other similar cases had occurred during
236 PRACTICAL MIDWIFERY.
the past week within a few miles, both primiparae, both under
allopathic treatment, and both had died. I found this report
upon careful inquiry to be strictly correct.
Finally, we as a School have thrown away the lancet, and
we"hope, but for very exceptional cases, forever. Are there
any imaginable circumstances in the treatment of puerperal
convulsions that might still suggest the propriety of its em-
ployment? I confess I speak here with hesitancy, for having
set out for the Promised Land, although its full enjoyment
may yet be distant, I feel no inclination to return to the flesh-
pots of Egypt.
Even our Allopathic brethren have to a great extent lost
their confidence in bleeding in this disease, and have nearly
discarded its use. Still there are cases reported of the convul-
sions finally ceasing immediately after venesection. If unmis-
takeable evidence exist of strong congestion in the brain, when
as yet we have reason to hope that rupture of the vessels has
not taken place, nor effusion considerably advanced, when the
pulse is full and strong, or on the other hand, as may be most
likely, oppressed and feeble, and when death already threatens
the patient unless relief be procured from some quarter—as yet
unexplored—let us try the lancet.
TALSE OR SPURIOUS PERITONITIS.
This is the name given by authors to an affection of child-
bed, which if it occur at all, usually takes place within a few
days, mostly a few hours after delivery. It is characterised by
an excessively severe pain originating in some spot in the ab-
dominal region, but if it continue for some time, seems to
spread over a larger space. It is important in several of its
aspects, although not necessarily a dangerous affection. In the
first place, it bears sufficient resemblance in its symptoms to
incipient peritonitis to excite great alarm on the part of the
patient and her friends, which is of itself an evil much to be
dreaded. In the hands of the allopathic practitioner, a mis-
take of this kind might lead to fatal results; for should he re-
sort to the lancet and freely abstract blood, the mischief in
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 237
some cases would be irreparable. With us, who ought to be
guided in our practice by the symptoms, not by the name, it is
true there is no such danger, but still it is proper we should
apprehend the true nature of the case.
False peritonitis, as it is with no great propriety of language
called, is not an inflammatory affection, but probably altogether
neurotic. It is not improbable, however, that severe cases ne-
glected or improperly treated, may sometimes induce or run
into true peritonitis.
The older writers upon midwifery took no notice of the
affection. According to Dr. Meadows, Dr. Gooch was the first
to describe it and point out the suitable treatment. I remem-
ber to have met with several cases in my own practice before I
met with any description of it in the authors to which I had
3,CCéSS.
I quote the following from Dr. Meadows’ “Manual of Mid-
wifery.” “It occurs,” says he, “mostly in women of delicate
and nervous habits, and is frequently met with in hysterical
persons. The pain is often of the most excruciating character,
and is greatly aggravated by any movement of the body. So
distressing is the pain, that persons will sometimes become
almost frenzied with it; they are quite incapable of bearing
even the slightest touch with the hand or the weight of the bed-
clothes on the body; but that which marks its strongly nervous
or hysterical character, and serves at once to distinguish it from
the truly inflammatory pain is, that if the patient’s attention
be distracted by conversation or other means from the seat of
pain, pressure, even to a considerable extent, if gradually and
cautiously applied, will be borne not only without complaint,
but apparently without her knowledge; but no sooner is her
attention again drawn to it, than the same exquisite sensitive-
ness again reveals itself, and she screams out lustily even at the
approach of pressure. Again, if by soothing words and promi-
ses of cautious proceeding we induce her to let us apply the
hand upon the abdomen so gently that it does not even rest its
weight upon it, we shall find that we may now gradually in-
crease the pressure until by degrees it becomes considerable,
not only without her feeling any increase of pain, but with
238 PRACTICAL MIDWIFERY.
complete relief, the pressure of the hand as it were appearing
to benumb the pain. If we withdraw the hand in the same
gradual manner, no pain will be induced, but if we remove it
suddenly, a spasm of the muscles with intense pain is immedi-
ately excited.” (Rigby.)
“With all this, there is often a great show of constitutional
disturbance, though it is all of the same evanescent character;
the tongue becomes dry, the pulse quick, small and jerking,
the skin is hot, but mostly covered with perspiration, and the
mental excitement is often very great.”
The patient too will often tell us she has had a chill. This
probably has been of a nervous character, like that which not
unfrequently occurs shortly after delivery. According to the
observation of authors who speak of this affection, it is most
frequently encountered in the case of women of previously
feeble health and nervous irritability. One of the worst cases
I have met was that of a woman who before and since has
suffered severe attacks of hay asthma.
As regards the treatment of this affection, I have always
found Acetate of morphia to give very prompt relief. One
grain in ten teaspoonfuls of water thoroughly dissolved, a tea-
spoonful every half hour till relief is experienced, then discon-
tinue rennedy. Patients generally reported relief after the
second or third dose, without experiencing in any degree the
narcotic effects of the drug. How much smaller doses might
answer the same purpose, I am unable to say ; I have succeeded
with the above, and have been Satisfied.
I have also used, at the suggestion of Dr. Ludlam, Atropia
3d dec. with excellent results. One or the other of these medi-
cines has promptly relieved all the cases I have met, and I
think will relieve generally, with few if any exceptions, if
resorted to in time and under the requisite concomitant
circumstances.
MASTITIS, OR IN FLAMMATION OF THE MAMIMARY GLANDS.
This affection often occurs to the nursing woman, and most
frequently shortly after delivery. We therefore speak of it as
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 239
One of the diseases of the puerperal state. It may, however,
take place at any time during lactation.
The immediate cause giving rise to inflammation of the
breasts, is obstruction to the flow of milk along the lactiferous
tubes, and consequently to its discharge by the nipples. En-
gorgement hence ensues, and if not soon relieved, inflammation
speedily follows. This obstruction may arise from various
causes—from neglect to draw the milk, through which the
milk tubes become distended, and crowd and compress each
other. Or it may owe its origin to undue congestion of the
blood-vessels, with which the substance of the mammary
glands is abundantly supplied. This congestion may arise
from chills or exposure to cold, perhaps strong mental emo-
tions, or any causes that disturb the equilibrium of healthy in-
nervation. The breasts during lactation, especially in its
earlier periods, are in a state of unwonted activity, both ner-
vous and vascular, and therefore readily receive the impression
of any morbific agent, upon whatever part of the organism its
primary impact may fall.
There are commonly reckoned by authors three varieties of
mastitis, viz., the sub-cutaneous, affecting the areolar tissue,
beneath the skin; the glandular, seated in the substance of the
gland itself, and the sub-glandular, in the cellular tissue be-
neath the gland. As inflammatory processes do not very scru-
pulously observe the limits prescribed by classification, these
varieties not unfrequently overstep their assigned bounds, so
that more than one of them may be encountered in the same
breast, either at the same time or in close succession.
The first named variety, if alone, is in its course the shortest
and least injurious to the functions of the organ, either for the
time or subsequently. The second and third, unless well man-
aged in the outsetting, are of long duration, and give rise to
untold suffering, and often render the breast incapable of per-
forming its functions after recovery.
The best treatment of this disease, as of many others to
which the puerperal woman is liable, is the prophylactic.
When inflammation of the mammary gland sets in, unless
treated very early, it is extremely liable to go on to suppura-
240 PRACTICAL MIDWIFERY.
tion. If it occur after the physician has ceased from his daily
attentions to his patient, she is apt to be subjected to a trial of
the many infallible cures known to the nurse or friends in
charge. When he is recalled it is usually too late to prevent
suppuration.
Enumerating prophylactic measures and going back to the
remotest of them, we would advise, as we have elsewhere done,
and which we need not fully repeat in this place, especially in
women pregnant for the first time, to pay early attention to the
condition of the nipples. This should be done for some time
before confinement.
We have thought that the administration of Arnica at the
close of labor, as is our uniform practice, has a tendency to pre-
vent mastitis, especially the phlegmonous or sub-cutaneous va-
riety of that disease. Its efficacy in the case of common boils,
is, I believe, pretty generally conceded.
After delivery, a great object will be to keep the breasts as
perfectly exhausted as possible. To this end, the child, if
healthy, should be early accustomed to suck. It should not be
unnecessarily fed before the Secretion of milk, and especially
upon panada and other articles, entirely unsuited to its diges-
tive powers, which impair its health and of course diminish its
appetite and disposition to take the breast freely. When the
milk cannot, for any reason, be fully drawn by the child, re-
course must be had, if necessary to prevent engorgement, to the
gentlest and least irritating means accessible, and the best of
these is the mouth of the nurse, and next to this the exhausted
bottle. These measures need be carried so far only as to pre-
vent excessive and painful accumulation of milk.
It has generally been advised, when a circumscribed hardness
takes place in any part of the gland, which the women usually
call “caking,” that the nurse, standing behind the patient, if
the latter be sitting up, having her hands lubricated with some
soft oil, should gently rub the breast forward toward the nip-
ple, very slightly increasing the pressure as the patient becomes
accustomed to it. Of late, however, such interference is dis-
countenanced by the “highest authorities.” We are very apt
to oscillate from one extreme to another, and very often pass
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 241
the truth lying midway between. When there is simple en-
gorgement or congestion, and the inflammatory process, pro-
perly so called, has not yet set in, judiciously applied pressure
in the form of gentle friction may, I think, sometimes be of
Service. Still it is perhaps better not to leave to the indiscre.
tion of the nurse the employment of a measure which if inju-
diciously applied, may do much harm.
At a meeting of the Obstetrical Society of London, held on
the 6th of January, 1875, a paper was read by Dr. W. Bath-
urst Woodman, “On the prevention of Mammary Abscesses by
the Application of the Principle of Rest.” An interesting
discussion on the subject of the paper ensued, in which some
of the most distinguished members of the society took part.
The author inferred from the rarity of mammary abscess in
the case of cats, dogs and other animals deprived of or ab-
sented from their young, and which are subjected to no inter-
ference, that the disease in the human female is rather hastened
than prevented by the usual measures employed for prevention.
The author does not tell us how much these animals suffer be-
fore they escape, and how much that suffering might be dimin-
ished by judicious appliances. In the case of mares, which
generally escape abscess, the “nimia deligentia’ is only too
often resorted to. It is highly probable the inferior animals
are naturally less liable to abscess than the human female.
These eminent gentlemen pretty generally agreed that it
was all important to secure perfect rest to the suffering organ,
and to abstain from the usual interference such as frictions,
external applications, etc. They recommend the use of the
suspensory bandage to relieve dragging and weight. Some
advised the application of the Belladonna plaster. Dr. Ash-
burton Thompson advised minim doses of Tincture of aconite
every hour, by which he had succeeded in cutting short in-
flammations of the breast, which there was no doubt would
have run on to suppuration—frequently, indeed, in three cases
out of four. In cases of still-birth he had hitherto found ab-
stention from fluids sufficient in every case to avoid every kind
of mammary disturbance.
Dr. Braxton Hicks thought the principle of rest had been
16
242 PRACTICAL MIDWIFERY.
gradually coming upon us for years, friction only being re-
sorted to among the poor and ill-educated. Surgery at the
present day was all tending to quietude, manipulations only
led to suppuration, and often produced the extra amount of
stimulation required to set it up.
Dr. Murray observed that the application of a Belladonna
plaster was of great service, keeping the arm at the same time
fastened to the side. In some instances a slight process of
friction upwards was productive of good. The foregoing are,
it is true, allopathic authorities; but I am not unmindful of
the words of the great Roman poet, “fas estab hoste doceri.”
That injudicious interference is injurious in the case of mas-
titis, and where is it not 7 is manifest from the fact that, so far
as I can remember, I can think of no case where the procedures
of ignorant women were freely resorted to, that did not end in
suppuration, often very extensive, and not unfrequently involv-
ing both glands.
The patient throughout the puerperal period should care-
fully avoid all imprudent exposures to currents of air or a
chilling atmosphere, or dampness. Owing to the cutaneous
surface being usually moist with perspiration, she readily
chills, and the injurious effect is often reflected upon the
breasts. After leaving her bed these organs should be care-
fully guarded against cold, but, on the other hand, should not
be kept too warm.
After the child commences to suck, every precaution should
be taken to avoid sore nipples. If these become tender, she
should procure a gum elastic nipple shield before abrasion
takes place. The nipples should be carefully washed after
each nursing of the child. If, notwithstanding all precau-
tions, they become abraded, ulcerated or chapped, the suitable
remedies, elsewhere laid down, should at once be had re-
COurse to.
Mammary abscess is usually ushered in by a chill more or
less severe. This is followed by fever and headache. The
mammary gland or a portion of it becomes hard, and to the
touch presents the sensation of a lump. T’ain sets in and
gradually increases until it deprives the patient of sleep, im-
AccIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 243
pairs or destroys appetite, and, if unchecked, completely unfits
her for every duty and all enjoyment.
When called in the stage of chilliness and fever, Aconite
should be given at short intervals, say every half hour, until
perspiration sets in, the patient keeping closely in bed. The
weight of the breast should be relieved by adhesive straps or
a properly adjusted suspensory bandage. Gentle but not ex-
cessive pressure may be applied, avoiding such a degree as to
increase pain or suffering.
Bryonia is indicated by hardness and distension of the
breasts, shooting pains, dry skin, thirst, etc.
Belladonna should be given when there is engorgement,
redness of the skin covering the breast resembling erysipelas,
headache, etc. We have seen few cases go on to suppuration
where Bell. was perseveriugly given. This remedy is thought
by some to be better suited to threatening of mammary abscess
at the time of weaning the child than shortly after labor.
Extract of Belladonna, softened or diluted with glycerine, and
spread upon the surface of the breast, will be found an excel-
lent application in glandular mastitis. It may be applied by
means of a cloth, having a hole cut in to fit the nipple.
Phytolacca decandra (poke weed) has been much praised by
some as a remedy for mastitis. It has been used in domestic
practice, and has been pretty generally thought to possess
curative powers in this disease. Dr. Hale, in his “New Rem-
edies,” speaks highly of it. I have occasionally used it; but
my experience with it has not been sufficiently extensive nor
my results sufficiently positive to speak very decidedly in its
favor. I would suppose it perhaps indicated where there is
aching of the limbs and a general feeling of malaise.
Phosphorus is a remedy of great value in this complaint.
Where the symptoms were not very acute in the outsetting,
consisting of hardness and soreness of a portion of the gland,
threatening a worse state of things if neglected, I have thought
Phosphorus, perseveringly used, has, in my hands, been of great
benefit. Sooner or later the hardness has generally passed
away and the Soreness subsided, the gland returning to its nor-
mal condition. I have generally applied a solution of a few
244 PRACTICAL MIDWIFERY.
drops of the saturated alcoholic tincture to the breast exter-
inally, by means of flannel cloths, or lint saturated with the so-
lution and covered with oiled silk, to preserve moisture, at the
same time giving it internally.
Where hardness remains after the use of other remedies, or
where suppuration is imminent, Mercurius will be found use-
ful. In the last named condition, Hepar sulphuris may be of
U1862.
Where mammary abscess has taken place, been badly man-
aged and assumed a chronic form, there being often several
fistulous openings, discharging pus or serous fluid, Silicea will
often prove an excellent remedy. I have seen such cases so
emaciated by long continued suffering as to present the appear-
ance of one in the advanced stages of consumption, who in a
few weeks, under the persistent use of Silicea, so changed their
aspect as to be scarcely recognizable.
It has been disputed whether poultices should be applied to
gathering breasts, at least before the breaking of the abscess.
If I were to express an opinion, it would be this—avoid poul-
tices until it is pretty certain that suppuration is inevitable—
then apply them in a very simple form, until, at least, the
bursting or opening of the abscess.
Again there is a difference of opinion as to whether we
should open the abscess with the lancet, or in all cases leave it
to open spontaneously. Truth is seldom found in extremes.
|Rules laid down, to be applied to all cases, are necessarily often
misapplied. My practice has been to avoid plunging the lan-
cet deeply into the gland, especially near the nipple. Many of
these abscesses, if encouraged by the use of Mercurius, will, in
due time, open themselves and thus save the pain and other
evils of a cutting operation. But when the matter has ap-
proached near the surface, that nothing but the skin needs to
be cut, where this latter does not seem to give way, and espe-
cially if discoloration over a considerable surface appears likely
to take place, and if in addition to this the patient is suffering
much pain, I do not hesitate to use the lancet and make a free
opening for the exit of the pus. The incision, especially if
near the nipple, should be made in a line as if radiating from
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 245
that point. In this way there is less risk of severing the milk
ducts; always, however, if possible, avoid an incision within
the limits of the areola. It is scarcely necessary to add, after
what I have already said, that the opening should be made
with a bistoury or abscess lancet, and not with the spring lan-
cet, used in phlebotomy, as has often been barbarously done.
Some women have the greatest horror of this operation,
partly from their consciousness of the excessive tenderness of
the part, and, perhaps, principally from nervousness induced
by loss of sleep and extreme protracted suffering. In such
cases there can be no valid objection against the use of an
anaesthetic, pushed to insensibility. If we decide upon this,
perhaps ether had better be selected, as the effect of fear is ex-
tremely paralyzing to the action of the heart; this effect,
added to that of chloroform, might produce disastrous conse-
quences. Ether has, at present, at least a less formidable repu-
tation, as a destroyer of life, than chloroform, and should it
produce this unfortunate result, it would be more readily ex-
cused than its competitor.
Quite lately it has been asserted that an application of a so-
lution of carbolic acid in glycerine, I think two parts of the
former to one of the lattter, will temporarily destroy the sen-
sibility of the skin. The application should be made five min-
utes before incision is attempted.
When pus is formed in the cellular tissue beneath the gland,
as evidenced by chills, extreme enlargement of the breast, in-
distinct fluctuation, etc., the puncture should be made at the
most dependent point beneath the margin of the organ, at
which the matter can be conveniently reached. In this variety
of mammary abscess, when the pus is left to find its own exit,
it not unfrequently discharges at several different points, form-
ing as many fistulous openings into the substance beneath the
gland. When matter accumulates and is long pent up in the
sub-glandular cellular tissue, it compresses the gland and brings
on disease of its substance, often resulting in abscess of that
organ itself, and greatly complicating the case.
Before closing this chapter, we will transcribe what Mr. Lis-
ter has written upon the treatment of abscess, according to his
antiseptic plan:—
246 PRACTICAL MIDWIFERY.
“A solution of one part of crystallized carbolic acid in four
parts of boiled linseed oil having been prepared, a piece of rag,
from four to six inches square, is dipped into the oily mixture
and laid upon the skin where the incision is to be made. The
lower end of the rag being then raised, while the upper end is
kept from slipping by an assistant, a common scalpel or bis-
toury, dipped in the oil, is plunged into the cavity of the ab-
scess, and an opening, about three-quarters of an inch in length,
is made, and the instant the knife is withdrawn the rag is
dropped upon the skin as an antiseptic curtain, beneath which
the pus flows out into a vessel placed to receive it. The cav-
ity of the abscess is firmly pressed, so as to force out all exist-
ing pus as nearly as may be (the old fear of doing mischief by
rough treatment of the pyogenic membrane being quite ill-
founded); and if there be much oozing of blood, or if there
be considerable thickness of parts between the abscess and the
surface, a piece of lint, dipped in the antiseptic oil, is intro-
duced into the incision, to check bleeding and prevent primary
adhesion, which is, otherwise, very apt to occur. The intro-
duction of the lint is effected as rapidly as may be, and under
the protection of the antiseptic rag. Thus the evacuation of
the original contents is accomplished with perfect security
from the introduction of living germs. This, however, would
be of no avail, unless an antiseptic dressing could be applied
that would effectually prevent the decomposition of the stream
of pus constantly flowing out beneath it. After numerous dis-
appointments I have succeeded with the following, which may
be relied upon as absolutely trustworthy. About six teaspoon-
fuls of the above mentioned solution of carbolic acid in lin-
seed oil are mixed up with common whiting (carbonate of lime)
to the consistence of firm paste, which is in fact glazier's putty,
with the addition of a little carbolic acid. This is spread upon
a piece of common tin-foil, about six inches square, so as to
form a layer, about a quarter of an inch thick. The tin-foil,
thus spread with putty, is placed upon the skin, so that the
middle of it corresponds to the position of the incision, the
antiseptic rag, used in opening the abscess, being removed the
instant before. The tin-foil is then fixed securely by adhesive
ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 247
plaster, the lowest edge being left free for the escape of the
discharge into a folded towel placed over it and secured by a
bandage. The dressing is changed, as a general rule, once in
twenty-four hours; but if the abscess be a very large one, it is
prudent to see the patient twelve hours after it has been opened,
when, if the towel should be much stained with discharge, the
dressing should be changed, to avoid subjecting its antiseptic
virtues to too severe a test. But after the first twenty-four
hours a single daily dressing is sufficient. The changing of
the dressing must be methodically done as follows. A second
similar piece of tin-foil having been spread with putty, a piece
of rag is dipped in the oily solution and placed on the incision
the moment the first tin is removed. This guards against the
possibility of mischief occurring during the cleansing of the
skin with a dry cloth and pressing out any discharge which
may exist in the cavity. If a plug of lint was introduced
when the abscess was opened, it is removed under cover of the
antiseptic rag, which is taken off at the moment when the
new tin is to be applied. The same process is continued daily
until the sinus closes.”
When a considerable cavity is formed in the breast and the
pus is fully evacuated, very gentle, equable pressure, sustained
by the dressing, will contribute very much to speedy and per-
manent repair.
It is of the utmost importance that an abscess, when formed,
should be properly treated, but, as before intimated, it is still
more important to prevent its occurrence, which may usually
be done by timely and judicious homoeopathic treatment.
248 PRACTICAL MIDWIFERY.
CHAPTER XI.
OBSTETRIC OPERATIONS.
FORCEPS.
The precise time when the forceps was first employed, has
not been well ascertained. It is generally believed that Dr.
Paul Chamberlen was the inventor of the instrument. For
Some time, however, he kept it a secret, and used it privately,
as is supposed prior to the year 1647. It was not, however,
generally known till long after that time. The forceps devised
by Chamberlen, of which the late Prof. C. D. Meigs possessed
and exhibited to his classes what he supposed to be an exact
fac-simile, was extremely rude. Perhaps no instrument has
passed through a greater number of modifications up to the
present time; a circumstance which shows its estimated im-
portance, and the desire cherished by the most eminent obstet-
ricians, to fully evolve its powers and facilitate its employment.
It would be incompatible with the prescribed limits and
scope of this work, to enter into a full description of the differ-
ent forms of the instrument now in use. The usual method
of attempting to convey a correct idea of these by means of
wood-cuts, for the most part results in failure ; as it is, an at-
tempt to depict solids upon a plain surface, which can be suc-
cessfully done only by a very exact observance of shading and
perspective, such as we can hardly expect to find in illustrations
accompanying books on midwifery. A far better idea can be
gained by examining the instruments themselves, usually kept
on hand by cutlers, who generally can exhibit the most ap-
proved forms used by the most prominent practitioners.
The most important requisites of a good forceps are the
following:
1. That it be as light in all its parts as is consistent with
the requisite amount of strength.
OBSTETRIC OPERATIONS 249
2. That the blades should be no wider than may be necessary
to avoid too concentrated pressure upon a circumscribed por-
tion of the cranium, and to secure a safe hold upon the head.
If too wide, the difficulty of introduction is materially in-
creased, while at the same time their mobility when within the
pelvis is diminished.
3. That it should have sufficient length to grasp the head
when necessary, at or above the superior strait.
4. That its cranial curve should be such that the inner sur-
face of the blade may, when applied, Gome into as extensive
contact as possible with the foetal head, and not rest merely
upon a few points, while the pelvic curve should be so modi-
fied as to endanger as little as possible the tissues of the mother
by undue compression or laceration.
5. The fenestrae or openings in the blades should be as large
as possible, consistent with the requisite strength, so that the
scalp of the child protruding through them, may serve to pro-
tect the maternal structures from undue direct pressure by the
instrument.
The blades of the forceps perhaps still most commonly used
in Great Britain have but one curve, namely, the cranial. This
instrument is generally designated as the straight forceps. It
is well suited for seizing and extracting the head when at the
lower strait, but exceedingly awkward when it is necessary to
take it above or at the entrance of the pelvis, or even when
high in the cavity. On the continent of Europe and in this
country, another curve is superadded to the above, termed the
pelvic curve, which, when the instrument is introduced, cor-
responds with the curve of the sacrum. The latter instrument
is, however, at present, meeting with more favor in the British
isles than formerly. In the United States, so far as I know, it
is almost exclusively used. In very nearly all cases likely to
occur, it is vastly preferable to the strait forceps. I can think
of no exception, unless it be when we desire to rotate the head
in mento-posterior presentations of the face.
Several distinct methods of locking or fastening the blades
together after they have been introduced, have been adopted.
In the forms in use with us, the blades cross each other in their
250 PRACTICAL MIDWIFERY.
introduction, and are afterwards brought together and secured
by what is called the English or the German lock. The former
consists in a mortise in the shank of each blade, by which one
passes into the other when brought together; the latter has a
mortise in the one shank, and a thumb screw in the other.
When approximated, the thumb screw is received into the
mortise, and with a few turns of the former the lock is secured.
The long forceps in use with us, so far as I have observed, is
furnished with the German lock; the short, or Davis' or Meigs'
forceps has the British.
Another form of the instrument, said to be an admirable
one, is that used by Prof. Lazarewitch, of Charkoff, Russia.
In this forceps, the blades lock without crossing. They are
simply opposed to each other and kept in place by a little button
in the handle. It is claimed that the introduction of this in-
strument is easier than that of those requiring the crossing of
the blades; that it is of no consequence which of the blades
may be first introduced; that dangerous compression is pre-
vented, and that from the arrangement and position of the lock
there is no risk of pinching the maternal structures. These
are advantages, it is true, but they may be all likewise secured
by proper attention, with the instruments in common use.
Every practitioner who is in the habit of frequently resorting
to the use of the forceps, usually has his own decided prefer-
ence. This preference often depends upon other circumstan-
ces than the real merit of the forceps. The influence of former
instructors, long habit, and often mere accident, may determine
his choice. For my own part, I set out with the use of Davis’
forceps, influenced no doubt by the eminent professor whose
lectures I had attended, and whose dexterity would have
enabled him to succeed with almost any instrument. After a
few years practice, however, I abandoned Davis’ forceps, and
substituted that of Dr. Hodge, which I still consider a much
superior instrument, and so far as I am able to judge, the best
in use among us. I prefer Dr. Hodge's to Davis', because the
former is long, while the latter is short, and not so well
adapted to cases where the head has to be taken at a consider-
able height. The blades of Davis’ forceps are wide and diffi-
OBSTETRIC OPERATIONS. 251
cult of introduction, especially in primiparae, or when there is
rigidity of the parts; whereas the blades of Hodge's, which
are perhaps as narrow as is consistent with their purpose, admit
of easy introduction and of being readily moved when within,
so as to bring them into the desired position. Davis’ forceps
is furnished with the British lock, which although possessing
the advantages of some yielding mobility, is not perhaps en-
tirely secure, while Hodge's instrument is fastened with the
German lock, which can be so adjusted as to admit of all neces-
Sary motion, while at the same time there is no danger of the
branches becoming unlocked in the course of an operation.
Whatever instrument we adopt, it is probably better to ad-
here to its use alone, at least in all ordinary cases. It may be
well enough to have another in reserve for very special occa-
sions. But by restricting ourselves to the use of a single in-
strument, we develope more fully its powers, become more
familiar with all its applications, and probably, on the whole,
obtain better results than we should do by having several in
use at the same time.
The occasions or emergencies requiring the employment of
the forceps are elsewhere treated of in this work. It will be
our business in this chapter, therefore, simply to point out the
mode of using this invaluable instrument, and designate the
proper moment for its employment, when this is deemed neces-
Sary.
When we have decided upon the expediency of an operation,
we should inform the patient and her friends of our decision,
explain to her our reasons, especially if she be intelligent, and
Quiet her apprehensions by assuring her that she does not incur
any serious risk by submitting to our wishes. If she be already
under the influence of chloroform, this procedure would of
course be unnecessary. But many women while in possession
of consciousness, have an insurmountable horror of the “use of
instruments.” When we consider how frequent is their abuse,
this is not at all wonderful.
The acquiescence of the patient being secured, the next thing
to be attended to, is her position preparatory to the opera-
tion. An important question is, what should this be? British
252 PRACTICAL MIDWIFERY.
obstetricians prefer what is called the usual obstetric posi-
tion —that is, to lie as in ordinary labor, upon the left side,
the knees drawn up, and the legs flexed at something like a
right angle upon the thighs. They claim for this position
that it disturbs the patient less, as she requires no removal
or additional adjustment, and is therefore less excited or
alarmed, than if more formal preparations were made. This
may be true in whole or in part, but it is more than doubtful
whether these supposed advantages are not much more than
counterbalanced. In this position she must necessarily have
her hips drawn very near the edge of the bed, so as to lie, one
would think, in a very constrained and uncomfortable posture.
The operator, too, must labor under disadvantage, for want of
ready access to his patient. Of course habit would, in some
measure, remedy this; but I cannot refrain from the belief that
the selection of this position is not so much from any real ad-
vantages it possesses, as from hereditary or national predilection.
The forceps may be applied by an expert operator in almost any
posture of the patient, but when there is no urgent contra-indi-
cation, we may as well as not avail ourselves of the advantages
of position, as it may thus be much more agreeable to ourselves
and much less dangerous to the patient. For my own part, I
greatly prefer to have the patient placed across the bed, and
upon her back, her hips drawn quite near the edge, for this
will cause her no discomfort, as she will have the whole width
of the bed to support her. Two chairs are placed beside the
bed, front to front, but sufficiently far apart to allow the ope-
rator to stand between them. The limbs of the patient, pro-
jecting beyond the bed, are flexed at the knee, and a foot placed
upon each chair. Some light covering is thrown over each
limb for protection, and a sheet or quilt from the bed should be
drawn over her person, to prevent exposure. An assistant on
each side takes charge of the limbs, by firmly taking hold of
the knee with one hand, and of the foot or ankle with the
other. The body of the patient should be slightly elevated by
bolsters, etc., placed underneath, and steadied, if possible, by a
strong and reliable assistant—the nurse, if present, will often
do very well. The blades of the forceps should now be warmed
OBSTETRIC OPERATIONS. 253
by immersing them in tepid water, hastily wiped dry, and
anointed externally with olive oil or a little fresh lard.
If there be no contra-indications to the use of chloroform, or
no serious objections on the part of the patient or her friends,
I would advise that she be rendered insensible before the intro-
duction of the blades of the forceps. She will thereby gene-
rally retain her position more steadily, and of course avoid the
danger of injury from the instrument through violent move-
ments. She will also escape suffering both from the introduc-
tion of the blades and from extraction, a matter of no small
importance, at least to herself, and what is perhaps no less to
be desired, will retain no horror of instrumental delivery, to
harass her with the dread of a like catastrophe in future labors.
Another advantage of chloroform is, that it suspends to a con-
siderable extent reflex action, and by thus partially holding in
check the action of the womb, so far as dependent upon that
cause, often greatly facilitates the introduction of the blades.
Formerly it was my practice to introduce and lock the
blades before I administered chloroform, and pressing upon the
handles, to ascertain by questioning the patient whether I had
included any of her structures in the grasp of the instrument.
But for some years past I have abandoned that precaution as
unnecessary, and thus far have had no reason to repent of this
course. I have, however, been the more careful to avoid such
accident when the patient was not in condition to apprise me
of its occurrence.
While I am myself most thoroughly convinced of the great
utility of chloroform in forceps operations, I am aware of the
many objections brought against it, even by respectable mem-
bers of the profession, and especially by those who have never
tried it. I will not here stop to answer any of these ; it is
enough for me if I can annul, or even diminish the sufferings
of my patients without doing any present or prospective injury.
I envy no man his feelings, who can coolly witness the agony
of an instrumental labor, such as it at least sometimes is, when
by dismissing his prejudices or his fears, he could save this
fearful penalty of maternity. At the same time I would say
to the young practitioner, be cautious.
254 PRACTIC AI, MIDWIFERY.
The next step is the introduction of the blades. How is this
to be done? According to authors and teachers generally, the
answer to this question is long, complicated, and often not very
intelligible. The truth is, the same unvarying rules have not
been universally accepted and taught. With most, however,
the object has been to apply the blades to the sides of the head
of the child whatever might be its position, and however high
or low it might be in the pelvis, even (if we understand them
rightly), above the superior strait. That very eminent Ameri-
can obstetrician, Dr. Hugh L. Hodge, admits of no exception
to this rule, but when the head is locked at the lower strait by
the bi-parietal diameter. In this case, he will allow the blades
to rest respectively upon the occiput and forehead; and we may
add, it is very difficult to conceive how in that circumstance
they could be applied in any other way.
To attain the object above stated, namely, to apply the
blades to the sides of the head, whatever its position or
wherever its place in the pelvis, would manifestly be often
difficult, and sometimes practically impossible. Hence the
rules laid down to accomplish this object are numerous, some-
times obscure, or even unintelligible, and not unfrequently as
given by different authors, contradictory. We have reason too
to believe that young and inexpert practitioners in their en-
deavor to recall and follow these rules at the bedside, frequently
do serious injury to mother or child, or both.
We will endeavor here to indicate a simpler and, as we
humbly believe, a better method; a method which may be
said to reduce the numerous rules for the application of the
forceps to a single one, or rather to substitute a single one in the
place of all others.
We should first, as usually enjoined, ascertain as nearly as
possible the position of the head. I say head, for if any other
part present, the forceps has nothing to do with it. This can-
not always be certainly determined, but generally it may be.
If we can reach the occiput in nearly all cases, it differs suffi-
ciently from the forehead to distinguish it from that part, and
of course to enable us to determine to which side it is turned.
The direction of the sagittal suture and the position of the
OBSTETRIC OPERATIONS. 255
fontanelles are generally relied upon as guides in enabling UlS
to decide this point. A little reflection will lead the student
to see how he may avail himself of these to ascertain the
position of the head. If, however, we cannot determine the
exact position, an approximation to it is all that is absolutely
necessary.
We will suppose all things ready, as we have before indi-
cated, that the woman is arranged in the posture for which
we have expressed our preference, which we need not again
describe, and that it is Dr. Hodge's long forceps that we are
about to use. We first oil the index and middle fingers of the
right hand, carefully insinuate them into the genital fissure,
carry them up in contact with that region of the foetal head,
which is turned to the left side of the mother. If the head
have not entirely escaped” from the womb, we must carefully
lift, as it were, the still encircling lip from the child’s head, so
as to leave room for the blade to pass between them. We
must continue to support the attenuated section of the OS uteri
upon the dorsal side of the fingers until the instrument is in-
troduced within. We then with the left hand take hold of
the blade, which, from its shape, we readily determine should
occupy the left side of the pelvis. In Hodge's forceps, this is
the one that carries the thumb-screw. It is held very much in
the manner we usually hold a pen. The handle is held slant-
ing and nearly over and parallel with the right groin of the
woman ; while the point of the blade is inserted along the
palmar surface of the insinuated fingers, and in close contact with
the foetal head. The object now is to carry up the instrument
so that the point follows the convexity of the cranium, until it
has reached the situation where it is to be left. While this
movement is being executed, the handle, at first nearly par-
allel with the right groin of the patient, is carried over to-
wards her left thigh and depressed so as to rest considerably
below it, and if not held in the hand of an assistant, is sup-
ported by the posterior commissure. It is better to leave it
* Unless the os uteri be well relaxed and very dilatable, we should not
attempt to pass the forceps within it. It will be better to wait under ordi-
nary circumstances till the head has fully passed from the womb.
256 PRACTIC AI, MIDWIFERY.
thus than to commit it to the care of an inexpert agitated
nurse, or like person, who may be present.
When the left blade is carried up to its place, the right is
introduced above it in a similar manner, the hands changing
office, and the operation being reversed. It must be remem-
bered that no force whatever is to be used in this stage of
the operation. The blades should be held so lightly that force
is impossible without taking a firmer grasp. If the point be
arrested in its progress, we may be sure it is going wrong, and
instead of compelling it to advance, the blade should be par-
tially or wholly withdrawn, and a second attempt made. We
should be careful to make the point of the instrument closely
hug the head; it cannot go wrong while following the sphe-
ricity of the foetal cranium. We should always desist from
our attempts at introduction during a pain. The blades thus
introduced along the sides of the pelvis, no matter where the head
may be, whether at the superior strait, in the cavity, or at the
lower strait, will lie the one upon the one extremity of it, and
the other upon the opposite. If at the superior strait, the one
will rest upon the occiput and the other upon the os frontis,
or frontal bone, or nearly so. If it have descended into the
cavity, it is likely to be grasped more obliquely; and again, if
the head have already reached the lower strait and completed
its rotation movement, the blades of the instrument will lie
upon its sides.
When we have succeeded in introducing the blades of the
forceps, the next step in the operation is to procure an easy
lock; that is to bring the handles into such proximity and
correspondence that the thumb-screw on the one can be intro-
duced into the mortise or notch in the other. Here, again, no
violence must be used to effect this object. If we do not at
first succeed, we must with all gentleness so alter the position
of the blades by partial withdrawal of them, or such other
movements as common sense suggests as likely to effect the
object. No specific rules can be given that will apply to all
cases, and if the operator have not sufficient ingenuity to see
what manipulation is likely to assist him to the attainment of
his purpose, he had better abstain from the operation alto-
OBSTETRIC OPERATIONS. 257
gether. If, however, the blades be well carried up, and the
handles well pushed back toward the posterior commissure, an
easy lock will very generally be readily procured. The observ-
ance of this latter expedient is very essential to success. When
the mortise fairly embraces the stem of the screw, a few turns
are given to the latter, just sufficient to prevent the blades
from separating, without making the lock too tight or unyield-
ing. The next step in the operation is extraction. To effect
this, we grasp the handle of the forceps with the right hand,
in order to apply the requisite force, while a couple of the
fingers of the left may be applied to the top of the child’s
head. Here, again, we must carefully abstain from all unne-
cessary violence. In grasping the handles of the long forceps,
we must remember they have great leverage power. When
merely extraction is the object, without compression, it will
be sufficient to seize the instrument near the lock, so that very
little compressive force will be exerted. We need not violently
squeeze the head to keep the instrument from losing its hold
or slipping. If the blades be well carried up, in ordinary cases,
they will not slip; the maternal parts will retain them in
place. Perhaps they are more likely to slip when violently
compressed than when gently held. We must remember, too,
that we are supposed, generally at least, to have in our grasp
the head of a living child, the continuance of whose life de-
pends upon our skill and care.
If the head be taken at the superior strait, the extracting
force should at first be applied, as nearly as we can, in the di-
rection of the axis of that strait, and varied as the head ap.
proaches the outlet. A good rule will be to apply the force in
the direction which the handle of the forceps, left free to
move, may point. This will be determined by the head mov-
ing in the direction of least resistance. The instrument should
be so held and traction so applied that the handle may rise,
and the whole instrument rotate in our hand, if the advancing
head dispose it so to do. What we have to do, is to apply the
vis a fronte, and leave the head to select its course according
to the law laid down in the chapter upon the mechanism of
labor.
17
258 PRACTICAL MIDWIFERY.
Some advise a simple extracting force, contending that the
forceps is or should be regarded as a simple tractor. Others,
and I think with better reason, maintain that the instrument
is not only a tractor but a lever, and that its leverage power
should also be subsidized in delivery. While authors generally
admit that the forceps is competent to act as a lever, the exact
nature of its leverage power seems not to be so clearly under-
stood. It has been represented as a double lever, the lock or
thumb-screw being the fulcrum upon which each blade or sep-
arate lever turns. This view is correct, if we regard only its
compressive power. When used simply as a compressor, each
blade acts as an independent lever, and the force of each is in
a direction exactly opposite to that of the other. These forces,
however, do not directly tend to effect delivery, but only indi-
rectly, if at all, by shortening one diameter of the foetal head.
It is only when the oscillatory movement is given to the
handle, that the leverage power of the instrument is called
into play so as directly to contribute to the delivery of the head.
Here each blade becomes alternately a lever and a tractor, and
each of the sides of the pelvis of the mother alternately the
fulcrum. When the handle of the instrument is made to sweep
round toward the right thigh of the woman, the blade upon
that side acts for the moment as a lever carrying the head
somewhat forward, and the internal surface of that side of the
pelvis is the fulcrum ; while the blade on the opposite side
performs the function of a tractor, tending thereby also to ad-
vance the head. When the movement is reversed, precisely
the opposite action ensues. Any one may demonstrate to him-
self the alternate traction power of the blades by grasping his
hand in the forceps, and then executing the oscillatory move-
ment of the handle.
When the head is small and has been arrested only through
want of uterine power, direct traction alone may be sufficient.
But when any considerable resistance is to be overcome, we
should unite a gentle oscillating movement of the handle from
thigh to thigh, and thus combine the leverage power of the
instrument with its traction force. This movement serves, as
it were, to tide the head over any obstruction created by the
OBSTETRIC OPERATIONS. 259
dragging down before it of the soft structures lining the par-
turient canal of the mother. When the head fits tightly,
these structures are liable to be torn or otherwise injured by a
simple, straightforward extracting force; whereas, by an os-
cillating or pendulum movement, when the head is thrown,
say to the right side, the corrugated tissues on the left are per-
mitted by their resiliency to fall back. Again, when the head
is thrown to the left side, it as it were oversteps the tissues
which had just partially receded upon that side, and allows
those upon the other to fall back in like manner, and so on
alternately, till the head has passed. Practically, all experi-
enced operators know how much, in difficult cases, gentle and
skillful oscillation contributes to the ease of delivery.
There should be no haste, at least in ordinary cases. “Time
enough if safe enough,” should be our motto. Sometimes, when
only gentle aid is required, in addition to the natural powers,
we may act very deliberately, relaxing our hold in the inter-
vals of the pains, and adding our assistance only as they recur.
But often a more speedy delivery will be proper, always, how-
ever, occasionally intermitting our efforts, in imitation of the na-
tural process of labor. No general rule applicable to all cases
can be laid down. When the resistance to be overcome is
great, we should act deliberately, giving time for the moulding
of the head, and the dilatation of the soft structures, through
which it must pass. The compressing power of the pelvis of
the mother, acting through the vis a tergo of the uterine force,
or the vis a fronte furnished by the forceps, is much better
than any compression by the violent grasp of the handle of the
instrument, which, while it shortens one diameter of the head,
lengthens another, and that the very one we desire to shorten.”
On the contrary the compressing, moulding force of the pelvis,
diminishes those diameters which encounter resistance, and
lengthens only that which meets with little or none, namely,
that corresponding with the axis of the parturient canal.
* It must be remembered that the contents of the cranium completely
fill its cavity, and therefore when they are forced by compression from one
diameter, they must distend the head in the direction of the diameter, at
right angles to it. This may be illustrated by compressing a bladder filled
with water.
260 PRACTICAL MIDWIFERY.
As the extracting force is continued, provided the head ad-
vance, the handle gradually rises, as the presenting part sweeps
over the curve of Carus, until it becomes, in some instances,
nearly parallel with the abdomen of the mother. This move-
ment should not be resisted, but rather encouraged.
When the top of the head reaches the perineum, and that or-
gan begins to be put upon the stretch, great care is to be taken
to prevent its laceration. This is avoided, not so much by fur-
nishing any imaginary support, as by operating slowly and cau-
tiously, so as to give it sufficient time to distend. Some advise
the disengaging of the forceps, when the head rests upon the
perineum, and the leaving of the delivery thenceforward to the
natural powers. But it is to be remembered that in many cases
requiring the forceps, the natural powers are for the time in
abeyance, and if the head be abandoned there, it will remain
there indefinitely. We much prefer completing the work we
have begun, and not removing the instrument until we have
fully delivered the head. As soon as the head is born, the in-
strument should of course be disengaged; and any further
assistance that may be necessary should be furnished by the
hands alone. A finger hooked in the axilla of the arm turned
toward the sacrum, will give the requisite aid for the delivery
of the shoulders.
We have thus far spoken of the introduction of the blades of
the forceps along the sides of the pelvis, without any special re-
gard to the situation or position of the head.
When the head is yet above the superior strait, or just enter-
ing the brim, its occipito-frontal diameter more or less nearly
corresponds with the transverse diameter of the pelvis. Conse-
quently if seized with the forceps introduced along the sides of
the pelvis, in this situation, one blade will rest upon the back
part and one in front. Fears, therefore, may be entertained
lest the instrument should bruise and disfigure the features of
the face. Practically, however, with care there is little danger
of this. It will be remembered that as the head presents at the
superior strait, it is strongly flexed upon the thorax, and be-
comes still more so as it dips into the brim. This flexion too,
is no doubt still further increased by the compressing force of
OBSTETRIC OPERATIONS. 261
the forceps. While one blade, therefore, rests upon the occi-
put, the other expends its force upon the os frontis, or frontal
bone of the cranium, and not upon the face. We have noticed
but one exception to this, of which we have elsewhere spoken
at some length. In this case there was a fluctuating tumor im-
mediately beneath the chin of the child, entirely filling the
space between the chin and thorax, and completely preventing
permanent flexion. The head failed to descend, or even fairly
to enter the superior strait. The forceps was applied before
rotation, if possible at all, could have taken place, and delivery
was effected without any unusual difficulty. A slight inden-
tation, which passed away in a very few days, was found close
to the root of the nose ; the skin was neither cut nor abraded.
But if even under the like unfavorable circumstances, the blade
situated in front of the head should rest upon the face, so little
compressive force is usually needed, that we may avoid doing
any serious, permanent injury.
Again, it may perhaps be doubted whether the head brought
down in this manner, can pass the inferior strait without effect-
ing the movement of rotation. That it can, has been again
and again practically demonstrated. Prof. Tarnier, the anno-
tator of Cazeaux’ Midwifery, admits that it may be sometimes
so delivered ; we believe from practical experience and obser-
vation that it may be generally so, and that without serious in-
jury to either mother or child, unless the latter be unusually
large, or the pelvis of the former abnormally small. Some as-
sert that the head not unfrequently rotates with the forceps —
some that it occasionally rotates within the forceps. We have
certainly experienced the former, and think we have met with
at least one case of the latter. It is moreover probable that
when the instrument is held with sufficient delicacy, the former
movement will usually take place when the occipito-frontal
diameter of the head is too long to pass the transverse diame-
ter of the lower strait. When the head rotates with the for-
ceps, known by the twisting of the handle in the hand of the
operator, it is better to disengage and re-apply the instrument.
We will probably then be able to apply the blades to the sides
of the child’s head ; or if the latter be not sufficiently rotated
262 PRACTICAL MIDWIFERY.
for this, we may attempt to complete the rotation with a
blade of the forceps, at least so far as to accomplish this object.
Again, when there is reason to suspect that the head when
seized by its long diameter at the brim, cannot pass the lower
strait without rotation, it will be best, when we have brought
it down within the cavity of the pelvis, to detach the forceps,
rotate the head with a blade of the instrument, the fingers or
the lever, and then reapply. This manoeuvre may not always
be practicable, but generally is. We can then deliver, having
the long diameter of the head to correspond with the long di-
ameter of the inferior strait.
When the head has already descended considerably into the
cavity, and rotation has partially taken place before we apply
the forceps, the obliquity may be such, that introducing the
blades along the sides of the pelvis, as we have above indi-
cated, they do not settle in sufficiently exact opposition to, or in
parallelism with each other, to rest steadily upon the cranium,
or to admit of an easy lock. When this is the case, they had
better both be withdrawn, and complete rotation effected as
above directed. This done, their reapplication will be easy
and satisfactory.
If the head have already reached the inferior strait, or be
resting upon the floor of the pelvis when we are required to
operate, the introduction is easy, inasmuch as to carry the
blades up the sides of the pelvis, is to place them upon the
sides of the foetal head. This of course assumes that rotation
is completed, and the occiput or forehead turned under the
arch of the pubis. But very slight extracting force is here ne-
cessary, the wedge and leverage power of the instrument being
often sufficient to effect delivery.
As soon as the operation is completed, the patient, unless in
a state of extreme exhaustion, should be replaced comfortably
in bed, and special care taken to remove all wet clothing from
contact with her person. This should be done not by at once
stripping off her clothes, but by withdrawing wet and soiled
garments, and interposing between them and her skin dry and
warm skirts. She should be strictly enjoined to avoid all con-
versation, excitement and exertion of every kind. As has been
OBSTETRIC OPERATIONS. 263
advised at the close of normal labor, a few drops of the tincture
of armica should be diffused in half a tumbler of water, of
which a teaspoonful may be given every two hours.
It is not uncommon, after instrumental delivery, for the
patient to be unable to pass her water. This should be par-
ticularly attended to. If she have been much exhausted, it
would be well to introduce the catheter and evacuate the urine,
without requiring her to make the effort to pass it herself.
Most women, at least shortly after delivery, are unable to pass
their water without assuming a more or less erect position.
This should be avoided if possible, immediately after all severe
labors as flooding or syncope or both may be the result.
Before closing this chapter, it may be well, although we
have repeatedly, in the course of this work, adverted to this
subject, to speak somewhat more fully and connectedly of the
precise moment when this operation, when deemed proper or
imperative, should be undertaken.
British practitioners formerly advised us not to apply the
forceps until an ear could be felt—that is, till the head was low
in the pelvis. This precept seemed to be given irrespective of
the suffering or exhaustion of the patient. Its strict observ-
ance necessarily led to a frequent resort to craniotomy. Again,
it was thought by some that the head must in all cases have
passed entirely out of the mouth of the womb before we should
interfere. Some again fixed the time for resort to the forceps
by the number of hours the head had been stationary in the
pelvis, or resting upon the perineum. They attempted to de-
monstrate the evils resulting from a too early use of the instru-
ment, by pointing to cases of contusion, inflammation and
sloughing of the vagina and neighboring structures. We now,
however, believe that these distressing accidents more fre-
quently arise from too long delay, than from precipitancy.
When the head is strongly driven against these tender parts
by a womb vigorously endeavoring to overcome resistance, or
when they are pressed by the cranium which has become
wedged within them, although the uterine powers may have
failed and ceased to act, the circulation is arrested, and this,
aided by the prostrated vitality of the patient, leads to a low
264 PRACTICAL MIDWIFERY.
grade of inflammation—call it what you please—and perhaps
subsequent sloughing.
To determine the exact time when interference is proper, we
should be guided by the condition and necessities of the patient.
It matters not whether according to the old classification the
labor be natural or preternatural, if we find the powers failing
or unequal to the task, and the case be one admitting the appli-
cation of the forceps, it is our solemn duty to render assistance
through its aid. We must not stand as idle spectators of the
struggle, nor content ourselves with the hope so, that the
powers of nature will ultimately prevail; we must become forth-
with parties in the contest, and ensure their safe and speedy
triumph.
We will derive aid in arriving at a correct conclusion, by a
just appreciation of the health, strength and powers of endur-
ance of our patient. In the case of constitutionally feeble
women, or those who have been debilitated by pre-existing dis-
ease, and whose natural resources there is reason to fear will
be inadequate to the task, at least without leading to extreme
and dangerous exhaustion, it will be well to apply the forceps
at a comparatively early period of the labor. In such patients,
it is of the utmost importance to husband their resources. When
intensely prostrated, they often become the prey of some fatal
accident or puerperal disease ; or if they recover, it is through
a tedious convalescence, and perhaps regain at best but imper-
fect health. In such cases the forceps may be introduced, not
with a view to immediate extraction, but to aid the patient at
the recurrence of each successive pain.
Bxtracting force may be applied at the commencement of a
uterine contraction, and the grasp relaxed when the pain passes
off. The womb is thus relieved of much of its task, and, as it
were, encouraged to increased effort.
In a word, we should carefully watch the condition of the
patient as labor progresses, and hold ourselves ready to dis-
charge our duty whenever her failing powers hang out the sig-
nal of distress. “The forceps,” said the late Dr. C. D. Meigs,
“is the child’s instrument,” but it should also be remembered
it is the mother's, too.
OBSTETRIC OPERATIONS. 265
Thus much in relation to the safety of the mother, but that
of the child no less, demands our attention. Unreasonable de-
lay may also jeopardize the life of the latter, at least under cer-
tain circumstances. It is well, therefore, to know what these
circumstances are, and when a regard for the safety of the child
should enter into our calculation in determining the proper
moment for resorting to the forceps.
It is surprising how often the child, after long delay, and
even when subjected to the powerful action of the womb, will
cry vigorously as soon as it is born. It would seem, therefore,
that delay alone is not necessarily fatal to its life.
So long as the action of the womb is intermitting—a quies-
cence of considerable length occurring between the pains, the
foetus will bear a great, amount of pressure without fatal in-
jury. But when the pains are not only violent but continuous,
as if provoked by Ergot, there is great danger to the child
from their direct effect upon the brain, as well as from com-
pression of the cord and premature detachment of the placenta,
accidents which under these circumstances are liable to occur.
When such is the case a resort to the forceps, where there is no
imperative contra-indication, should be seriously thought of.
When at any point in its descent the head ceases to advance,
but recedes somewhat in the interval of the pains, there is no
special reason for apprehension, even though the womb be act-
ing with great vigor. On the contrary, if the head remain sta-
tionary, do not in any degree fall back when the pain subsides;
delay is then dangerous, and may be fatal to the life of the
child.
When, in connection with any of the foregoing circum-
stances (or, indeed, independent of them), the foetal heart-beats
are manifestly growing feebler, and the accustomed foetal move-
ments less distinctly felt by the mother, danger is to be appre-
hended, and it becomes our duty to act accordingly.
Within the last few years a resort to the forceps has become
much more common than formerly. This has arisen in part
from the happier results obtained in the application of the in-
strument, owing to its greater perfection, and greater skill and
simplicity in its application. The fact, too, that many of the
© sº ". .
e e T o º º
266 PRACTICAL MIDWIFERY.
disasters once charged to the premature use of the forceps, are
now shown to have been due to culpable delay, has done much
to remove the unreasonable prejudice that long existed against
an operation so conservative of maternal and infantile life. It
may be, however, we are at this moment in danger of drifting
upon the opposite extreme. While, therefore, we advocate the
free and intelligent use of this noble instrument, we would so-
lemnly warn, especially young practitioners, to guard against
its too frequent and unnecessary employment in obedience to
a mere whim of fashion.
WERSION.
The term version, or turning, is applied to that operation by
which one part of the foetus is substituted for another, with a
view to greater advantage in delivery. There are two varieties
of this operation, respectively called cephalic version and po-
dalic version. The former supplants the existing presentation
by bringing the head to the entrance of the superior strait, the
latter the pelvic extremity of the child, that is, the breech, the
knees, or the feet.
When cephalic version is practicable and not contra-indi-
cated by co-existing circumstances, it is preferable to podalic,
inasmuch as delivery by the head is usually safer to both
mother and child than delivery by the feet.
And first, we will speak of cephalic version. This method
of turning has at different times in the history of midwifery
been proposed and advocated, but has again as often sunk into
neglect. Lately, however, since what is called the bi-manual
method of operating has been more distinctly described and
successfully practiced, it has once more come into favor, and
is more likely now to retain its reputation than heretofore.
Cephalic version is generally applicable to those cases where
the head, although not corresponding to the entrance into the
upper strait, is nearer to it than is the pelvic extremity of the
child, where the waters either have not been evacuated at all,
or have been but partially drained off, and where the present-
ing part is still movable. Before proceeding to operate, it will
OBSTETRIC OPERATIONS. 267
of course be necessary to ascertain the presentation of the
foetus, that is what part is nearest the entrance of the superior
strait, and, as it were, waiting to engage in it, and against
which the finger first impinges, when it is within reach, in
making the examination. We should, moreover, if possible,
satisfy ourselves of the position of the presenting part, or its
relation to the pelvis of the mother. Having ascertained these
particulars, the next thing to consider is the proper position of
the patient, in order to facilitate the operation. She may con-
tinue to lie upon the left side as usual, her hips being placed
as near as possible to the edge of the bed, her right leg being
elevated and supported by an assistant, with one hand placed
under the knee and the other grasping the ankle. This will re-
move obstruction out of the way of the right hand of the accouch-
eur as he employs it in external manipulations. The head of
the patient had better be directed toward the middle of the
bed, so that the operating arm be not unnecessarily bent or
twisted, and all pillows and supports removed, so that the
pelvis, shoulders and head be as nearly as possible upon the
same level. If, however, the case is likely to prove difficult,
the position upon the back, similar to that we have advised for
the forceps operation, is to be preferred. The objection that it
gives additional trouble and disconcerts the patient, is not a
very valid one, when weighed against real advantages. When
the woman is very weak, however, or very nervous and apt to
be alarmed by what might seem to her more formidable prepa-
tions, this arrangement, unless considered very important, had
better be dispensed with. Before proceeding to turn by this or
any method, the os uteri should be so far dilated as to admit
the introduction of two or three fingers and dilatable—that is,
soft to the touch, so as to afford assurance that it will readily
yield to distending force. We will suppose the case to be a
presentation of the shoulder, the membranes are either intact
or have been lately ruptured, and the presenting part is not
deeply forced down into the pelvis, but still movable at the
brim. The patient may or may not be under the influence of
chloroform, although this agent is a most important adjuvant
in both varieties of version, as it generally secures steadiness
268 PRACTICAL MIDWIFERY.
on the part of the patient, a very great advantage. The ac-
coucheur should strip off his coat, roll his sleeves above the
elbows, anoint thoroughly the dorsal surface of the fingers and
hand, and it may be well to introduce a piece of lard between
the labia. Two or three fingers of the left hand are then gently
insinuated into the vagina and carried up to the presenting
part. Some difficulty may be experienced in the introduction
from the labia being as it were inverted and pushed up by the
fingers. This may be corrected with the fingers of the right
hand parting the labia by a movement such as we use in sepa-
rating the eyelids. In order to have the entire command of
the presenting part, it will probably be necessary to carry the
entire hand into the vagina, and this should be accomplished
in the most gentle manner. We may succeed better by taking
advantage of the presence of a pain if the patient be not
anaesthetized, as her natural suffering will divert her attention
from that caused by the introduction of the hand. When the
presenting part is reached and well under the control of the
fingers, it should be gradually pushed up, in the absence of
pain, the head reached, and by a coaxing motion of the fingers
drawn toward the entrance of the pelvis, while the right hand
applied externally, operates upon the opposite pole of the
foetus, and in an opposite direction, that is, toward the fundus
of the womb. This method is called bi-manual, because both
hands are employed working to each other's aid, the one inter-
nally and the other externally; bi-polar, because both poles or
ends of the foetus are simultaneously acted upon.
When the head is brought fairly over the entrance into the
pelvis, it should be retained there, if there be no reason to
hasten delivery, until through the force of the womb it begins
to engage in the upper strait, when the labor may be aban-
doned to the natural powers. But if for any sufficient reason
it be deemed necessary to expedite delivery, the forceps must
be applied, subject to the same rules governing their applica-
tion, in a spontaneous or natural vertex presentation.
Cephalic version may also occasionally be effected, when the
foetus lies somewhat transversely and the head is too high to
be felt by the ordinary examination per vaginam. In the first
OBSTETRIC OPERATIONS. & 269
place, the patient, laid upon her back, should be fully anaesthe-
tized with chloroform, and the position of the head ascertained
by palpation. One hand then is externally applied above the
head, and by a sliding movement, gently presses it down toward
the entrance of the superior strait, while the other hand acts in
a similar manner upon the other end or pole of the foetus, and
in the opposite direction. When the head is brought suffi-
ciently low to be within reach, the fingers of the left or right
hand, as best suited, may be introduced into the vagina, carried
up and made to play upon the cranium, so as, with the aid of
the external hand still operating, to bring it over the entrance
into the pelvis. When this is effected, the head should be re-
tained in this position and the membranes ruptured, when, as
the waters flow off, it will engage in the upper strait, and the
labor, if there be no indication requiring prompt delivery, may
be left thenceforward to the powers of nature.
Cephalic version, however, although greatly facilitated and
extended by the introduction of the bi-polar method, accredited
to Dr. Braxton Hicks, but probably practiced long before there
was any written account of it, must always be limited in its
application, and in very many cases requiring version, alto-
gether impracticable. Where this fails, podalic version must
be our resort.
As we have in the course of this work generally pointed out
the indications requiring turning, it will be sufficient here to
state that this latter variety of the operation should be had re-
course to only when the former is deemed inapplicable, or upon
trial has failed. Podalic version is justly regarded as a serious
operation, both as regards the mother and the child, and should
not therefore be adopted, unless the circumstances imperatively
require it.
When we have decided that a case demands podalic version,
the next point upon which we wish to satisfy ourselves is how
shall we perform it 2
In giving this information to the student we will first speak
of the preliminary measures to be adopted, in order to ensure
convenience in operating, safety and success.
It is generally advised, first to empty the bladder by means
270 PRACTICAL MIDWIFERY.
of the catheter, and the rectum by administering an enema.
If, however, we have required the patient, as we should do, fre-
quently to pass her water during the progress of labor, the cath-
eter may be dispensed with. In like manner, if the bowels
have been freely evacuated shortly before labor set in, it is not
likely that any accumulation has taken place demanding our
interference. Under the opposite circumstances, the above pre-
cautions had better be regarded.
The position of the patient preparatory to the operation is
another matter of importance. I have generally permitted her
to retain that ordinarily recommended for natural labor,
namely, upon the left side. It has the advantage, whatever
that may be, of requiring but little change in the surroundings
of the patient, and therefore avoids excitement or alarm. In
difficult cases, however, I prefer the dorsal position, with the
hips drawn near the edge of the bed, as advised for the applica-
tion of the forceps. It is necessary when the patient lies upon
the left side, that the right leg should be elevated, and so held
by the hands of an assistant.
The bi-polar method is sometimes applicable also to podalic
version. When this can be successfully employed, it much di-
minishes the risks to the mother, inasmuch as it is not neces-
sary, in order to execute it, to carry the hand into the womb.
It may, moreover, be commenced while there is yet less dilata-
tion of the os uteri than would be necessary were we obliged at
once to insinuate the whole hand through that aperture. The
bi-polar method, where it is not manifestly impracticable,
should always first be tried.
The left hand should be well oiled upon its dorsal surface
and a lump of lard introduced between the vulvae. It is bet-
ter, as a general rule, to divest ourselves of the coat, and turn
up the shirt sleeves above the elbows, although this precaution
may not always be necessary.
If there be present no circumstance requiring speedy de-
livery, we may wait till the mouth of the womb is pretty fully
dilated. If otherwise, if it be sufficiently so to admit one fin-
ger, we may commence the operation, by artificially promoting
dilatation, either with the fingers or by introducing Doctor
OBSTETRIC OPERATIONS. 271
Barnes' gum elastic dilators. When we can insinuate three
fingers, we may begin to turn.
The fingers of the hand to be introduced are collected in the
form of a cone, and tenderly carried up till, if necessary, the
whole hand is within the vagina. The direction in which the
occiput is turned must be well ascertained, and then by a dex-
terous, gentle motion of the fingers, the head is to be propelled
ăn that direction, while the right hand applied externally, upon
the opposite pole of the foetus, is made to operate in the oppo-
site direction. By this conjoined operation of the two hands,
the head is made to ascend upon the one side, while the breech
is caused to descend upon the other. The right hand, exter-
nally, is shortly applied to the ascending head of the child,
while the left hand internally comes in contact with the knees,
descending upon the side of the womb, opposite to that along
which the head has ascended.
If the foetus float in a large amount of amniotic fluid, it is
not likely to remain stationary in the position in which it has
been placed through the force exerted upon it by the hands of
the accoucheur. It is better, therefore, if the membranes have
not before been ruptured, when a knee comes within reach of
the fingers of the left hand, to make an opening, and permit
the waters, at least partially, to drain off. This will give
stability to the foetus, and probably enable the practitioner to
hook down a knee. Either knee may be taken. Dr. Barnes
prefers the more distant one, but if this be not easily caught,
he does not think it worth while to lose time in searching.
Traction upon the knee aided still by the co-operation of the
hand upon the outside, will complete version, and bring the
pelvic extremity of the child to occupy the lower portion of
the womb.
The next step in the operation of delivery by podalic ver-
sion or turning by the feet is extraction ; for be it remembered,
turning is one thing and extraction is another and a very differ-
ent thing. We may turn, and when this is executed leave
the future process to be completed by the natural powers, or
we may supersede them by art. Generally, however, the same
considerations that prompt us to turn, also demand delivery
with as little delay as possible.
272 PRACTIC AI, MIDWIFERY.
When, therefore, a knee is secured, we proceed to bring
down the limb and apply sufficient traction, slowly and care-
fully, to cause the body of the child to descend. In doing this
we must be careful simply to supply force, as far as possible in
the axis of the superior strait. We are not to think of turn-
ing the child one way or the other, according to our views of
the course it ought to take. We should hold the limb so loosely
in our hand that it may revolve if so disposed, or allow the
hand to be so passive, as to turn with the revolving limb. If
simple force be supplied, we may rest assured that the body
acted upon, if it move at all, will move in the direction of least
resistance; and that direction here is the proper one.
When the body of the child is born as far as, or a little past
the umbilicus, we must see to the cord—prevent it if possible
from being exposed to pressure. In order to effect this object,
we should draw down a considerable loop of it, and remove the
remainder so far as we can, to such situation as will give it
most room, or place two fingers thrown slightly apart, one on
each side of it, so as to form a channel between, in which the
cord may securely repose.
The next difficulty to be encountered is with the arms.
These members are usually inclined inwards and are folded in
front of the child. When traction is made upon the body,
they are liable to be displaced and carried upward through
friction upon the maternal parts. Hence they sometimes
oppose a very formidable resistance to the further progress of
delivery.
If the child be small however, or the maternal passage wide,
or both, these conditions coexist, even this accident may cause
no trouble and the child be wholly born without any difficulty.
If otherwise, however, it will be necessary to bring down the
arms by the side of the child. In order to do this successfully
and safely, it is necessary to bear in mind the construction of
the joints, in what way they naturally bend, and carefully
avoid forcing them to bend in an opposite direction. The
hand should be passed up over the shoulder of the child and
carried along the humerus until it reaches the elbow. The
arm is then tenderly straightened by drawing it over the face
OBSTETRIC OPERATIONS. 273
and breast and bringing it down by the side of the child. In
the choice of the arm first to be operated on, Dr. Barnes ad-
vises us to take the one we can move with the greatest ease,
for if this be brought down it leaves more space for the adjust
ment of the other.
After the arms are brought down the next difficulty to be
encountered, is the delivery of the head. In the chapter upon
breech presentations we have spoken so fully of the delivery
of the after-coming head, that it is unnecessary to repeat what
we have there said, or to add anything in this place.
Turning by the feet, while the membranes are still intact, or
even where the waters are but partially drawn off, usually pre-
sents no very great difficulty, even where the bi-polar method
fails and we are obliged to carry a hand up into the womb and
bring down a foot. To perform this the left hand and arm are
well anointed with lard, the former only on its dorsal aspect.
The fingers, gathered in the form of a cone, are very tenderly
insinuated into the os uteri, the membranes ruptured, if still
entire, and the whole hand carried up within the womb until
a foot is felt, and grasped. But it is not a matter of indiffer-
ence which foot we seize. If the arm be prolapsed, we may
know from examination whether it is the right or left. This
determined, we take the foot of the opposite side, for this,
when acted upon, will cause the most easy and natural rota-
tion of the body of the child and ascent of the prolapsed arm.
In general that foot should be taken which will rotate and
turn the child with least violence to the articulations, prevent
the unfolding of the limbs from their natural intra-uterine
position, and that will most tend to throw the forehead into
the hollow of the sacrum in the progress of delivery. In in-
troducing the hand, we should advance only in the absence of
pain, and if the uterine contractions be powerful, we should
flatten the hand upon the surface of the child, until the pain
subsides. When we have selected and seized the proper foot,
we commence traction, operating during the pains, and sus-
pending our efforts while they are absent. There should be
no hurry—no violence. The hand not employed in traction,
should be applied externally, to support the womb, and to as-
18
274 PRACTICAL MIDWIFERY.
sist in completing version, by pressing up the head. When
version is completed, it should aid the extracting force, by
downward pressure. It is surprising with what, facility turn-
ing is effected while the waters are retained, and if the mem-
branes are first ruptured when the hand is carried up to oper-
ate, so completely is the aperture plugged by the arm that
very little of the fluid escapes. The delivery of the child here
is of course the same as when a foot is brought down by the
bi-polar method.
But while the operation, as above described, is sufficiently
simple, we are often called upon to perform it under very differ-
ent circumstances. The patient may have been long in labor,
the amniotic fluid dribbling away for many hours, so that we
find the womb tightly embracing the child on all sides, indeed
insinuating itself into all the sinuosities of the foetus. Turn-
ing, when the waters are thus almost completely evacuated, is,
to use the language of the late Prof. C. D. Meigs, “a horrible
operation.”
We have said, in speaking of cephalic version, the patient
may be under the influence of an anaesthetic or not, as pre-
ferred by herself or deemed proper by her attendant. But in
the case here supposed, deep anaesthesia is of the utmost im-
portance. Indeed the success of the operation sometimes de-
pends wholly upon this resource. I have succeeded in cases
of this kind by the aid of chloroform, where, I believe, turn-
ing would have been impossible without it. But in order to
be certain of its salutary effects, we must continue the inhala-
tion until we secure complete insensibility to pain, which is
usually attended by complete relaxation.
We will sometimes find the presenting part, the shoulder
for instance, so completely forced down and blocking up the
passage that all attempts at introducing the hand are baffled.
But after deep anaesthesia is induced, we are surprised at the
ease with which we overcome what was before an insurmount-
able obstacle. It is in these cases of the utmost importance
that we use all gentleness and care in carrying up the hand, in
desisting from efforts during pain, especially if the pains be
violent, as they usually are, until the womb becomes quiescent
OBSTETRIC OPERATIONS. -- 275
through exhaustion. The turning of the child is now effected
with great difficulty, and it is, therefore, important we should
operate slowly, giving the tissues abundant time to yield.
Every step of the process should be taken with the utmost
care and precaution.
Where there is no necessity for an immediate operation, and
especially when we have no assistant present capable of ad-
ministering the chloroform, so as to steadily keep up its effects,
I would advise, as I have done when speaking of Deviated
Presentations of the Head, to give the patient one-fourth of a.
grain of morphia, and wait for its effects before commencing
the inhalation. If she be suffering very severe pain, the dose
may be repeated or a somewhat larger amount given at first.
When the patient is previously under the influence of mor-
phia, a smaller quantity of chloroform is required, and the
effect is much more profound and persistent. Indeed, through
the combined aid of these two agents, I have turned and de-
livered in the most difficult cases, while the patient did not
utter a moan nor move a limb throughout the whole operation.
If morphia be previously given, it is important that the de-
livery should be conducted slowly, to avoid shock, the dangers
of which, I think, are probably increased by the administra-
tion of that drug. Indeed, under circumstances wherein we
have reason to apprehend severe shock, morphia had probably
better be omitted. Hydrate of chloral, 15 grains, repeated at
intervals of twenty minutes, may, in that case, be preferably
used ; but I think morphia unsurpassed in its power to relax
spasm, and bring such cases completely under our control.
I know this practice will be strongly objected to by some as
unhomoeopathic. But I apprehend these cases lie outside the
homoeopathic law, and even that, nothing to its discredit. I
no less believe in the truth of the law of similars, because I
know it is not applicable to the setting of a broken limb, or
the reduction of a dislocated joint. Our aim is here to bring
the impossible within the limits of possibility, and to save our
patient from horrible suffering; and if we can devise any
means to accomplish these purposes without entailing upon
her lasting injury, it is our duty as men, and especially as
276 PRACTICAL MIDWIFERY.
physicians, to adopt such means, asking no questions and solic-
iting no man’s approbation.
CRANIOTOMY.
Under circumstances to which we have repeatedly alluded
in the course of this work, craniotomy, or the opening of the
head of the child, becomes an unavoidable necessity if we
would save the life of the mother. To decide when such ne-
cessity exists is always a painful and solemn duty, unless we
have sufficient reason to believe the child is no longer living,
when of course the safety of the parent is the only object of
concern. Otherwise, nothing but the saving of the life of the
mother can justify us in taking away that of the child.
The operation when fully performed, consists of two steps or
stages, namely, perforation and extraction.
The instruments employed for these purposes have been
various. For perforation, Smellie's scissors has perhaps been
most extensively used. It consists of two blades jointed to-
gether similarly to the blades of the instrument after which it
is named. These are made very strong, with cutting edges
upon the back, and when brought together form a sharp point
at the ends well adapted to perforate the skull. An instrument
invented by M. Blot is preferred by many to the foregoing, and
is perhaps likely to supersede it. It is constructed pretty much
upon the same principle as Smellie's scissors. Both these in-
struments may be found with the cutlers, where an accurate
idea of their form and peculiarities may be had.
When we have decided upon the necessity of this horrible
operation, the first thing to be done is to place the patient in
a convenient position, so as not only to render her as comfort-
able as possible, but so that we can have the most ready access
to her, and be the least hampered in the performance of our
duty. She may be placed either upon the left side or the back,
but generally, the latter is much the best. Her fears, if she
be conscious, should be as far as possible removed by assurances
that she incurs but little personal risk in submitting to the ope-
ration. If there be no cogent reason to the contrary, she had
OBSTETRIC OPERATIONS. 277
better be fully anaesthetized and well steadied by reliable as-
sistants. All things being properly adjusted, we proceed as
follows:
If we select for perforation the instrument of Smellie or
Blot, we take it in the right hand, while two fingers of the left
are passed up the vagina till they reach the head—we must be
sure that it is the head we feel. A spot should be selected
where the perforator may be placed most nearly at right angles
to the surface of the cranial bone, in order to diminish the
chance of slipping. The point of the instrument is then carried
up in contact with the inserted fingers and protected by them,
until it reaches the selected spot upon which it is firmly im-
planted, and then by a rotating movement it is forced through
the skull. The sensation imparted to the hand will inform us
of this event. The handles are then opened and the instru-
ment rotated so as to enlarge the opening sufficiently for the
contents of the cranium to be discharged. When this is done,
the head collapses and may usually be extracted by one of the
instruments in use for the purpose. That which has hitherto
been most commonly used is called the crotchet, a most dan-
gerous instrument. It is in the form of a hook, the point of
which is flattened, and the shaft terminated by a handle cross-
ing it at right angles like that of a tooth key. The hook is
fastened by its point upon the skull, either outside or within
the perforation, and in either case is liable to slip and do great
injury to the soft structures of the woman.
If this instrument be used at all, the point should be very
carefully guarded in the act of extraction by the fingers, which
are themselves very liable to be wounded. A still better ad-
vice is to discard the crotchet altogether.
The late Dr. C. D. Meigs of Philadelphia has proposed two
pairs of forceps, known as Meigs' Craniotomy Forceps, which
answer an excellent purpose. They resemble pincers with long
handles, the one bent in the mandibles, the other straight.
The latter, when the skull is quite soft, may be used to perfo-
rate, the former to extract.
I have performed the operation very satisfactorily as follows:
I select as a perforator an instrument resembling a chisel; this
278 PRACTICAL MIDWIFERY.
implement itself will answer the purpose very well, if a better
be not at hand. If used, the corners and edge should be some-
what blunted to avoid cutting the maternal parts. A better
instrument however may be imagined by supposing the chisel
terminated in a flat angular point, with edges sharp enough to
penetrate the cranium under moderate force, but not to cut the
soft structures of the mother, with which it may accidentally
come in contact. The instrument is forced through the skull
by a direct, not rotating movement, and thus makes in the
Scalp an incised, not lacerated wound. If the instrument do
not readily penetrate, a slight stroke or tap with a small ham-
mer upon the end of the handle, while the point is securely
held in place, will accomplish this object. The instrument is
then rotated, and will thus enlarge the opening in the skull to
more than the width of its blade, which may be half an inch
or more, while all the debris of bone will remain within the
Scalp, inasmuch as the wound in the latter is a simple gash,
the lips of which when parted, tend immediately to fall to-
gether and enclose the crushed bone underneath. We then
take Meigs' bent forceps and carefully guiding the upper man-
dible inside the cranium, and the lower between that bone and
the scalp, seizing a portion of the skull, we remove it, carefully
guarding it with the fingers as it is withdrawn, so as not to
wound the mother's tissues with its sharp edges. We should
be careful not to tear away the scalp in this operation, but
simply to remove the underlying bone. When we have suffi-
ciently enlarged the opening to give free exit to the brain,
which should be thoroughly broken up by the perforating in-
strument before it is withdrawn, we should then take a firm
hold upon the margin of the perforated bone, the mandibles
being adjusted as above directed, and carefully extract in the
axis of the parturient canal. While we make extraction, the
inserted fingers should be still kept near the point of the in-
strument, so that should the portion of bone fastened upon
break off, we may prevent it from wounding the passage. This
accident is not likely to happen, but had nevertheless better
be guarded against. When the scalp is thus left intact except
the mere incision at first made by the perforator, it is manifest
OBSTETRIC OPERATIONS. 279
its edges will overlap the edges of the cranial bone, and pre-
vent them, in extraction, from lacerating the maternal tissues.
The use of the speculum has been advised in the operation
of craniotomy, but it seems to me it would be very much in
the way, and after all contribute no important aid. Any one
who cannot trust his sense of touch, had better employ another
to operate for him.
The operation is most simple when the top of the head can
be selected for the opening, but this cannot always be done.
With proper care and dexterity other parts may be perforated
and the operation successfully performed.
CEPHALOTRIPSY.
This operation contemplates the reduction of the size of the
foetal head by the crushing of the cranial bones, in order to
effect delivery in cases where the deformity of the pelvis is
too great to admit of it, with safety, by craniotomy alone.
Although some allusions seem to indicate that an indistinct
idea of the operation was entertained long ago, practically it is
of recent date. As the hint was probably first taken from the
action of the obstetric forceps, which in early days no doubt
too often and unintentionally served as a cephalotribe, cepha-
lotripsy must have been introduced subsequently to the inven-
tion of the former instrument. The obstetric forceps of Cou-
touly, Assalini, Delepech and Lauverjat acted as powerful
compressors, and used as such would readily suggest the idea
of a stronger instrument to be applied to the crushing and the
further reducing of the size of the foetal cranium.
The credit of inventing the cephalotribe (the name given to
the instrument used in the operation, of which we now speak)
is attributed to A. Baudeloque, nephew to the celebrated ob-
stetrician of the same name. Its construction is similar to that
of the obstetric forceps, but the blades are narrower and stronger
than those of that instrument, and usually destitute of the
pelvic curve, and possessing the cranial, only in a slight degree.
Various contrivances have been adopted for applying the com-
pressive force. Some modification of the screw power has been
280 PRACTICAL MIDWIFERY.
the most common. A screw is passed from one handle through
the other, and worked by a lever in the form of a windlass.
It is manifest this would exert immense power in approxi-
mating the handles, and act with a proportionate force in the
crushing of the head.
The instrument as above described is a heavy and clumsy
one, of difficult application, and in some respects lacking in
efficiency when applied. M. Cazeaux enumerates the follow-
ing defects, viz.: “1. It is too straight to accommodate itself
to the curvature of the pelvis, and it is therefore applied with
difficulty to the side of the head. 2. As the clams are nearly
plain, they open like a pair of scissors, and do not encase the
head as the concave blades of the ordinary forceps do; conse-
quently they are liable to slip, and thus give rise to serious
accidents. 3. Tractions made by it are very often ineffectual,
even when well applied to the head; because it necessarily
draws in a direction different from the axis of the superior
strait, owing to the absence of curvatures in the edges of the
blades.”
Influenced by these serious objections, M. Cazeaux procured
a forceps with a curvature, as he says, slightly exceeding that
of Levret's, which he considered more easy of application, and
more safe and effective in traction. To this he also applied
the screw arrangement to secure the crushing force. Where
the screw and windlass are used it is important their mecha-
nism should be such as to admit of easy application and detach-
ment; otherwise by their weight and inconvenient extension,
they render the instrument difficult and even dangerous in
manipulation. *
We have thought the following modification of the cephalo-
tribe might be a convenient one, as it certainly would be more
simple than that in common use. Let a pair of forceps be
made similar to those of Cazeaux above described, sufficiently
strong in all its parts, and with handles so short as to be con-
venient in introduction, but sufficiently strong to bear any re-
quired amount of force. At the distal end of each of these
handles let there be an arrangement for connecting an exten-
sion long enough to secure any desired amount of leverage,
OBSTETRIC OPERATIONS. 281
simply by the application of the hand. This, perhaps, might
be effected by making a socket in the end of the handle similar
to that we sometimes find in one leg of mathematical compasses
or dividers, when it is desirable occasionally to substitute one
leg for another. The extension piece could be slipped into the
socket after the instrument was introduced and locked, and
firmly secured by a small thumb screw inserted in the side.
This arrangement, it is thought, would avoid the inconvenience
and danger to the patient in the introduction, arising from
the handling of a heavy instrument, and the force being
applied directly by the hand, the operator could more accu-
rately feel through the instrument, and be more fully conscious
of the effect produced. It would also be more manageable in
applying traction, and more readily withdrawn, for reapplica-
tion, or detached when the operation was finished.
Generally, when it can be done, the head should be perfo-
rated, as in ordinary craniotomy, before the application of the
cephalotribe. This allows the escape of the cranial contents
under compression, and avoids, in great measure, the bulging
of the head in the diameter at right angles to that compressed,
and also the risk of rupturing the scalp, and thus allowing spi-
culae of bones to protrude. Even with this precaution it has
been shown that the bulging takes place to some extent, but
far less than if the precaution be omitted. As the head is
generally grasped in the transverse diameter of the pelvis, that
most lengthened by compression would be the one correspond-
ing with the antero-posterior of the mother, and which is the
one usually shortened in deformity. According to experiments
of Hersent, all the diameters except the one included in the
blades are lengthened under pressure on an average of about
seven-sixteenths of an inch; when the cephalotribe is applied
without previous craniotomy, but where the latter had first
been performed, although there was still extension, it did not
exceed from one-sixteenth to three-sixteen, hs of an inch.
Authorities differ (and in what do they not differ), as to the
extreme limit of contraction of the pelvis rendering the suc-
cessful application of the cephalotribe impossible. The inven-
tor of the instrument claimed that it might be easily and effi-
282 PRACTICAL MIDWIFERY.
ciently applied in cases where the antero-posterior diameter of
the upper strait measures more than one inch and eleven six-
teenths of one inch. Hersent fixed the extreme limit at two
and a half inches, while perhaps the majority of accoucheurs
maintain that the operation may be successfully performed with
a diameter of two inches, unless the child be very large. Dr.
Darnes believed the instrument could be applied and the head
crushed with a diameter of one inch and a half.
It should be borne in mind, however, that as we approach
the extreme limit of the possibility of cephalotripsy, the opera-
tion becomes more and more perilous to the mother, from the
difficulty of applying the instrument and the consequent irrita-
tion set up in the parts, from repeated unsuccessful attempts.
The danger may nearly or quite equal that of the Caesarean
section, without the partially redeeming trait of the possible,
sometimes probable, saving of the child. In these extreme
cases, therefore, it may be regarded only as a last resort, short
of Caesarean section, having as its brightest prospect the rather
uncertain salvation of the mother, but the certain loss of the
child.
In the application of the cephalotribe, we should be guided
by the same general principles which we have already laid
down, when speaking of the use of the obstetric forceps. As
in these cases, however, the necessity of the operation arises
from pelvic deformity, that very circumstance greatly increases
the difficulty of its performance, and that, just in proportion to
its extent. It is therefore important the greatest care should
be taken in the introduction of the blades. We should carry
up the hand as far as possible to guide their course, and to ex-
plore the obstructions that may exist, and scrupulously abstain
from all undue force or violence. An assistant should always
steady the head by pressure over the hypogastric region. As
the instrument is heavy and the blades more pointed than those
of the obstetric forceps, if they be incautiously propelled, they
may easily inflict injury upon the maternal structures. If we
fail at once to get the blades into their proper places, so as to
lock, we had better withdraw one or both, and make another
attempt. Sometimes it is advised to reverse the order of their
OBSTETRIC OPERATIONS. 283
introduction—sometimes when the first blade has been easily
brought to its place, and the course of the second seems to be
obstructed, it is thought best to carry the second up over the
first, or rather, along the surface of the same hand that served
to guide the first, to be properly adjusted after it is fairly with-
in. It is recommended by some, after the blades are intro-
duced, to push back the handles as far as possible towards the
perineum, because it is alleged that in deformed pelves the pro-
montory of the sacrum projects so far towards the os pubis as
to push the head forward against the anterior abdominal wall
of the mother, so that if this precaution be not used, the vault
of the cranium alone will be crushed. In some cases this ad-
vice may be good, but is not applicable to all.
Care should be taken to pass the blades as high as possible,
so that they may include in their grasp the base of the skull,
as it is all important in order to effect delivery that this should
be thoroughly compressed.
When the instrument is properly adjusted the next step is
to apply the compressing force, whether this be by screw
power or otherwise. This force should be very gradually ap-
plied, so as not to destroy the integrity of the scalp nor cause
spiculae of bone to project through it. We should be satisfied
that the head is completely crushed, and the contents of the
cranium as nearly as possible evacuated. Of the former we
may form an opinion by the amount of crepitation under the
force of the instrument, whether this be heard or felt, and of
the latter by the amount of cerebral matter evacuated through
the opening previously made in the scull. If we have reason
to believe that the head is not completely crushed by the first
application of the instrument, we should withdraw and reapply
it, being careful to prevent its falling into the groove made by
the first compression. An examination should be made with
the finger to ascertain whether there are any spiculae project-
ing through the opening previously made in the scull, and if
so, remove them. If the perforation have been made in the
manner we have indicated in the chapter on craniatomy, there
is not likely to be any trouble from this source.
When the operation of crushing is completed, unless the de-
284 PRACTICAL MIDWIFERY.
formity be very great, and consequently the passage very nar-
row, we usually apply extractive force. The cephalotribe, as
commonly made, on account of the slight curvature of its
blades, is not so good a tractor as the obstetric forceps. As
before observed it is apt to lose its hold and slip. This occur-
rence may be ascertained by the sensation imparted to the
hand. It may be readjusted and another trial made.
As the head is usually seized in the transverse diameter of
the pelvis of the mother, and its diameter therefore more or
less elongated in the direction of the antero-posterior of the
pelvis, extraction often becomes difficult. To obviate this, it
is advised to rotate the instrument, so as to bring the lengthened
diameter of the head in accord with the transverse diameter of
the pelvis; and when the head is thus brought down into the
cavity, to rotate again, so as to suit the changed diameters of
the pelvis. If, however, simple extraction force be applied
with gentle Oscillating movement, it is probable, in obedience
to the law again and again referred to in this work, the diame-
ters of the head will spontaneously accommodate themselves
to those of the pelvis.
When the upper strait is very much narrowed through de-
formity, the head within the grasp of the instrument cannot
be brought down. In such cases, after the crushing is thor-
oughly completed, it is better to leave the future process to the
powers of the womb, provided they be vigorously in action.
The head now made soft and yielding, will be gradually moulded
to the shape of the abnormal pelvis, and pass the superior strait,
either spontaneously or with such gentle aid as the exigencies
of the case may demand, and a little ingenuity suggest. If
the size of the after coming parts create difficulty, the instru-
ment may, in turn, be applied to them so as to facilitate delivery.
In very difficult cases some authors advise repeated crushing
operations, with an interval of several hours between, as less
dangerous than prolonged efforts at the same time. In the
interval the patient is strengthened by taking appropriate
nourishment. I apprehend the danger here would, in many
cases be, the hopeless exhaustion of the woman through pro-
longed suffering. This might perhaps be in some degree
OBSTETRIC OPERATIONS. 285
counteracted by the judicious use of chloroform or of morphia,
to such extent as to temporarily arrest uterine action and pro-
cure sleep—the great objection to the latter would be the prob-
able increase of the risk of severe shock.
M. Pajot, of Paris, details his method of practicing the oper-
ation substantially as follows. After thoroughly, but carefully
crushing the head, he endeavors to make the reduced diameter
thereof to correspond with the contracted diameter of the pel-
vis, by rotating the instrument to the right or left, as may be
most easy, while it still retains the head firmly in its grasp.
If he find such rotation difficult to accomplish, he desists from
further attempts, and carefully withdraws the instrument with-
out making the least traction. The force of the womb, he finds
will usually, and often in an incredibly short time, mould the
altered head to suit the passage it has to fraverse, at the same
time imparting to it the movement of rotation so difficult to
effect by means of the instrument.
When necessary, he repeats the operation of crushing, at an
interval of two, three or four hours, according to the woman’s
condition, as determined by the symptoms, allowing two or
three introductions of the instrument for each time. It is at-
tempted to support the strength of the patient in the mean-
while with light nourishment. M. Pajot purposely avoids
traction upon the head by means of the cephalotribe, and styles
his method “céphalotripsie répété sans tractions.”
The foregoing method would, no doubt, in most cases effect
delivery, if the patient should live long enough for that pur-
pose; but it is not so certain what would afterwards become
of her.
It will be consolatory to know that this horrible and revolt-
ing operation is seldom necessary with American women, and
especially in practice in rural districts. We do not often meet
with a pelvis requiring the head to be reduced in size, in order
to effect delivery, unless the cranial bones be unusually ossified
or the head of the child abnormally large. Even in such cases
the large proportion can be successfully and safely managed by
the skillful and dextrous use of craniotomy instruments alone.
Cephalotripsy should, therefore, be regarded as a last resort
286 PRACTICAL MIDWIFERY.
this side the Caesarean section, and applied only to those cases
in reference to which it may justly be asked: What better can
be done 7
INDUCTION OF PREMATURE LABOR.
This operation, as the name imports, contemplates the effect-
ing of delivery before the normal close of utero gestation. It
is performed in the interest of the mother, of the child or
simultaneously of both. It is a procedure of comparatively
recent date; and although it is impossible to say with cer-
tainty when the first trial of it may have been made, it was
not until 1756 that it met with professional approbation. Den-
man tells us that in that year a congress of the most eminent
physicians met in London to discuss its merits, and who sanc-
tioned its legitimacy and utility. From that time it has grown
slowly but steadily in professional favor. At the present day,
perhaps, no enlightened physician doubts its propriety under
circumstances demanding the kind of relief which it, when
properly performed, undoubtedly affords.
In general terms, this operation is indicated where the cir-
cumstances of the mother or child are such as to expose either
or both to imminent risk to life by the continuance of gesta-
tion to full term, but which there is a reasonable prospect of
averting or greatly diminishing by the induction of premature
labor.
Dut to speak more particularly, it is indicated in cases of
pelvic deformity of such degree, as to render impossible the
birth of a living child of ordinary size, at term, when such
might be born by anticipating, by a few weeks, the normal
period of delivery.
To quote from Prof. Thomas: “It is difficult to say what
degree of deformity calls for the procedure, but in general terms,
it may be stated that wherever it is estimated, or, as is far
better, where it is proved that a child at full term cannot be
delivered by instrumental or manual means, premature de-
livery is called for. Still, speaking generally, the normal
length of the shortest diameter of the pelvis is four inches;
#
OBSTETRIC OPERATIONS. 287
between this and three inches is the domain of the forceps;
between three inches and two and a half, that of version; be-
tween two and a half and two, that of craniotomy; and under
two inches that of the Caesarian section. I shall not argue as
to the propriety of preferring premature delivery to the terrible
risks attendant upon the graver of these procedures, for all
will admit it.”
Again we may regard as fit subjects for premature delivery
those cases wherein obstruction to the birth of a full grown
child is created by tumors, such as ovarian growths, cancerous
tumors and the like. In some such cases a child after it has
reached viability may be safely delivered by premature labor,
which would be necessarily sacrificed if allowed to go on to full
term ; while at the same time the life of the mother might also
be sacrificed.
We occasionally meet with cases where the death of the
foetus in former pregnancies has occurred at a given period
toward the close of gestation. In such we may resort to the
induction of premature labor so as to forestall this accident.*
In order to accomplish this, it will be necessary, near the time
assigned by the mother as the period of the death of the child
on former occasions, to watch carefully its condition as sig-
nalled by the usual signs of approaching dissolution, such
as violent and uneasy movements, weakening of the heart's
action, etc. When we notice these prognostications, if the
child be of viable age, it will generally be best to propose pre-
mature delivery. If the pregnancy, however, has not advanced
so far as to afford reasonable hope of saving the life of the
child, it is perhaps scarcely necessary to interfere. There will
sometimes be considerable difficulty in determining this matter.
In order to fix as nearly as possible the exact point in the pro-
gress of utero-gestation, Dr. Barnes advises us to “reckon the
pregnancy from the day after the last cessation of the menstrual
period, the most probable time of conception.” There are cases,
however, where conception has taken place in the absence of
the usual catamenial manifestations, and here we have no
* See “Disorders of Pregnancy.”
288 PRACTICAL MIDWIFERY.
other aid to a correct conclusion but the unreliable one afforded
by the time of quickening.
As to the viability of the child, Prof. Thomas asserts :
“Little hope should be entertained if the delivery be brought
on at, or just after the seventh month ; almost none should be
indulged in before the seventh month, while a child delivered
at or after the eighth month, provided its vital forces have not
been depreciated by the abnormal state which has necessitated
delivery, has, with proper management, almost as good a pros-
pect of life as one arrived at full term.”
“The end of the eighth month, i. e. the ninth menstrual
epoch, is the most favorable time for the induction of prema-
ture labor.”
This operation is moreover indicated when the pregnant
woman has become the subject of some disease inherent in her
condition, which if unrelieved seriously threatens her life, as
well as that of the foetus, if utero-gestation be permitted to
proceed to term, and which all known remedial measures have
been unavailing to arrest. Another condition is that there be
reasonable ground of hope that the timely induction of prema-
ture labor may save the life of mother or child or of both. In
this class are included cases of excessive and intractable vomit-
ing, causing extreme prostration and emaciation, aggravated
uraemia, etc. The number of such cases I humbly trust will
be greatly diminished under homoeopathic treatment, as our
mild specific remedies will be found to reach many of them
which have heretofore been abandoned by the old school as ir-
remediable by medicinal agents.
There is in the children of some women a tendency to ex-
treme ossification of the cranium before birth. Such cases at
full term, unless the pelvis be very roomy, or the head very
small, necessitate delivery by craniotomy, and of course the
loss of foetal life, or Caesarean section, exposing the mother to
imminent peril. By anticipating natural labor by two or three
weeks, it is believed the child in such cases may usually be
saved, while the mother herself is exposed to less risk than she
is in delivery at term.
Finally, there are cases of placenta praevia, where the haem-
OBSTETRIC OPERATIONS. 289
orrhage sets in early, several weeks before the normal close
of utero-gestation, is at times violent, or persistent as a constant
drain, reducing the strength of the patient to such an extent as
to render it extremely doubtful as to her safety, if premature
delivery be not effected. Here not only is the life of the mother
seriously imperilled, but scarcely less that of the child. By the
induction of labor before the mother's strength is hopelessly
prostrated, or the child rendered feeble and anaemic by the loss
of its accustomed supply, both may perhaps be saved.
As the induction of premature labor is an operation of great
responsibility, it should never be undertaken without the most
serious and conscientious consideration. Under no circumstances
is it without risk, and sometimes it may be said to be very
hazardous. In most cases, however, where circumstances are
fayorable, when resorted to in time, and properly performed, it
may be regarded as scarcely attended with more danger than
natural labor. We should always previously inform the patient
of its nature, design, and probable advantages, and at the same
time not conceal from her what we may suppose, in her particu-
lar case, to be its risks. If at all practicable, we should have
Our decision sustained by the opinion and approbation of at
least one professional friend of good reputation.
The methods employed for the induction of premature de-
livery have been and still are very varied. While different
cases may require different modes of management, the selec-
tion of the best, the most efficient and safest means is of the
utmost importance.
Certain medicinal agents taken into the circulation and
through it, acting upon the nerves, controlling the functions of
the womb, are capable of bringing on contractions of that,
organ and effecting the expulsion of its contents. Such is the
Secale cornutum, or Ergot of rye. This has been used for the
purpose under discussion, and effectively, but given in the large
doses customary, where uterine contractions are produced, they
are usually so violent and unremitting as to endanger rupture
of the womb, or the death of the child or both. It is to be re-
membered that at the time when it is sought to effect prema-
ture delivery, the organs are in a state of unpreparedness, the
19
290 PRACTICAL MIDWIFERY.
os uteri undilated and undilatable, and hence not disposed to
respond in a kindly way to the -force pressing the presenting
part violently upon it. Ergot has therefore been abandoned,
on account of its violent action, and the dangers to mother and
child arising therefrom. I am not certain that it might not be
available, given in small and oft repeated doses, as I have else-
where advised for other purposes, while at the same time Ac-
taea racemosa might be given in alternation with it, which
would serve to relax the structures, and in some measure obvi-
ate the difficulties arising from their rigidity. This is, how-
ever, only a suggestion; I have no personal experience in such
a mode of treatment, nor have I seen any case reported as thus
treated.
Puncturing the membranes, so as gradually to drain off the
liquor amnii, will, in most cases, sooner or later bring on labor
pains. This method is however considered dangerous to the
child, as when the waters are evacuated the womb contracts
forcibly upon it, and being usually more feeble than at full term,
it is more liable to injury. We lose, moreover, the advantage of
the wedge power furnished by the bag of waters in dilating the
OS uteri, and this remaining undilated, is another source of
danger to the child and suffering to the mother.
In effecting premature delivery, the more nearly we can imi-
tate natural labor, the more satisfactorily and safely we will
accomplish our object. What then takes place in natural labor,
and in what order of sequence? First, the os uteri gradually
relaxes, then labor pains set in, the bag of waters is formed,
protrudes through the os, and by its distending power, aided
by other forces, accomplishes complete dilatation, the mem-
branes rupture, the presenting part enters the upper strait, de-
scends through the pelvis, and the child is born.
Now to imitate this process, in the first place let us effect
partial dilatation of the os uteri. This may be done by intro-
ducing a laminaria tent. Possibly a tent made in suitable
form, of dried slippery elm bark, might be safer, and act as
well. To bring on labor pains, we push up a gum elastic cath-
eter, with the usual wire stilet within, to be withdrawn when
the catheter is in place. Instead of the catheter we may use a
OBSTETRIC OPERATIONS. 291
gum elastic bougie, which is, perhaps, preferable. It should
be very gently pushed up several inches between the uterus and
the membranes, very carefully avoiding the rupture of the lat-
ter, and also keeping clear of the site of the placenta. The
bougie should be left in this situation for several hours, if ne-
cessary, till labor pains come on. In the meanwhile we may
go on with the dilatation of the os by the introduction and ex-
pansion of Barnes' dilators, of which we have elsewhere spoken.
When the os is fairly dilated, if necessary, we may give small,
repeated doses of Ergot, and in due time rupture the mem-
branes. This latter measure should be resorted to for bringing
on the pains, if the introduction of the bougie do not. The
conduct of the labor thenceforward is the same as if at full
term.
We have already spoken of the viability of the child. As to
the time we should select for the operation, when circumstances
admit of choice, one general remark may be made. We should
always allow the child to attain to as great an age as is consist-
ent with the particular object we have in view. The nearer
the natural close of utero-gestation it can be safely delivered,
the greater is its chance for continued life.
Infants prematurely born require especial care. Dr. Thomas
advises them to be kept in an atmosphere of 95° Fah., until they
are capable of generating the amount of heat necessary to sus-
tain life. When other means of maintaining warmth are not at
hand, bottles containing warm water should be laid around
them. They should be carefully fed upon diluted milk, or,
better still, that drawn from the breast of a healthy wet-nurse,
till the mother herself is prepared to suckle them.
CAESAREAN SECTION.
This operation has for its object the extraction of the child
through an incision artificially made, in the abdominal and
uterine wall of the mother. It takes its name from Claudius
Caesar and Julius Caesar, both of whom, according to tradition,
were delivered in this way—the evidence of its truth, however,
is now somewhat misty. The fatality of this operation to the
292 PRACTICAL MIDWIFERY.
mother is, up to the present time, very great, viz.: according
to statistics collected by Dr. Clay, of Manchester, about 1 to 24.
It therefore should be regarded only as a last resort, where the
mother is living.
The circumstances under which the Caesarean section becomes
a legitimate operation are very few. It may, in the first place,
be had recourse to, when a woman far advanced in pregnancy,
from any cause dies suddenly, there being reason to believe that
the child within her womb is still alive ; or, even if she die by
the slower process of disease, when there is a reasonable hope
of saving the child by the operation. This, however, in the
latter case, is probably seldom accomplished, as the time con-
sumed in procuring the attendance of the operator, will be
generally fatal to the life of the child, even if that be not ex-
tinct at the moment of the mother's death. Even though the
surgeon should be present, the friends of the woman must be
sufficiently assured of her death, before any attempt is made to
operate, and this delay would perhaps usually be sufficient to
defeat the purpose. The objection to turning in these cases is
the undilated condition of the passages, except where the pa-
tient expired in the act of parturition.
In case of the living woman, the operation is justifiable only
in such circumstances where delivery cannot be effected by any
other means, without subjecting the patient to equal or greater
risks than those known to appertain to the Caesarean section.
I hold the mother should never be exposed to great risks simply
to save the life of the child, at least unless she, in the full pos-
Session of her reason, so elect.
The mortality attendant upon the Caesarean section is prob-
ably greatly increased by the circumstances under which it is
usually performed. From the extreme abhorrence which every
one, unless perhaps a special operator, must feel towards the
operation, it is likely to be postponed to the latest moment, and
until the patient is exhausted by the agonies of a fruitless labor,
and therefore in a condition unfit to endure a severe operation
of any kind. Hence it is advised, where it is known before-
hand, that a necessity for such an operation exists, to perform
it before the advent of labor. This advice is undoubtedly
OBSTETRIC OPERATIONS. 293
rational, but would, in many cases, be exceedingly difficult to
follow. If delayed till labor sets in, and it be fully determined
that it is absolutely necessary, as giving the mother and the
child the only chance for life, the sooner it is resorted to the
better for both. Dr. Clay tells us that “the operation is justifi-
able with an antero-posterior diameter of an inch and a half
and three inches transverse, or under, or almost perfect obliter-
ation of the passage by Osseous growths.”
As preliminaries to the operation the bowels should be well
evacuated by the most gentle means, avoiding all drastic pur-
gation. Inspissated Ox gall is highly spoken of, as not only
clearing out the bowels effectually, but removing flatulency.
The urine should be fully evacuated, either by the natural
efforts of the patient or by the gum elastic catheter. The po-
sition of the placenta should be carefully ascertained, so as to
avoid its site, if possible, in making the incision in the womb.
The temperature of the apartment should be raised to 75° F.
and maintained at that during the operation, having the air
also moistened by the evaporation of water. It is hardly
necessary to say the patient should be fully anaesthetized before
the operation is commenced. To this, however, some object,
on account of the liability to vomiting, which, under proper
management, is not likely to occur.
The incision should be made as nearly as possible in the
linea alba, so as to avoid wounding the epigastric arteries, and
thereby causing haemorrhage. It should commence a little
above the umbilicus and be carried a few inches below, cutting
around and not through the umbilicus. The skin and muscu-
lar fibres are carefully cut through, until the peritoneum is
reached, which is known by its peculiar shining appearance.
A small opening is made in this membrane, which may be
done by pinching up a portion of it with forceps or by
a very cautious stroke with the point of the scalpel. It is
then divided to the length of the incision in the external
layers, by means of a director, or inserting the fingers of the
left hand underneath, to elevate it, and serve as a guide to the
probe pointed bistoury employed in severing it. An assistant
then, with one hand on each side of the incision, pushes for-
294 PRACTICAL MIDWIFERY.
ward the womb, in which an incision is made, corresponding
in situation and length with that in the abdominal walls,
avoiding the fundal region and the placenta, if possible. When
the incision is made into the womb, the assistant should insert
a finger into each end of the wound, and thus draw up the
organ tightly against the abdominal walls, so as to prevent
blood and the liquor amnii from escaping into the abdominal
or peritoneal cavity. The membranes are then punctured and
divided, and the child is carefully removed, the head and
shoulders, if practicable, being delivered first. The placenta
and membranes are then extracted and the womb left to con-
tract as speedily as possible. If it do not contract spontane-
ously, gentle pressure is applied. It should be ascertained, by
digital examination per vaginam or by passing up a catheter,
that the OS is patulous, so that the lochia may escape. It is
not agreed whether it is better to close the uterine wound by
sutures or leave that to be effected by its own contractile pow-
ers. Probably it had better be secured by animal sutures,
such as carbolized cat-gut, cut short, or silver wire. The ob-
jection to the former is their liability to open prematurely
when continuously exposed to moisture. If silver wire be
used, after twisting, the points should be so bent as not to irri-
tate the tissues with which they may come in contact. Spen-
cer Wells used a continuous silk thread, one end of which he
brought out through the os and vagina, so as to permit its re-
moval. It is advised not to close the abdominal wound until
the risk of haemorrhage is past. All blood and discharges
should first be removed, by means of moist warm sponges,
from among the abdominal viscera. This precaution cannot
be too scrupulously attended to, as, if it be neglected, these
matters necessarily become putrid, and almost certainly create
septicaemia.
The edges of the abdominal wound are carefully approxi-
mated and secured by pins or silver wires passed deeply
through the tissues; some say, including the peritoneum itself.
These pins or sutures are inserted about an inch apart, begin-
ning above and passing downward. As to including the peri-
toneum, there is a difference of opinion. Dr. John L. Atlee,
OBSTETRIC OPERATIONS. 295
in his ovariotomy cases, does not include that membrane. The
idea that approximation of its edges is effected by including
it in the sutures, is probably fallacious; for the edges of so
thin a membrane are not likely, by the operation, to be
brought into close juxtaposition through any considerable por-
tion of their extent. Then, on the other hand, the pressure of
the pins or wire would be likely to produce irritation, and,
perhaps, light up inflammation.
When the wound is closed, it is covered with folded lint,
which is secured by adhesive straps and a suitable bandage,
prevented from slipping up, by attachments passed around the
thigh. The bladder should be relieved, as often as necessary,
with the catheter, and the bowels kept perfectly at rest.
Arnica, in water, should be given as after labor, alternated
with Ars. a.”, and continued. All the symptoms that may
arise, should have their appropriate remedy. The diet should
be of the lightest possible character. In case of great pros-
tration, beef tea or essence of meat may be given, in quantities,
however, strictly regulated by the exigencies of the case.
Dr. Robert P. Harris, member of the Philadelphia Obstetri-
cal Society, etc., has lately published (American Journal of the
Medical Sciences, for April, 1878,) an interesting article upon
the Operation of Gastro-Hysterotomy, “viewed in the light of
American experience and success.” He has collected seventy-
two cases, of the operation performed in America, which he
gives in more or less in detail. The conclusions, at which he
arrives, are the following: That the success of American sur-
geons has heretofore been greater than that of the European,
especially than that of the surgeons of Great Britain. The
failure in the latter country he attributes rather to the faulty
habits of the women than to any want of dexterity or skill
on the part of the surgeons themselves. The beer drinking
propensity of the people he thinks an important factor in the
ill-success. -
The doctor very rationally insists upon early operation,
where it is found to be necessary, and, when thus performed,
believes it more conducive to the safety of the mother, in
cases of extreme contraction of the pelvis, than craniotomy or
embryulcia, supposing these to be at all practicable.
296 PRACTICAL MIDWIFERY.
The statistics of Dr. Harris seem to favor the employment
of sutures in closing the uterine wound. He collected twelve
cases in which they have been used, with five recoveries;
whereas the general result of his observations is, thirty-five
saved and thirty-seven lost.
CHAPTER XII.
ANAESTHESIA IN LABOR.
As frequent reference is made in this work to the use of
anaesthetics in the conduct of labor, it may be proper to devote
a chapter specially to this subject. Here, however, it will be
our object, not so much to direct attention to the indications
which, in our opinion, call for their employment, as to answer
some of the objections preferred against their use, in any cir-
cumstances whatever, and then indicate the method by which
they may be most safely and efficiently administered. I have
already, and elsewhere, pointed out the indications demanding
their employment. Let me, moreover, premise, that my re-
marks, unless otherwise distinctly stated, are intended to
apply to Chloroform, the only agent worthy the entire confi-
dence of the obstetric practitioner. Ether, so much lauded in
surgery (especially when largely mixed with chloroform),
scarcely deserves a moment's consideration here.
I do not advocate the indiscriminate employment of anaes-
thetics in labor. Where it is natural, the patient courageous
and strong, where she suffers no unusual amount of pain, and
where, moreover, no special indications are present, it would
be a sakeless procedure to administer chloroform or any other
anaesthetic. Such patients would usually object to it them-
selves. But, on the contrary, where there is intense suffering,
from any cause whatever, and where insensibility or a relaxed
ANAESTHESIA IN LABOR. 297
condition of the tissues is desirable, this agent comes into
play, and usually fully meets the expectations of both patient
and attendant.
One of the most urgent objections brought against the use
of chloroform, in labor, has been its supposed immediate dan-
ger. This objection, of course, falls to the ground, when it is
shown that no such danger exists, or, if it exist at all, it is in
such a trifling degree that it does not deserve to be taken into
the account. I apprehend that the supposed danger of chloro-
form, in surgery and midwifery, are different and very distinct
questions. That accidents do not unfrequently happen in sur-
gical practice, from the use of chloroform, cannot be denied.
While the patient is being anaesthetized, preparatory to a sur-
gical operation, he is mostly under the influence of fear, very
frequently, intensely so. We all know the depressing power
of this emotion—how it lowers and unsteadies the action of
the heart. It therefore lays the foundation for the worst effects
of chloroform, namely, paralysis of that organ. We will say
nothing of the reckless and unscientific manner in which the
chloroform is often administered by a young assistant. On
the other hand, when chloroform is used in labor, there is usu-
ally no such depressing antecedent emotion. The patient, on
the contrary, begins the inhalation under the inspiring influ-
ence of hope. She is told by her attendant, in whom she has
confidence, and truly so, that she may not only expect immu-
nity from danger, but a speedy suspension of all her sufferings.
Under this favorable moral condition she commences inhala-
tion. The frequent recurrence of the antidotal pain, or con-
traction of the womb, is, probably, also an element Qf safety.
At each effort of this organ the energies of the whole system
are aroused afresh, and this circumstance prevents the patient
from sinking into so deep a state of narcotism as to seriously
endanger life. The organism, too, has accumulated a store of
energy, to fit it for the function of parturition, which enables
it to resist the power of any lethal agent tending to cause
death by arrest of circulation or the paralyzing of the nervous
power. At the recurrence, moreover, of each successive pain,
an additional amount of blood is thrown upon the brain, thus
298 PRACTICAL MIDWIFERY.
supplying the deficiency which might ensue from partial para-
lysis of the heart.
But the strongest proof of immunity from any serious im-
mediate danger, is the incontestable fact, that accidents rarely
happen to patients in labor under the influence of chloroform.
We have for many years, read the details of casualties from
this agent, as given in our Journals, and we can remember but
one related, as having occurred to a parturient patient. This
was a case that is said to have happened in the city of New
York. The patient had been suffering from a severe cold upon
the chest—was under the influence of chloroform but half an
hour until her child was born. She waked up considerably
oppressed in her breathing, owing, probably, to her cough and
expectoration being held in check by the anaesthetic. The
doctor administered an opiate, doubtless tending to deepen the
narcotism, and still longer to suspend the needed cough. At
his visit next morning he found her still more oppressed in
her breathing, and administered a dose of tartar emetic, shortly
after which she died. Comment is unnecessary.
But, then again, some, not so certain of immediate danger,
point to that more remote. Though the patient may, for the
time, escape the peril with her life, yet “vengeance suffereth
not to live.” She is doomed to the consequences of a wrecked
nervous system and broken down health throughout the re-
mainder of her earthly pilgrimage. We conceive this also to
be a false alarm. We ourselves have seen nothing of it. I
have made it my business to call upon almost every woman to
whom I have given chloroform during labor, and to inquire
minutely, into the condition of her health, and the result has
been that I have found the recovery of these as complete, to
say the very least, and their health as good as in the same
number of cases to whom no chloroform had been given at
all. I know it is customary, where an anaesthetic has been
administered, to attribute whatever follows, from whatever
cause, to that influence alone. A writer in one of our Jour-
mals met with quite a number of cases of prolapsus uteri, all
the subjects of which had taken chloroform in labor, and to
this cause the accidents were referred. On the other hand, I
ANAESTHESIA IN LABOR. 299
meet with very few such cases, although I often use chloro-
form. My colleague's cases may, therefore, most probably, be
attributable to some other and very different cause. It should
be remembered, moreover, that it is principally in the most
perilous labors the anaesthetic is used.
Again we are told that chloroform often gives rise to post
partum haemorrhage. That it never constitutes a factor in the
production of that accident, would be as hard to deny, as it
undoubtedly is, upon sufficient evidence, to affirm that it does.
The only way in which I can conceive that it would contri-
bute to this result, is by its general relaxing power. If, how-
ever, we make our deductions from observation, rather than
from theory, we shall, I think, arrive at a very different con-
clusion. While the relaxing effect of chloroform upon the Os
can hardly be doubted, I do not think there is any evidence
that it, at least in the vast majority of cases, interferes with
the contractile power of the muscular fibres of the body of the
womb. I think I as frequently find that organ firmly con-
tracted after the expulsion of its contents, where chloroform
has been given, as where it has not. I do not remember to
have met with any case of severe flooding after its administra-
tion. On the contrary, the worst cases of haemorrhage that
have occurred to me, and they have been but few, were those
in which no anaesthetic had been used at all. But if we have
any fears upon this subject, haemorrhage may be anticipated
and prevented by administering Ergot before the birth of the
child, which will pretty certainly secure contraction after the
womb is emptied of its contents. This recommendation may
be considered as not homoeopathic. I am not altogether cer-
tain whether it is or is not. But I do know it is consistent
with common sense. By the physiological action of Ergot
we procure the contraction of the tissues of the womb, and
thereby the closure of the open mouths of the vessels. Or, if
you prefer the theory that flooding arises from congestion of
the small vessels of the walls of the uterus, then contraction
should relieve congestion, by forcing back the blood, and, con-
sequently, while it lasts, secure against haemorrhage by dia-
pedesis.
300 PRACTICAL MIDWIFERY.
It is further objected by some that chloroform retards labor,
and sometimes necessitates the use of the forceps. Let it be
granted that it may in some few instances postpone delivery,
it at the same time removes suffering, and the patient is uncon-
scious of the lapse of time. “Beati non numerant horas.”
The only inconvenience this is likely to cause, is merely to tax
the patience of the attendant. Should the delay endanger the
child, the forceps may be used, and as for the mother, as she is
relieved from suffering, she is not so likely to become ex-
hausted. The truth, however, is, as verified by abundant expe-
rience, that chloroform in very few cases indeed retards labor
at all. This is thé true deduction from observation, the oppo-
site rests, for the most part, upon theory. By relaxing the
tissues and promoting an abundant secretion of mucus to lubri-
cate the surfaces, as well as by blunting sensibility, and modi-
fying reflex action, so that the will makes no effort to suppress
the efforts of the womb, labor is, in most instances, accelerated
not retarded, by the administration of chloroform. The asser-
tion that it prevents the accessory muscles, as the abdominal,
being called in to aid the womb, is by no means sustained by
accurate observation.
As regards the objection based upon the questionable morality
of the use of anaesthetics, it scarcely merits notice, for it may
be brought with almost equal force against any means what-
ever, employed for the relief of human suffering.
Finally, the objectors to the use of chloroform in labor are
found principally amongst two classes of persons: doctors, who
are unwilling to take the pains to become experts in its use, or
who under-estimate the importance of their patient's sufferings;
and the anility, who, now exempt from the pains of child bear-
ing themselves, can see no good reason why the younger women
should be saved from what they once suffered.
There can be little doubt but that the safety and efficiency
of chloroform in labor, as well as for other purposes, depends
much upon the manner in which it is given. A very common
practice now is, to fold a napkin in the form of a hollow cone,
the smaller end representing a truncated apex. This cone is
inverted in the hand, and an indefinite quantity of chloroform
ANAESTHESIA IN LABOR. 301
thrown at random into the larger opening of the base, to light
Somewhere upon the inner surface. The larger end is then ap-
plied over the nose of the patient, and we are told that the
smaller opening admits sufficient air—more than can pass
through the glottis. Perhaps it may, but who can say what
percentage of the vapor of chloroform it may contain when in-
haled into the lungs. The fluid when thrown in may lodge
principally upon the surface nearest the mouth and nose of the
patient when the napkin is applied, and the warmth of the
hand grasping it may hasten evaporation, so that the air when
inhaled may contain a dangerous proportion of vapor.
A safer and more manageable method of administering chlo-
roform is the following: A clean, linen handkerchief, free as
possible from starch, is folded in the usual manner, until about
as large in surface as the palm of the hand. This is laid upon
the palmar surface of the left hand, while a four ounce vial,
filled with chloroform, and having a pretty wide mouth, is held
in the right. The folded handkerchief, by a suitable movement
of the left hand, is brought over the open mouth of the vial,
when the latter, by a quick tilting movement, is made to im-
part a small quantity of chloroform to be absorbed in the folds
of the former. The handkerchief is then quickly brought
within an inch of the patient’s nose, the moistened portion
being opposite the nostrils. She is then requested to dismiss
all apprehension, to breath quietly and to resign herself wholly
to the influence of the anaesthetic. As the chloroform evapo-
rates, as it rapidly does, another and another portion is succes-
sively applied as before directed, and the inhalation continued
until its effects are fully perceptible upon the patient. The
handkerchief may soon be brought nearer, but I never approxi-
mate it closer than to rest upon the end of the patient’s nose.
When the inhalation has been continued for a few minutes, she
will often begin to snore, and then the handkerchief had better
be withdrawn for the time. When the next contraction of the
womb takes place, the patient usually moans and manifests
other signs of suffering, although if afterwards interrogated it
would often seem that she had been at the same time insensi-
ble. When we apprehend that she still really suffers upon the
302 PRACTICAL MIDWIFERY.
recurrence of pain, the chloroform should again be quickly ap-
plied, to be withdrawn when the contraction ceases. We
should endeavor all the while carefully and accurately to esti-
mate the degree of anaesthesia produced, and not to push it
further than simply to secure insensibility to pain, at least in
the earlier stages of labor. Toward the close, if there be ap-
prehension of much suffering, a profounder impression may be
made. The nose and lips should be smeared with thick sweet
cream, to prevent the irritating effects of the chloroform.
If it be asked at what stage, if chloroform be at all used, its
inhalation should be commenced, I would say that it is usually
better to begin before the sufferings become intense. When
they have risen to an extreme height, it is difficult afterwards
to produce complete insensibility, or at least that beautiful
tranquility which it is generally possible to secure. The woman
is apt to carry with her the remembrance of her previous agony,
as a troubled dream, throughout the whole future course of her
labor. She will speak of her sufferings while under the influ-
ence of the chloroform, although she may seem to have forgot-
ten them after she is fully awake. On the other hand, I never
begin the use of chloroform, if I can help it, till the bearing
down or expulsive pains set in.
Again, if it be asked how long a woman may with safety
be kept in a state of pretty profound anaesthesia, I would reply
that this will somewhat depend upon circumstances. I remem-
ber having kept one patient in a state of insensibility a little
over ten hours continuously. This woman, a primipara, and of
delicate scrofulous constitution, had had a rather severe attack
of cholera morbus just prior to her confinement, brought on by
imprudently eating of green corn. This attack had greatly
weakened her general powers, and her labor was consequently
modified thereby. She had some flooding an hour or two
after delivery, apparently brought on by an attempt to raise
her to pass water. The haemorrhage was not alarming, and
readily yielded to my efforts to suppress it, for I had not
yet left the house. She made as good a recovery as could be
expected from the circumstances of her labor, leaving chloro-
form altogether out of the question. This lady removed from
ANAESTHESIA IN LABOR. 303
the neighborhood before she again became pregnant, but has
since given birth to at least one child. She now resides in Mis-
souri, and I have quite lately heard of her having had the sin-
gular misfortune to suffer an abortion on board a railway car,
in travelling eastward. I have frequently inquired about her
health, and have always been told it was as good as usual with
persons of like constitution. I have said thus much of this
patient, because in her case I would have apprehended unpleas-
ant after-consequences, rather than in any in which I remem-
ber to have used chloroform.
When delivery is accomplished, or the operation concluded
for which the anaesthetic has been used, the patient will some-
times still continue in a comatose condition more or less pro-
found. We need feel no uneasiness about this, provided the
breathing be good, and the pulse regular and of sufficient force.
It is probably better to allow her gradually to return to con-
sciousness, than to suddenly awake her. Where the narcotism
has not been very profound, or if the patient be of a wakeful,
anxious disposition, she will generally be aroused by the crying
of the child. When she continues to sleep, we should very
carefully attend to the condition of the womb ; be careful to
see, or rather feel, that it has fully contracted and that it main-
tains its contraction. If there seem to be a disposition in the
organ to become relaxed, or if we have not been able to secure
proper contraction, we should be on the alert to guard against
haemorrhage. When chloroform is administered, it is an ex-
cellent precaution, above referred to, to give occasionally to-
ward the close of labor, very moderate doses of Ergot, which
usually ensures contraction, and is an excellent preventive of
severe after pains. In recommending this practice I am not to
be understood as admitting what I have already denied, that
there is more risk of haemorrhage when chloroform is adminis-
tered, than when it is not.
When it is for any reason desirable to arouse the patient
Sooner than she will awake when left to herself, we may call
her by name in a tone of voice pretty loud, but not harsh or
such as to startle her. If this be not sufficient, we may sprinkle
a little cold water upon her face. The first of these expedients
is generally sufficient, and the latter I have never seen fail.
304 PRACTIC AT, MIDWIFERY.
I have fortunately never had occasion to resort to any of the
means advised, to arouse the patient from apparent death.
Here they would perhaps be alike unavailing. Of those readily
accessible I would rely most upon flagellation upon the bare
skin, with a wet towel, having first taken care to draw the
tongue forward, so as not to obstruct the entrance of air into
the trachea. If breathing had ceased, I would resort to some
of the means of artificial respiration, with which the young
practitioner should familiarize himself, as found usually in the
books on the treatment of asphyxia. It has been recommended
to introduce air into the lungs by means of a syringe and cath-
eter passed through the glottis. Nelaton, in cases of apparent
death from chloroform, inverts the patient, suspending her by
the feet, while the head hangs downward.
When the woman has been for a considerable time under the .
influence of chloroform during labor, as we have elsewhere re-
marked, the child frequently does not cry immediately when
born. This need cause no alarm. The mucus should first be
removed from the upper part of the throat and mouth with the
finger. If it do not then cry it may be moderately slapped
with the palmar surface of the hand or fingers. If this do not
succeed, a little cold water may be sprinkled upon its body
from the ends of the fingers, or the body immersed in water as
warm as can be safely borne, and then cold sprinkling applied.
One or other of these expedients will always succeed if its still-
ness depend only upon narcotism through the blood derived
from the mother.
Finally, we should be exceedingly careful that the chloroform
we use be of an undoubtedly good quality. To ensure this we
should never purchase an article because it is cheap, nor should
we use any unless we know pretty well through whose hands
it has come, and it should always bear the name of a manufac-
turer whose reputation is a sufficient guarantee for its excel-
lence. While in our possession we should keep it well corked,
So as to exclude the air, and always set away in a dark place.
Recently, hydrate of chloral has been used to produce insen-
sibility to suffering in labor. It is claimed for this agent that
it may be given earlier than is generally thought proper to use
ANAESTHESIA IN LABOR. 305
chloroform, without at all retarding the process. It is, more-
over, said to be very efficient in producing relaxation of the OS
uteri, when any difficulty arises from its rigidity. Dr. Play-
fair, in his late work, speaks very favorably of chloral, and ad-
vises to give it in doses of fifteen grains every twenty minutes,
till three doses have been taken. If its effects are not satisfac-
torily apparent after taking the third dose, he gives, at the ex-
piration of an hour, a fourth, but this, he says, will rarely be
found necessary.
I have, up to this time of writing, tried the chloral only in a
single case. This was one which I thought well suited to such
a trial. I gave it when the preparatory pains became annoy-
ing, and before the dilatation of the os, in doses and at the in-
tervals advised by Dr. Playfair, until forty-five grains had been
given. I ruptured the membranes artificially, and as the head
descended and the pains seemed still to cause much suffering,
I resorted to chloroform, of which less seemed to be required
to produce insensibility, than if the chloral had not previously
been given. The chloral, I think, diminished the suffering,
but did not entirely suppress it. There seemed to be no inter-
ference with the action of the womb. If I may pass an opinion
from so small an experience, I would say that chloral is, upon
the whole, far inferior to chloroform. The patient, however,
to whom I here refer, the mother of several children, and whom
I attended now for the first time, was greatly pleased with the
result—said “she had never had so good a time,” and she made
an excellent recovery. -
We occasionally meet with patients, especially primiparae,
who, when the pains set in with severity, become so restless,
that it is very difficult to keep the handkerchief applied suffi-
ciently near the mouth, or they begin to scream whenever they
feel the pain approach, so as not to inhale the chloroform, in-
deed, blow it all away. In such cases, I think the Hydrate of
chloral may do excellent service. I would give it early, after
the plan of Dr. Playfair, until its full effects were secured, until
there appeared considerable drowsiness and at least partial
insensibility to pain. If necessary, I would then resort to
chloroform. We doubtless would find the patient inhale much
20
306 PRACTICAL MIDWIFERY.
better, and a comparatively small quantity of the latter anaes-
thetic produce the desired effect.
This method would probably answer well in the few cases
occasionally met with, in which chloroform seems to exert but
little anaesthetic power, to do but little to deaden sensibility to
pain.
If in such cases as those just referred to, deep anaesthesia were
desirable, on account of a severe intended operation, the desired
end might be reached by giving Morphia some time before the
chloroform is administered, should the chloral not answer the
purpose.
I have for many years used chloroform freely in cases of diffi-
cult and painful labor. Of the many advantages which I be-
live it possesses, I consider the following as by no means the
least. Every practitioner will meet with cases, especially
among primiparous women, wherein great anxiety and even
alarm is manifested by the patient. This is usually more or
less participated by her surrounding friends, especially the
mother, if she be present. The consequence often is, the at-
tendant is entreated to do something for the relief of the suf-
ferer, and if he be a young practitioner, or lacking in firmness
or self-reliance, he is sometimes tempted to interfere prema-
turely and incur the consequences of “meddlesome midwifery.”
Chloroform quiets the patient, and consequently stops the
mouths and dries up the tears of her sympathizing friends.
The labor progresses, perhaps slowly, but without improper in-
terference, until it terminates spontaneously, or the opportune
moment arrives for the legitimate interference of art.
Since writing the foregoing portions of this chapter, I re-
sorted to the following expedient in a single case, with the re-
sults of which I was much pleased. The patient was a lady
of very nervous temperament, had several times been prema-
turely delivered of dead foetuses, mostly, I think, more or less
putrid. In the last of these accidents I had attended her, and
conditionally promised her a better result should she become
pregnant again. I had carefully treated her during this last
pregnancy, and, of course, felt deep anxiety for a satisfactory
termination. As I had nine miles to go when summoned, the
ANAESTHESIA IN LABOR. 307
labor was somewhat advanced when I arrived—the head fairly
entering the upper strait, the pains strong and her suffering
severe, with much nervous jactitation. I immediately gave
her about fifteen grains of hydrate of chloral, and very shortly
began cautiously to administer chloroform by inhalation. She
readily passed under its influence, the action of the womb kept
up undiminished, and in about an hour she gave birth to a
fully developed vigorous boy, which cried lustily as soon as
released. The patient told me she had no suffering after in-
haling the chloroform, and made an excellent recovery.
In some cases of labor the so-called “preparatory pains" are
exceedingly severe, cansing great suffering to the patient, and,
especially in the case of primiparae, great discouragement.
To this state of things Dr. Playfair has thought the hydrate
of chloral specially suited. If, however, this extreme suffer-
ing be owing, as it possibly may be, to a hyperaesthesia or other
abnormal condition of the sympathetic nerves controlling uter-
ine function, a theory, I believe, held by M. Beau, there is
another class of remedies which may prove advantageous,
some or all of which are certainly worthy of trial. I have
elsewhere spoken of the arsenite of copper, an excellent agent
in the treatment of neuroses of the sympathetic. I once gave
it to a patient during her precursory pains, who, not knowing
my intention, expressed herself relieved. Then we have sev
eral remedies which have proved so useful in our hands in the
treatment of dysmenorrhoea of a neuralgic or rheumatic char-
acter. All these are worth trial, although I am as yet unable
to vouch for their efficacy from any experience of my own. I
would especially recommend for trial, Viburnum opulus, Vi-
burnum prunifolium and Xanthoxylum fraxineum. We have
already advised these to be given in case of severe pains in
the uterine region, prior to labor, a condition, which, if unre-
lieved, we believe we have often seen followed by intense suf
fering in the first stage.
SYNOPSIS OF THERAPEUTICS.
Abdominal pains during pregnancy: Cup., Ars., Morphia, Acet.
Abortion, threatened, to prevent: Arn., Bell., Ipecac., Sab.,
Sec. cor., Viburnum opulus; Viburnum prunifolium ; when
habitually occurring at the same period, chloride of gold
and Sodium. *
Abscess in lips of cervix uteri: Calc., Hepar sul.., Lachesis,
Merc., Phos., Sil., Sulphur.
Agalactia: Calc., Caus., electricity, Rhus.-Acon., Bell., Bry.,
Cham., Merc.
Albuminaria during pregnancy: Apis, Ars. alb., Equisetum
h., Merc. cor., Phos.
Anorexia during pregnancy: Ars., Ant. crud., Calc. car., Nux
vom., Puls., Sul., Ver. alb.
Anteversion of the uterus during pregnancy: Replace and en-
join supine posture till uterus rises above the pelvis.
Apoplexy of new-born children: Cut and suffer the cord to
bleed.
Ascites during pregnancy: Apis, Ars., Digitaline.
Asthma during labor: Ars., Etherial tincture of Lobelia in-
flata by inhalation; drop doses of the alcoholic tincture.
Bladder, paralysis of, after labor: Tincture Sec. cor., 10 drops
every thirty minutes.
Constipation after delivery: Bry., Nux, Sul. ; enemata of warm
Water.
Convulsions, puerperal : Acon., Actaea, Arg. nit., Arnica, Ars.,
Dell., Bry., Cham., Gels., Hyosc., Opium, Stram., Veral. vir.,
Zinc, ; chloroform by inhalation and injection: Coffea,
Cup.
Cramps, local: Cup. met., Ignat., Val., Zinc.; in the lower
limbs: Viburnum opulus, Viburnum prunifolium.
Eclampsia during pregnancy: Bell., Gels., Opium.
(308)
SYNOPSIS OF THERAPEUTICS. 309
Galactirrhoea: Iodide of Potassium.
Giddiness during pregnancy: Bell., Merc. viv.
Haematemesis during labor: Acid nit., Ham. virg., Terebinth.
Hemicrania during pregnancy: Acon., Chin., Col., Ignat.,
Spig.
Hemiplegia during pregnancy: Bell., Caus., Cocc., Ignat., Nux
vom., Sepia.
Haemorrhage, uterine, during pregnancy: Apoc, can., Erig.
can., Trill. pend.
Haemorrhoids during pregnancy: Aesculus hip., Aloes, Collin-
sonia can., Nux vom., Sul.
Haemoptysis during labor: Ham. v.
Icterus during pregnancy: Phos.
Insanity during pregnancy: Actaea racemosa.
Leipothymia during pregnancy : Acon., Carb. veg., Cham.,
Hepar sul., Moschus, Nux wom.
Leucorrhoea during pregnancy: Ergot., Helonias, IHydrastis,
Iod. ars., phosphate of lime.
Lochia, too scanty: Acon. ; if colic, diarrhoea or toothache set
in, Cham.; if tympanitic, Col. ; too long continued and
bloody, Nux mos., 1st dec.
Milk fever, to prevent: Arn. ; if it occur, Acon.
Neuralgia during pregnancy: Acon., Ars., Bell., Gels., Nux
vom., Puls.
Nipples excoriated: Hydrastia in glycerine, externally; cracked
or chapped, Nitrate of Silver.
GEdema of labia externa: Apis.
Paralysis during pregnancy: Ignat., Nux v., Plumbum.
Paralysis, facial: Caus., Graph., Opium, Plumb.
Pityriasis during pregnancy: Alum., Ars., Bry., Lyc., Phos.,
Sep.
Plethora during pregnancy: Bell., Graphites.
Pruritus of the vulvae during pregnancy: Sepia. Apply ex-
ternally a solution of sulphite of soda, Solution of borax or
a very weak solution of corrosive sublimate.
Ptyalism during pregnancy; Kreasote, Merc.
Pyrosis during pregnancy: Calc. carb., Caps., Caus., Carb. an.,
Nux v., Puls., Sepia.
310 PRACTICAL MIDWIFERY.
Retention of urine after labor: Sec. cor. ; this failing, use
catheter.
Rheumatism or neuralgia of uterus during pregnancy: Caul.,
Viburnum, Xanthoxylum fraxineum.
Secondary haemorrhage: Apoc. can., Erig. can., Tril. pend.
Side, pain in the right: Actaea racemosa.
Toothache: Acon., Alumina.
Trismus nascentium : Passiflora incarnata.
Urethra, painful in micturition, urine sometimes mixed with
blood: Equisetum h.
Vomiting during pregnancy: AEsthusa cynapium, when milk
is not tolerated: Ipec., Kreasot., Nat, sulph., Nux wom.,
Oxylate of Cerium.
Vomiting, irrepressible: Cup. ars., Calomel, 2d dec., grain
doses, three or four times a day, continued for eight or
ten days.
INDEX.
Bladder, evacuation of after delive
ery, 76.
Breasts, condition of should be ob-
served, 94.
Breast pump, Dr. Meigs', 94.
Breech, presentation of, mechanism
of labor in, 56, 147, 148.
diagnosis of, 146.
positions of, 146.
rates of mortality to child, 145.
management of, 149.
Bruce Dr., method in asphyxia, 84.
Bºn's views on separation of child,
8.
Caesarean section, 291.
mortality of, 292.
when justifiable, 293.
preliminary expedients, 293.
method of operating, 293, et seq.
of dressing wound, 294, et seq.
American success compared with
European, 295.
Catalysis, what, 207.
Catamenia, cessation of a sign of
pregnancy, 1.
from other causes, 2.
recurrence during pregnancy, 2.
Catheter, how to use, 20.
Caul, born with a, meaning of, 70.
Caulophyllum, as a partūs accelera-
tor, 107.
given prior to labor, 59.
Cavity of the pelvis, 49.
Cephalotripsy, 277.
cephalotribe, 279.
construction of 279, et seq.
proposed modification, 280.
method of operating, 281, et seq.
M. Pajot's method, 285.
Child, management of, 81.
ablution of, 81.
asphyxiated, treatment of, 81, et
Seq.
when born does not cry, causes
of 69, 70.
Abortion and premature delivery, 31.
management of, 35.
reºval of placenta in cases of,
6
to prevent septicamia after, 38.
haemorrhage after, 39.
convalescence, 39.
Actaea racemosa, given prior to labor,
its uses, 59.
Adherent placenta, 163.
treatment of, 165.
Afterbirth, delivery of, 71, et. seq.
undetached, 74.
Aftercoming head, management of,
150, 151.
Anaesthesia in labor, 296.
chloroform most reliable agent
in, 296.
when anaesthesia is indicated,
296.
answer to objections to its em-
ployment, 297, et seq.
safety of, 297.
not necessarily followed by hac-
morrhage, 299.
Antecedent disease as modifying la-
bor, 102.
how treated, 108.
Areola around nipples, change dur-
ing pregnancy, 4.
Arnica given after delivery, 90.
Arrest of process of parturition, 57.
Arsenicum a., an antiseptic, 90.
After-pains, remedies for, 92–93.
Anteversion of the womb, treatment
of, 20.
Arrangement of bed and dress of pa-
tient in labor, 61.
Ascites, intra-uterine of foetus, 123.
Back, pain in, treatment of, 18.
Ballottement, a test of pregnancy, 7.
how performed, 8.
when available, 8.
Binder, when to be applied, 75.
how long to be worn, 76.
(311)
312
INDEX.
Child, mucus to be removed from
mouth, 67.
retention of urine, 80.
when should be put to the
breast, 86.
management of, regarding food,
colic of, how caused, 87.
causes preventing sucking, 88.
Coryza, relation to permanent
deafness, 89.
methods of separating, 67,68.
when should be removed, 68.
born asphyxiated, 82,83.
Chloroform, in painful labor, 128.
in rigidity of perineum, 113.
use in turning in shoulder pre-
sentations, 155.
method of administering in la-
bor, 301, et seq.
how long a patient may safely
be under its influence, 302.
how awaked, 303.
management of patient in appa-
rent death from, 304
Nélaton's method, 304.
Chorea, treatment of, 17.
Clots, means of expelling, 181.
Colostrum, its uses, 87.
Constipation, management of, 17.
Constriction, spasmodic, of OS uteri,
treatment, 112.
Contractions of the womb, persist-
ent, 6.
irregular, 103.
Countenance, indicative of preg-
nancy, 3.
Cord, management of, 66.
dressing of, 81.
non-ligation, of, 68.
risk of haemorrhage from, 68.
Cramps, 24.
Craniotomy, 276.
a last resource, 129.
instruments used, 276.
position of the patient, 276.
method of Operating 277, et seq.
Meigs' craniotomy forceps, 277.
spot to be selected for perfora-
tion, 277.
speculum advised by some, 279.
Deafness caused by sucking when
the nose is obstructed, 90.
Death of the foetus, a cause of re-
tarded labor, 127.
Deformity of the pelvis, abnormal
labor caused by, 115.
characteristics of, 116.
Deformity, labors in, 119.
Deviations from normal labor, 101.
Diameters of the pelvis, 49.
of the foetal head, 50.
measurement of, 49, 50.
Diarrhoea, treatment of, 18.
Disorders of pregnancy, 12.
Disproportion between the foetal
head and the parturient canal, 105.
Dropsical effusion beneath the chin
of the foetus, a case of, 123.
Duncan Dr. Matthew’s experiments
on strength of foetal spine, 152.
Engorgement of breasts, 94.
Ergot as a uterine stimulant, 107.
Examination, vaginal, how to make,
Excitement, injurious effects of, 91.
Extension of foetal head, 53.
aided by muscles of the peri-
neum, 53.
False pains, treatment of, 63.
False or spurious peritonitis, 236.
Acetate of Morphia in, 238.
Atropia, 3d, 238.
Fatigue of the womb in labor, how
treated, 109.
Fissures or chaps
Graphites in, 97.
Foetal heart sound, a proof of preg-
nancy, 11.
head, diameters of, 50.
flexion of, 50.
ascites and hydrothorax, man-
agement of cases of, 131.
Flooding after delivery of the after-
birth, 177.
foreshadowed by pains of la-
bor, 178.
Food of the lying-in woman, 97.
Forceps, 248.
requisites of, 249.
Pritish form, 249.
American, 249.
methods of locking, 249–50.
forceps of Lazarewitch, Hodge,
Davis, Meigs, 250.
operation, 251 et seq.
how used to effect gradual de-
livery, 129.
position of the patient, 252.
Chloroform in operation, 253.
introduction of the blades, 254
et Seq.
locking the blades, 256 et seq.
how an easy lock may be pro-
cured, 257.
in nipples,
INDEX.
313
Forceps, extraction, how effected,
257.
extracting force, in what direc-
tion applied, 257.
forceps, both tractor and lever,
258.
how it acts in each capacity, 258.
oscillation of the handle facili-
tates delivery, 259. *
perineum, how protected, 260.
blades introduced along the
sides of the pelvis, 260.
management when head rotates
with the forceps, 261.
when head cannot pass lower
strait without rotation, 262.
management of patient after
operation, 262.
time when forceps should be
applied, 263 et seq.
Fundamental law of the Mechanism
of Labor, 52.
illustration, 52.
Haemorrhage in pregnancy, treat-
ment, 22.
from cord, precautions, 77.
in labor, 166.
ante-partum, accidental, 167.
causes of, 167–68.
violent after delivery, 185.
pressure upon the aorta as a
remedy, 186.
post-partum, secondary, 187.
causes of, 189 et seq.
Haemorrhoids, treatment of, 25.
Hall, Dr. Marshall, method in as-
phyxia, 83.
Head, presentation of, how diag-
nosed, 63.
Heart, foºtal, sound of, an evidence
of pregnancy, 10.
how heard, 10.
Hydrate of Chloral, as an anaes-
thetic, 304.
use with patients who inhale
Chloroform badly, 305.
Hyperasthesia of uterine nerves,
1
treatment of, 114.
Induction of premature labor, 286.
when indicated, 286 et seq.
Prof. Thomas on the viability
of the child, 288. (See Pre-
mature Labor, induction of.)
Inferior strait, 49.
Internal haemorrhage, 184.
symptoms of, 185.
Internal haemorrhage, treatment of,
185.
Irregular contractions of the uterus,
how treated, 109.
Ischuria, treatment of, 19.
Kyesteine, a sign of pregnancy, 9.
in suckling women, 9.
Labor, 41.
time of occurrence, 41.
methods of calculation, 42.
proximate cause of, 43.
precursory signs of, 43.
phenomena of, 45, et seq.
mechanism of, 48.
spurious, how detected, 63.
management of, 58.
abnormal, originating in the
child, 122, et seq.
Laceration of perineum, 194.
supposed causes of, 194.
means of preventing, 195.
support as a means of preven-
tion, 196.
rigidity a cause of rupture, treat-
ment of, 197.
grades of laceration, treatment
of each, 199.
Law controlling the movement of
the presenting part of the foetus,
52
Lines of the skin of the breasts dur-
ing pregnancy, 5.
Liquor amnii, too large a quantity
modifying labor, 102.
treatment, 108.
Loins, pain in, treatment of 18.
Lying-in room, arrangement of 90,
91.
Lying-in woman, management of,90.
Mal-position of foetus, treatment of
60
Puls. recommended in, 59.
corrected by natural powers, 59.
Mammary gland, when “caked,”
management of, 95.
Management of lying-in woman
after labor, 90.
Mastitis, or inflammation of the
breasts, 238. te
preventives, 240, et seq.
symptoms, 242.
treatment, 243, et seq.
Mr. Lister's antiseptic treat-
ment, 246, et seq.
Measurement of diameters of pelvis,
49, 50.
314
INDEX.
Mechanism of labor, 48.
Membranes, artificial rupture of, 64,
65.
Milk fever, 94.
Monstrosity of foetus, 124, et seq.
Morning sickness, a sign of preg-
nancy, 3.
how treated, 14.
Morphia, given before chloroform
deepens its effects, 159.
Movement of descentriot necessarily
uniform, 58.
Muriate of Hydrastia, a remedy for
excoriated nipples,
Nipples, attention to, 95, 96.
excoriation, chaps, etc., 95, 96.
tanning, 96.
management of while nursing,
Nitrate of Silver, a remedy for ul-
cerated nipples, 97.
Obliquely distorted pelvis, what, 116.
Obstetric operations, 248.
CEdema, see puerperal convulsions,
229.
Pains, severe before labor, Vib. and
and Xanth. in, 59.
object of 59.
continuous after delivery, 94.
Passive exercise after confinement,
100.
Pelvimeters, 117.
method of using, 117.
Pelvis, diameters of, 49.
Perineum, management of during
labor, 66.
rigidity of, Gels., Lob. inf. and
Chloroform useful in, 113.
application of lard, internally
and externally, with rubbing,
advised by Dr. Clay, 113.
Perchloride of Iron as a haemostatic,
when to be used, 182 et seq.
Pessaries, choice of, 16.
Placenta, delivery of, 70.
gritty, causing excessive suffer-
ing, 106.
praevia, 169.
diagnosis of, 169.
Dr. Barnes' theory of, 170.
criticism upon, 170.
treatment of, 171 et seq.
Plural births, 125 et seq.
management of, 133.
Positions, primary, of the foetal
head, 51.
Post-partum haemorrhage, 175.
causes of, 179.
treatment of, 176.
Dr. Hyatt's method, 177.
prevention, 180.
remedies for, 180.
Posture in labor, 78–79–80.
upon the knees, 80.
Premature labor, induction of, 286.
methods employed, 289 et seq.
Ergot, 289.
puncturing membranes, 290.
gum elastic catheter, 290.
management of infant, 291.
Presentations, unfavorable, of the
foetus, 135.
of the face, 135.
how caused, 136.
diagnosis of, 137.
difficulty of, 138.
management of, 139 et seq.
Pº, Penrose's expedient in,
140.
when the chin turns backward,
142.
of the back and sides, diagnosis
of, 143.
management of 144 et seq.
of knees, 152.
of feet, 152.
deviated, of the head, 153.
shoulder, 153.
positions of, 154,
diagnosis of, 157.
Prolapse of arm, 153.
umbilical cord, 160.
treatment of, 162–163.
Pruritus in pregnancy, treatment of,
24
Puerperal convulsions, 220.
greater liability to, of primi-
parae, 224.
of unmarried girls, 224.
Dr. Lilienthal’s case, 225.
symptoms given by Dr. Barker,
225 et seq.
prognosis, 228.
prophylaxis, 229.
treatment, 230 et seq.
Chloroform in, 232 et seq.
lancet in, 236.
Pulse, quick after delivery, forebod-
ing haemorrhage, 76, 178.
Quickening, when it occurs, 10.
value of, as a sign of pregnancy,
10.
Regimen of the lying-in woman, 98.
INDEX.
315
Restitution, meaning of, 53.
Retarded labor, 101.
Retention of urine after delivery, 77.
Ergot as a remedy in, 77.
Retraction, premature, of the body
of the uterus, 103.
how treated, 110.
Retroversion of the womb, treat-
ment of 20.
Rigidity of the os uteri, a cause of
tedious labor, 104.
how treated, 110.
of the perineum a cause of de-
lay in labor, 105.
how treated, 112.
Bisks of non-ligation of the cord, 68.
Rotation, process of, 52.
aided by the perineum, 54.
Rupture of the womb endangered
by violent contractions, 129.
Salivation a sign of pregnancy, 4.
Sebaceous follicles around nipples,
enlargement of, in pregnancy, 5.
Shoulder, presentation of, manage-
ment, 158.
Shoulders, delivery of, 67.
Sitting up after confinement, 99.
Sleep as a renovator of uterine
energy, l08.
Sleeplessness, treatment of, 21.
Sucking, obstacles to, 88.
Sum of forces employed in parturi-
tion, 57.
Superior strait, 49.
Tedious labor, causes of, 101, et seq.
Tissue around nipples, change in
pregnancy, 5.
Toxaemic puerperal disease, 201.
factors in its production, 202.
proximate causes of, 202, et seq.
changes produced in the blood
by its agency, 206.
action probably catalytic, 207.
lesions found after death, 209.
Toxaemic puerperal disease, symp-
toms, 209, et seq.
prophylaxis of, 211, et seq.
Arnica as a preventive, 212.
principle upon which prophy-
laxis may be successful, 214, et
Sec.
trºnent of toxaemic puerperal
disease, 218, et seq.
Treatment preparatory to labor, 59.
Trocar to be used in case of hydro-
cephalous head, 130.
Trunk, delivery of, 67.
Tumors of the head of the foetus, 67.
Twins, presence of, retards labor,
125, et. seq.
management in cases of, 133.
Umbilical cord, management of, 67.
non ligation of 68, 69.
separation of 85.
haemorrhage from, 86.
Uterine growths simulating preg-
nancy, 5.
cysts, 6.
Utero-gestation, normal term of, 41.
Vaginal examination, how made, 62.
Version, 266.
cephalic version, 266, et seq.
position of patient, 267.
bi-manual method, 268.
podalic version, 269, et seq.
application of bi-manual, or bi-
polar method, 270.
management of the arms, 272.
delivery of the head (see Pre-
sentation of the Breech).
which foot should be selected in
podalic version, 273.
anaesthesia of great importance
in difficult cases of turning,
274.
Morphia as an adjuvant of chlo-
roform, 275.
to be avoided when severe shock
is apprehendod, 275,
Viburnum op. and Viburnum prun.,
suggested for trial in precursory
labor pains, 307.
Vomiting of pregnancy, remedies
for, 15.
caused by anteversion, 15.
Xanthox. frax., for severe prepara-
tory pains of labor, 307.
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Cloth, • • I 5o
This little book had a very large sale, and but few physicians' offices will be found with-
out it The work was, without exception, very highly commended by the homoeopathic press.
BERJEAU, J. PH. The Homoeopathic Treatment of Syphilis,
Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised,
with numerous additions, by J. H. P. FROST, M.D. 256 pages. 12mo.
Cloth, . . § •' tº dº tº º gº . $1 50
“This work is unmistakably the production of a practical man. It is short, pithy, and
contains a vast deal of sound, practical instruction. The diseases are briefly described; the
directions for treatment are succinct and summary. It is a book which might with profit
be consulted by all practitioners of homoeopathy.”—NORTH AMERICAN JOURNAL. .
BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi-
cines. 383 pages, e wº e e © • , , . $ I 25
Interleaved with writing paper. Half morocco, . tº • $2 25
We quote from the author's preface:
“It has been my aim, throughout, to arrange in as concise form as possible, the leading
symptoms of all well-established provings. To accomplish this, I have compared Lippe's
Mat. Med. ; the Symptomen-Codex; Jahr's Epitome; Boenninghausen's Therapeutic Pocket-
Book, and Hale's, New Remedies.”
BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo-
pathic Medicine, Alphabetically and Nosologically arranged, which
may be used as the Physicians' Wade-mecum, the Travellers' Medical
Companion, or the Family Physician. Third edition. 352 pages.
18mo. Cloth, . to gº º e © ſº . $1 5o
BUTLER, DR. JOHN. Electricity in Surgery. Pp. 112. Cloth,
$I. oo.
These few pages are intended as a practical guide for the use of the specialist and general
practitioner, and aim at showing the necessity of attaining accuracy of detail in all electro-
surgical operations.
The scope of the work precludes the possibility of more than cursory allusion to clinical
cases, but is based almost entirely upon the author's own personal experience, and is for the
most part composed of articles written from time to time for different periodicals, revised
and condensed.
BUTLER, Dr. JOHN. A Text-Book of Electro-Therapeutics
and Electro-Surgery, for the Use of Students and General
Practitioners. By JoHN BUTLER, M.D., L.R.C.P.E., L.R.C.S.I.,
etc. Second edition, revised and enlarged. 350 pages, 8vo. Cloth,
3 Oo.
“Butler’s work gives with exceptional thoroughness all details of the latest researches on
Electricity, which powerful agent has a great future, and rightly demands our most earnest
consideration. But Homoeopathia especially must hail with delight the advent from out the
ranks of her apostles of a writer of John Butler's ability. His book will also find a large
circle of non-homoeopathic readers, since it does not conflict with the tenets of any thera-
peutic sect, and particular care has been bestowed on the technical part of electro-therapeia.”
—HomoeoPATISCHE RUNDSCHAU. . . 1 --> *
3.
HOMOEOPATHIC PUBLICATIONS. 3
DAKE, DR. W.M. C. Pathology and Treatment of Diphtheria.
By WM. C. DAKE, M.D., of Nashville, Tenn. 55 pages. 8vo. Pa-
per, . * e sº tº & © e ſº e 5o cts.
This interesting monograph was enlarged from a paper read at the Third
Annual Meeting of the Homoeopathic Society of Tennessee, held at Mem-
phis, September 19, 1877. i>
It gives a report of one hundred and seventy-six cases treated during a
period of eleven months. It well repays a careful perusal.
DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science
of Therapeutics. A collection of papers elucidating and illustrating
the principles of homoeopathy. 529 pages. 8vo. Cloth, . . $3 oo
Half morocco, g e $4 Oo
“After reading this work no one will attempt to justify the practice of alternation of
remedies. It is simply the lazy man’s expedient to escape close thinking or to cover his
ignorance. The one remedy alone can be accurate and scientific; a second or third only
complicates and spoils the case, and will inevitably ruin a good reputation. But to come to
more practical matters, more than one-half of this volume is devoted to a careful analysis of
various drug-provings. It teaches us Materia Medica after a new fashion, so that a fool can
understand, not only the full measure of usefulness, but also the limitations which surround
the drug. . . . We ought to give an illustration of his method of analysis, but space
forbids. We can only urge the thoughtful and studious to obtain the book, which they will
esteem as second only to the Organon in its philosophy and learning.”—THE AMERICAN
HOMOEQPATHIST.
DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Med-
ica. 858 pages. 8vo. Cloth, . o * * * iº . $5 Oo
Half morocco, . gº o G C. sº tº de . $6 oo
* @ “Vol. I is adorned with a most perfect likeness of Dr. Dunham, upon which
stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy
there will be seen the unmistakable impress of the great soul that looked so long and stead-
fastly out of its fair windows. But our readers will be chiefly concerned with the contents
of these two books. They are even better than their embellishments. They are chiefly
such lectures on Materia Medica as Dr. Dunham afone knew how to write. They are pre-
ceded quite naturally by introductory lectures, which he was accustomed to deliver to his
classes on general therapeutics, on rules which should guide us in studying drugs, and on
the therapeutic law. At the close of Vol. II we have several papers of great interest, but
the most important fact of all is that we have here over fifty of our leading remedies pre-
sented in a method which belonged peculiarly to the author, as one of the most successful
teachers our school has yet produced. . . . Blessed will be the library they adorn, and
wise the man or woman into whose mind their light shall shine.”—CINCINNATI MEDICAL
ADVANCE.
EATON, DR. MORTON. M., on the Medical and Surgical Dis-
eases of Women, with their Homoeopathic Treatment. Fully illus-
trated. Pp. 781. 8vo. Sheep, . e se © Q. . $6 5o
This work is received with great favor by the profession, and is com-
mended by the homoeopathic press as being the best and most complete
work on the subject hitherto issued.
“This is a large, handsome volume of 782 pages, beautifully printed on good paper,
and strongly bound in leather. The illustrations are numerous and good and well bring
out the anatomical relationship of the parts, and put the various dislocations before the mind
very clearly indeed; in fact, almost too clearly, for he who learns thus, and then tries to
carry his knowledge into practice, will feel rather disappointed at the less obliging disposi-
tion of nature herself. Drawings of almost all the principal instruments are given, and the
whole subject brought down to date. There is an air about this work that commends it
very much to our judgment for the use of the student, and of the general practitioner, and
4 BOERICKE & TAFEL's
Q $
hence, we believe, it is destined to become thc class-book in homoeopathic colleges for many
years to come. There is a healthy absence of the scissors and paste business. The author
holds the candle of his own experience, and thus affords a reliable aid to the gynaecological
path-finder in all his freshness and inexperience.”—From the HoMCEOPATHIC WORLD for
January, 1881.
EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine
and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3 5o
The author brought here together in an admirable and comprehensive
arrangement everything published to date on the subject in the whole homoe-
opathic literature, besides embodying his own abundant personal experience.
The contents, divided into eight parts, are arranged as follows:
Part I. Treats on Menstruation and Dysmemorrhaea; Part II. Menor-
rhagia; Part III. Amenorrhaea ; Part IV. Abortion and Miscarriage; Part
V. Metrorrhagia ; Part VI. Fluor albus, Part VII. Zochia ; and Part
VIII. General Concomitants. No work as complete as this, on the subject,
was ever before attempted, and we feel assured that it will meet with great
favor by the profession.
“The book is a counterpart of Bell on Diarrhoea, and Dunham on Whooping cough.
Synthetics, Diagnosis and Pathology are left out as not coming within the scope of the work.
The author in his preface says: Remedies and their symptoms are left out, and the symp-
toms and their remedies have received sole attention—that is what the busy practitioner
wants. The work is one of the essentials in a library.”—AMERICAN OBSERVER.
“A most exhaustive treatise, admirably arranged, covering all that is known of thera-
peutics in this important department.”—HOMCEOPATHIC TIMES.
GUERNSEY, DR. H. N. The Application of the Principles
and Practice of Homoeopathy to Obstetrics and the Dis-
orders Peculiar to Women and Young Children. By HENRY
N. GUERNSEy, M. D., Professor of Obstetrics and Diseases of Women
and Children in the Homoeopathic Medical College of Pennsylvania,
etc., etc. With numerous Illustrations. Third edition, revised, en-
larged, and greatly improved. Ioo.4 pages. 8vo. Half morocco, $8 oo
This standard work, with the numerous improvements and additions, is the most com-
plete and comprehensive work on the subject in the English language. Of the previous
editions, almost four thousand copies are in the hands of the profession, and of this third
edition a goodly number have already been taken up. There are few other professional
works that can boast of a like popularity, and with all new improvements and experiences
diligently collected and faithfully incorporated into each successive edition, this favorite
work will retain its hold on the high esteem it is held in by the profession, for years to come.
It is superfluous to add that it was and is used from its first appearance as a text-book at the
homoeopathic colleges.
GUERNSEY, DR. E. Homoeopathic Domestic Practice. With
Full Descriptions of the Dose to each single Case. Containing also
Chapters on Anatomy, Physiology, Hygiene, and an abridged Materia
Medica. Tenth enlarged, revised, and improved edition. 653 pages.
Half leather, © tº ę ſº e ge g º . $2 5o
GUERNSEY, DR. W. E. The Traveller's Medical Repertory
and Family Adviser for the Homoeopathic Treatment of
Acute Diseases. 36 pages. Cloth, tº & te . 3o CtS.
This little work has been arranged with a view to represent in as compact a manner as
possible all the diseases—or rather disorders—which the non-professional would attempt to
HOMOEOPATHIC PUBLICATIONS. 5
r—
prescribe for, it being intended only for the treatment of simple or acute diseases, or to allay
the suffering in maladies of a more serious nature until a homoeopathic practitioner can be
summoned.
HAHNEMANN, DR. S. The Lesser Writings of. Collected and
Translated by R. E. DUDGEON, M.D. With a Preface and Notes by E.
MARCY, M.D. With a Steel Engraving of Hahnemann from the statue
of Steinhauser. 784 pages. Half bound, . Q we . $3 oo
This valuable work contains a large number of Essays, of great interest to laymen as
well as medical men, upon Diet, the Prevention of Diseases, Ventilation of Dwellings, etc.
As many of these papers were written before the discovery of the homoeopathic theory of
cure, the reader will be enabled to peruse in this volume the ideas of a gigantic intellect
when directed to subjects of general and practical interest.
HAHNEMANN, DR. S. Organon of the Art of Healing. By
SAMUEL HAHNEMANN. “Aude Sapere.” Fifth American edition, trans-
lated from the Fifth German edition, by C. WESSELHCEFT, M.D. 244
pages. 8vo. Cloth, . gº tº º tº tº e . $1 75
This fifth edition of “Hahnemann Organon” has a history. So many
complaints were made again and again of the incorrectness and cumbersome
style of former and existing editions to the publishers, that, yielding to the
pressure, they promised to destroy the plates of the fourth edition, and to
bring out an entire re-translation in 1876, the Centennial year. After due
consideration, and on the warm recommendation of Dr. Constantine Hering
and others, the task of making this re-translation was confided to Dr. C.
Wesselhoeft, and the result of years of labor is now before the profession,
who will be best able themselves to judge how well he succeeded in acquit-
ting himself of the difficult task.
“To insure a correct rendition of the text of the author, they (the publishers) selected as
his translator Dr. Conrad Wesselhoeft of Boston, an educated physician in every respect,
and from his youth up perfectly familiar with the English and German languages. than
whom no better selection could have been made.” “That he has made, as he himself de-
clares, ‘an entirely new and independent translation of the whole work,’ a careful compari-
Son of the various paragraphs, notes, etc., with those contained in previous editions, gives
abundant evidence; and while he has, so far as was possible, adhered strictly to the letter of
Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids
the harshness of a strictly literal translation.”—HAHNEMANNIAN MONTHLY.
HALE, DR. E. M. Lectures on Diseases of the Heart. In Three
Parts. Part I. Functional Disorders of the Heart. Part II. Inflamma-
tory Affections of the Heart. Part III. Organic Diseases of the Heart.
Second enlarged edition. 248 pages. Cloth, tº * . $1 75
HALE, DR. E. M. Materia Medica and Special Therapeutics
of the New Remedies. Fifth edition, revised and enlarged. In
two Volumes.
Vol. I. Special Symptomatology. With new Botanical and Pharmaco-
logical Notes and Appendix. 1882. 746 pages. Cloth, . . $5 Oo
Half morocco, * tº e tº sº * > & * . 6 oo
Vol. II. Special Therapeutics. With Illustrative Clinical Cases.
90o pages. Cloth, . gº & • {º e tº ic . $5 Oo
Half morocco, e tº gº g •º º wº º . $6 oo
6 BOERICKE & TAFEL's
—-º- -**
“Dr. Hale's work on ‘New Remedies’ is one both well known and much appreciated
on this side of the Atlantic. For many medicines of considerable value we are indebted to
his researches. In the present edition the symptoms produced by the drug investigated and
those which they have been observed to cure, are separated from the clinical observations,
by which the former have been confirmed. That this volume contains a very large amount
of invaluable information is incontestable, and that every effort has been made to secure
both fulness of detail and accuracy of statement, is apparent throughout. For these reasons
we can confidently commend Dr. Hale's fourth edition of his well-known work on the ‘New
Remedies' to our homoeopathic colleagues.”—MONTHLY HOMOEOPATHIC REVIEW.
“We do not hesitate to say that by these publications Dr. Hale rendered an inestimable
service to homoeopathy, and thereby to the art of medicine. “The school of Hahnemann in
every country owes him hearty thanks for all this; and allopathy is beginning to share our
gain.” The author is given credit for having in this fourth edition corrected the mistake
for which the third one had been taxed rather severely, by restoring in Vol. II the ‘special
therapeutics,’ instead of the ‘characteristics’ of the third edition.”—BRITISH JOURNAL OF
HOMCEOPATHY.
HALE, DR. E. M. The Medical, Surgical, and Hygienic Treat-
ment of Diseases of Women, especially those causing Ster-
ility, the Disorders and Accidents of Pregnancy, and Pain-
ful and Difficult Labor. By EDwiN M. HALE, M.D., Professor of
Materia Medica and Therapeutics in the Chicago Homoeopathic College,
etc., etc. Second enlarged edition. 378 pages. 8vo. Cloth, $2 50
“This new work embodies the observations and experience of the author during twenty-
five years of active and extensive practice. and is designed to supplement rather than super-
cede kindred works. The arrangement of the subjects treated is methodical and convenient;
the introduction containing an article inserted by permission of Dr. Jackson, of Chicago, the
author upon the ovular and ovulation theory of menstruation, which contains all the obser-
vations of practical importance known on this subject to date. The diseases causing sterility
are fully described, and the medical, surgical and hygienic treatment pointed out. The
more generally employed medicines are enumerated, but their special or specific indications
are unfortunately omitted. The general practitioner will find a great many valuable things
for his daily rounds, and cannot afford to do without the book. The great reputation and
ability of the author are sufficient to recommend the work, and to guarantee an appreciative
reception and large sale.”—HAHNEMANNIAN MONTHLY.
HART, DR. C. P. Diseases of the Nervous System. Being a
Treatise on Spasmodic, Paralytic, Neuralgic and Mental Affections.
For the use of Students and Practitioners of Medicine. By CHAs. Por-
TER HART, M.D., Honorary Member of the College of Physicians and
Surgeons of Michigan, etc., etc., etc. Pp. 409. 8vo. Cloth, $3 oo
“This work supplies a need keenly felt in our school—a work which will be useful,
alike to the general practitioner and specialist; containing, as it does, not only a condensed
compilation of the views of the best authorities on the subject treated, but also the author's
own clinical experience; to which is appended the appropriate homoeopathic treatment of
each disease. It is written in an easy, flowing style, at the same time there is no waste of
words. * * * * * We consider the work a highly valuable one, bearing the evidence
of hard work, considerable research and experience.”—MEDICO-CHIRURGICAL QUARTERLY.
“We feel proud that in Hart’s “Diseases of the Nervous System’ we have a work up to
date a work which we need not feel ashamed to put in the hands of the neurologist or
alienist for critical examination, a work for which we predict a rapid sale.”—North AMER-
ICAN JOURNAL OF HOMOEOPATHY.
HELMUTH, DR. W. T. A System of Surgery. Illustrated with
568 Engravings on Wood. By WM. ToD HELMUTH, M.D. Fourth edi-
tion. Iooo pages. Sheep, . º e e º * . $8 5o
This edition of Dr. Helmuth's great work is already in appearance a great improve-
ment over the old edition, it being well printed on fine paper, and well bound. By in-
creasing the size of the page, decreasing the size of type, and setting up solid, fully one-half
more printed matter is given than in the previous edition, albeit there are over 200 pages
HOMOEOPATHIC PUBLICATIONS. 7
less; and while the old edition, bound in sheep, was sold at $11.5o by its publishers, this
improved third edition is now furnished at $3 less, or for $8.50. The author brought the
work fully up to date, and for an enumeration of some of the more important improvements,
we cannot do better than to refer to Dr. Helmuth's own Preface.
HEMPEL, DR. C.-J., and DR. J. BEAKLEY. Homoeopathic
Theory and Practice. With the Homoeopathic Treatment of Surgi-
cal Diseases, designed for Students and Practitioners of Medicine, and
as a Guide for an intelligent public generally. Fourth edition. 11oo
pages, . tº e tº * > © e tº & & . $3 OO
HERING, D.R. C. Condensed Materia Medica. Second edition.
More condensed, revised, enlarged, and improved, te . $7 Oo
In February, 1877, we were able to announce the completion of Hering's Condensed
Materia Medica. The work, as was to be expected, was bought up with avidity by the pro-
fession and already in the fall of 1878 the author set to work perfecting a second and im-
proved edition. By still more condensing many of the remedies, a number of new ones
could be added without much increasing the size and the price of the work. This new
edition is now ready for the profession, and will be the standard work par excellence for the
practitioner's daily reference.
HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo-
pathic Drugs. Translated from the German by EMIL TIETZE, M.D.,
of Philadelphia. 576 pages. 8vo. Cloth, . tº tº . $3 5o
This work, but shortly issued, is already meeting with a large sale and an appreciative
reception. It differs from most works of its class in these respects:
I. That the symptomatic outlines of the various drugs are based exclusively upon the
‘pathogenetic” results of provings. -
2. That the anatomico-physiological arrangement of the symptoms renders easier the
understanding and survey of the provings.
3. That the pathogenetic pictures drawn of most of the drugs, gives the reader a clearer
idea and a more exact impression of the action of the various remedies. &
Each remedy is introduced with a brief account of its preparation, duration of action
and antidotes.
HOLCOMBE, DR. W. H. Yellow Fever and its Homoeopathic
Treatment, wº † ſº * Q Q º ſº . IO CtS.
HOLCOMBE, DR. W. H. What is Homoeopathy P A new ex-
position of a great truth. 28 pages. 8vo. Paper cover. Per dozen,
$1.25, & gº tº e e ſº * tº ſº • . I 5 CtS.
“Prove all things, hold fast that which is good.”—ST. PAUL.
HOLCOMBE, DR. W. H. How I became a Homoeopath. 28
pages. 8vo. Paper cover. Per dozen, $1.25, . . gº . I 5 CtS.
HOLCOMBE, DR. W. H. Special Report of the Homoeopathic
Yellow Fever Commission, ordered by the American Institute of
Homoeopathy for presentation to Congress. 32 pages. 8vo. Paper.
Per hundred, $4.oo, . • * * ſº e gº 5 cts.
This Report, written in Dr. Holcombe's masterly manner, is one of the best campaign
documents for homoeopathy. The statistics must convince the most skeptical. and every
homoeopathic practitioner should feel in duty bound to aid in securing its widest possible
circulation. *
HOMCEOPATHIC POULTRY PHYSICIAN (Poultry veteri-
narian); or, Plain Directions for the Homoeopathic Treatment of the
8 BOERICKE & TAFEL's
most Common Ailments of Fowls, Ducks, Geese, Turkeys and Pigeons,
based on the author’s large experience, and compiled from the most re-
liable sources, by Dr. Fr. Schröter. Translated from the German. 84
pages. I2mo. Cloth, tº * * º º e G . 5o cts.
We imported hundreds of copies of this work in the original German for our customers,
and as it gave good satisfaction, we thought it advisable to give it an English dress, so as to
make it available to the public generally. The little work sells very fast, and our readers
will doubtless often have an opportunity to draw the attention of their patrons to it.
HOMCEOPATHIC COOKERY, Second edition. With Additions
by the Lady of an American Homoeopathic Physician. Designed chiefly
for the Use of such Persons as are under Homoeopathic Treatment. I 76
pages, tº tº º • * * tº o tº º . 5o CtS.
HULL’S JAHR. A New Manual of Homoeopathic Practice.
Edited, with Annotations and Additions, by F. G. SNELLING, M.D.
Sixth American edition. With an Appendix of the New Remedies, by
C. J. HEMPEL, M.D. 2 volumes. 2076 pages, . & . $9 Oo
The first volume, containing the symptomatology, gives the complete pathogenesis of
two hundred and eighty-seven remedies, besides, a large number of new remedies are added
by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Re-
pertory. Each chapter is accompanied by copious clinical remarks and the concomitant
symptoms of the chief remedies for the malady treated of, thus imparting a mass of informa-
tion, rendering the work indispensable to every student and practitioner of medicine.
JAHR, DR. G. H. G. Therapeutic Guide; the most Important Re-
sults of more than Forty Years' Practice. With Personal Observations
regarding the truly reliable and practically verified Curative Indications
in actual cases of disease. Translated, with Notes and New Remedies,
by C. J. HEMPEL, M.D. 546 pages, . e g gº . $3 Oo
“With this characteristically long title, the veteran and indefatigable Jahr gives us
another volume of homoeopathics. Besides the explanation of its purport contained in the
title itself, the author’s preface still further sets forth its distinctive aim. It is intended, he
says, as a “guide to beginners, where I only indicate the most important and decisive points
for the selection of a remedy, and where I do not offer anything but what my own individual
experience, during a practice of forty years, has enabled me to verify as absolutely decisive
in choosing the proper remedy. The reader will easily comprehend that, in carrying out
this plan, I had rigidly to exclude all cases concerning which I had no experience of my
own to offer. . . . . We are bound to say that the book itself is agreeable, chatty, and
full of practical observation. It may be read straight through with interest, and referred to
in the treatment of particular cases with advantage.”—BRITISH JOURNAL OF HOMOEOPATHY.
JAHR, DR. G. H. G. The Homoeopathic Treatment of Dis-
eases of Females and Infants at the Breast. Translated from
the French by C. J. HEMPEL, M.D. 422 pages. Half leather, $2 oo
This work deserves the most careful attention on the part of homoeopathic practitioners.
The diseases to which the female organism is subject are described with the most minute
correctness, and the treatment is likewise indicated with a care that would seem to defy
criticism. No one can fail to study this work but with profit and pleasure.
INDEX to the first eighteen volumes of the North American Journal of
Homoeopathy. Paper, . & wº * te tº wº . $2 oo
JONES, DR. SAMUEL A. The Grounds of Homoeopathic
Faith. Three Lectures, delivered at the request of Matriculates of the
Department of Medicine and Surgery (Old School) of the University of
HOMOEOPATHIC PUBLICATIONS. 9
Michigan. By SAMUEL A. Jones, M.D., Professor of Materia Medica,
Therapeutics, and Experimental Pathogenesy in the Homoeopathic
Medical College of the University of Michigan, etc., etc. 92 pages.
12mo. Cloth. Per dozen, $3.oo; per hundred, $20.oo, -. 3o cts.
Lecture first is on THE LAW OF SIMILARs; ITS CLAIM TO BE A SCIENCE IN THAT IT
ENABLEs PERVERSION. Lecture second, THE SINGLE REMEDY A NECESSITY OF SCIENCE.
Lecture third, THE MINIMUM DOSE AN INEVITABLE SEQUENCE. A fourth Lecture, on THE
DYNAMIZATION THEORY, was to have finished the course, but was prevented by the approach
of final examinations, the preparation for which left no time for hearing evening lectures.
The LECTUREs are issued in a convenient size for the coat-pocket; and as an earnest testi-
mony to the truth, we believe they will find their way into many a homoeopathic household.
JOHNSON, DR. I. D. Therapeutic Key; or, Practical Guide for
the Homoeopathic Treatment of Acute Diseases. Tenth edition. 347
pages. Bound in linen, tº * e ſº ſº e . $1 75
Bound in flexible cover, ſº © tº & ge o . $2 25
This has been one of the best selling works on our shelves; more copies being in circu-
lation of this than of any two other professional works put together. "It is safe to say that
there are but few homoeopathic practitioners in this country but have one or more copies of
this little remembrancer in their possession.
JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De-
signed for the use of Families and Private Individuals. 494 pages.
Cloth, . e © tº º tº º & * ſº . $2 oo
This is the latest work on Domestic Practice issued, and the well and favorably known
author has surpassed himself. In his book fifty-six remedies are introduced for internal ap-
plication, and four for external use. The work consists of two parts. Part I is subdivided
into seventeen chapters, each being devoted to a special part of the body, or to a peculiar
class of disease. Part II contains a short and concise Materia Medica, i. e. gives the
symptoms peculiar to each remedy. The whole is carefully written with a view of avoiding
technical terms as much as possible, thus insuring its comprehension by any person of ordi-
nary intelligence. A complete set of remedies in vials holding over fifty doses each, is fur-
nished for $7, or in vials holding over one hundred doses each for $10, or book and case
complete for $9 or $12 respectively. Address orders to Boericke & Tafel's Pharmacies at
New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco.
JOSLIN, DR. B. F. Principles of Homoeopathy. In a Series of
Lectures. 185 pages. I2mo. Cloth, fº e e . 6o cts.
KREUSSLER, DR. E. The Homoeopathic Treatment of Acute
and Chronic Diseases. Translated from the German, with Im-
portant Additions and Revisions, by C. J. HEMPEL, M.D. 190
pages, tº sº sº º © e * e o . 60 cts.
The author is a practitioner of great experience and acknowledged talent. This work
is distinguished by concise brevity and lucid simplicity in the description of the various
diseases that usually come under the observation of physicians, and the remedies for the
various symptoms are carefully indicated. Dr. Hempel has interspersed it with a number
of highly useful and interesting notes, which cannot fail to enhance the value of this work
to American physicians.
LAURIE and McCLATCHEY. The Homoeopathic Domestic
Medicine. By Joseph LAURIE, M.D. Ninth American, from the
Twenty-first English edition. Edited and Revised, with Numerous and
Important Additions, and the Introduction of the New Remedies. By
R. J. McCLATCHEY, M.D. 1 oz. 4 pages. 8vo. Half morocco, #5 od
“We do not hesitate to indorse the claims made by the publishers, that this is the most
complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis-
10 BOERICKE & TAFEL's
eases extant. This handsome volume of nearly eleven hundred pages is divided into six
parts. PART ONE is introductory, and is almost faultless. It gives the most complete and
exact directions for the maintenance of health, and of the method of investigating the con-
dition of the sick, and of discriminating between different diseases. It is written in the
most lucid style and is above all things wonderfully free from technicalities. PART Two
treats of symptoms, character, distinctions, and treatment of general diseases, together with
a chapter on casualties. PART THREE takes up diseases peculiar to women. PART FOUR
is devoted to the disorders of infancy and childhood. PART FIVE gives the characteristic
symptoms of the medicines referred to in the body of the work, while PART SIX introduces
the repertory.”—HAHNEMANNIAN MONTHLY.
‘ Of the usefulness of this work in cases where no educated homoeopathic physician is
within reach, there can be no question. There is no doubt that domestic homoeopathy has
done much to make the science known; it has also saved lives in emergencies. The prac-
tice has never been so well presented to the public as in this excellent volume.”—NEw
ENG. MED. GAZETTE. &
A complete set of remedies of one hundred and four vials, containing over fifty doses
each, is furnished for $12, put up in an elegant mahogany case. A similar set in vials con-
taining over one hundred doses each, is furnished for $18. or book and case complete for
$17 or $23 respectively. Address orders to Boericke & Tafel's Pharmacies at New York,
Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco.
LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S.
LILIENTHAL, M.D., Editor of North American Journal of Homoeo-
pathy, Professor of Clinical Medicine and Psychology in the New York
Homoeopathic Medical College, and Professor of Theory and Practice
in the New York College Hospital for Women, etc. Second edition.
8vo, . º o tº © º tº tº tº e . $5 Oo
Half morocco, . . . ſº e tº º de * > . $6 oo
“Certainly no one in our ranks is so well qualified for this work as he who has done it,
and in considering the work done, we must have a true conception of the proper sphere of
such a work. For the fresh graduate, this book will be invaluable, and to all such we un-
hesitatingly and very earnestly commend it. To the older one, who says he has no use for
this book, we have nothing to say. He is a good one to avoid when well, and to dread
when ill. We also hope that he is severely an unicum.”—PROF. SAM. A. JONES IN AMERI-
CAN HOMOEOPATHIST.
“ . . . It is an extraordinary useful book, and those who add it to their library
will never feel regret, for we are not saying too much in pronouncing it the BEST work ON
THERAPEUTICs in homoeopathic (or any other) literature. With this under one elbow, and
Hering's or Allen's MATERIA MEDICA under the other, the careful homoeopathic practitioner
can refute Niemayer's too confident assertion, “I declare it idle to hope for a time when a
medical prescription should be the simple resultant of known quantities.” Doctor, by all
means buy Lilienthal’s HoMCEoPATHIC THERAPEUTICS. It contains a mine of wealth.”—
PROF. CHAS. GATCHEL IN IBID.
LUTZE, DR. A. Manual of Homoeopathic Theory and Prac-
tice. Designed for the use of Physicians and Families.
Translated from the German, with additions by C. J. HEMPEL, M.D.
From the sixtieth thousand of the German edition. 750 pages. 8vo.
Half leather, tº e tº iº . . º ſº . $2 5o
This work, from the pen of the late Dr. Lutze, has the largest circulation of any homoeo-
pathic work in Germany, no less than sixty thousand copies having been sold. The Intro-
duction, occupying over fifty pages, contains the question of dose, and rules for examining
the patient, and diet; the next sixty pages contain a condensed pathogenesis of the remedies
treated of in the work; the description and treatment of diseases occupy four hundred and
eighteen pages, and the whole concludes with one hundred and seventy-three pages of reper-
tory and a copious index, thus forming a concise and complete work on theory and practice.
MALAN, H. Family Guide to the Administration of Homoeo-
pathic Remedies. II 2 pages. 32mo. Cloth, © • 30 CtS.
HOMOEOPATHIC PUBLICATIONS. - 11
—-------º
MANUAL OF HOMOEOPATHIC VETERINARY PRAC-
TICE. Designed for all kinds of Domestic Animals and Fowls, pre-
scribing their proper treatment when injured or diseased, and their par-
ticular care and general management in health. Second and enlarged
edition. 684 pages. 8vo. Half morocco, tº & . $5 Oo
“In order to rightly estimate the value and comprehensiveness of this great work, the
reader should compare it, as we have done, with the best of those already before the public.
In size, fulness and practical value it is head and shoulders above the very best of them,
while in many most important disorders it is far superior to them altogether, containing, as
it does, recent forms of disease of which they make no mention.”—HAHNEMANNIAN
MONTHLY.
MARSDEN, DR. J. H. Handbook of Practical Midwifery, with
full instructions for the Homoeopathic Treatment of the
Diseases of Pregnancy, and the Accidents and Diseases in-
cident to Labor and the Puerperal State. By J. H. MARSDEN,
A.M., M.D. 315 pages. Cloth, . . . . iº . $2 25
“It is seldom we have perused a text-book with such entire satisfaction as this. The
author has certainly succeeded in his design of furnishing the student and young practitioner,
within as narrow limits as possible, all necessary instruction in practical midwifery. The
work shows on every page extended research and thorough practical knowledge. The style
is clear, the array of facts unique, and the deductions judicious and practical. We are par-
ticularly pleased with his discussion on the management of labor, and the management of
mother and child immediately after the birth, but much is left open to the common-sense
and practical judgment of the attendant in peculiar and individual cases.”—HOMCEOPATHIC
TIMES.
MOHR, DR. CHARLES. The Incompatible Remedies of the
Homoeopathic Materia Medica. By CHARLEs MoHR, M.D., Lec-
turer on Homoeopathic Pharmaceutics, Hahnemann Medical College,
Philadelphia. (A paper read before the Homoeopathic Medical Society
of the County of Philadelphia.) Pamphlet, in cover, . . Io CtS.
This is an interesting paper, which will well repay perusal and study. It gives a list of
fifty-seven remedies and their incompatibles, diligently collated from the best-known sources.
MORGAN, DR. W. The Text-book for Domestic Practice,
being plain and concise directions for the Administration of Homoeo-
pathic Medicines in Simple Ailments. 191 pages. 32mo. Cloth, 5o cts.
This is a concise and short treatise on the most common ailments, printed in convenient
size for the pocket; a veritable traveller's companion.
A complete set of thirty remedies, in vials holding over fifty doses each, is furnished for
$4.50, in stout mahogany case; or same set in vials holding over one hundred doses each,
for $6.50; or book and case complete for $5 or $7 respectively. Address orders to Boericke
& Tafel's Pharmacies, New York, Philadelphia, Baltimore, Chicago, New Orleans, or San
Francisco.
MURE, DR. B. Materia Medica; or, Provings of the Principal Ani-
mal and Vegetable Poisons of the Brazilian Empire, and their Applica-
tion in the Treatment of Diseases. Translated from the French, and
arranged according to Hahnemann’s Method, by C. J. HEMPEL, M.D.
220 pages. 12mo. Cloth, . g º • . 4 × . $1 Oo
This volume, from the pen of the celebrated Dr. Mure, of Rio Janeiro contains the
pathogenesis of thirty-two remedies, a number of which have been used in general practice
ever since the appearance of the work. A faithful wood-cut of the plant or animal treated
of accompanies each pathogenesis. gº
12 BOERICKE & TAFEL's
-w
NEIDHARD, DR. C. on the Universality of the Homoeopathic
Law of Cure, . & * > ſº tº tº º ſº • 3O CtS.
NEW PROVINGS of Cistus Canadensis, Cobaltum, Zingiber and Mer-
curius Proto-Iodatus. 96 pages. Paper, . tº tº . 75 CtS.
NORTH AMERICAN JOURNAL OF HOMCEOPATHY. Pub-
lished quarterly on the first days of August, November, February and
May. Edited by S. LILIENTHAL, M.D. Vol. X, New Series, com-
menced in August, 1879. Subscription price per volume, in advance,
$4 Oo
Complete sets of the first twenty-seven volumes, in half morocco bind-
ing, including Index to the first eighteen volumes, tº . $90 oo
Index to the first eighteen volumes, . tº e Q . $2 oo
OEHME, DR. F. G. ‘Therapeutics of Diphtheritis. A Compila-
tion and Critical Review of the German and American Homoeopathic
Literature. Second enlarged edition. 84 pages. Cloth, . 60 cts.
“This pamphlet contains the best compilation of reliable testimony relative to diph-
theria that has appeared from the pen of any member of our school.”—OHIO MEDICAL AND
SURGICAL REPORTER.
“Although he claims nothing more for his book than that it is a compilation, with
‘critical reviews,’ he has done his work so well and thoroughly as to merit all praise.”—
HAHNEMANNIAN MONTHLY.
. “Dr. Oehme's little book will be worth many times its price to any one who has to treat
this terrible disease.”—BRITISH Journal OF HOMOEOPATHY.
“It is the best monograph we have yet seen on diphtheria.”—CINCINNATI MEDICAL
ADVANCE. *
PETERS, DR. J. C. A Complete Treatise on Headaches and
Diseases of the Head. I. The Nature and Treatment of Head-
aches. II. The Nature and Treatment of Apoplexy. III. The Nature
and Treatment of Mental Derangement. IV. The Nature and Treat-
ment of Irritation, Congestion, and Inflammation of the Brain and
its Membranes. Based on Th. J. Rückert's Clinical Experiences in
Homoeopathy. 586 pages. Half leather, . ge . . . $2 5o
PETERS, DR. J. C. A Treatise on Apoplexy. With an Appendix
on Softening of the Brain and Paralysis. Based on Th. J. Rückert's
Clinical Experiences in Homoeopathy. 164 pages. 8vo. Cloth, $1 oo
PETERS, DR. J. C. The Diseases of Females and Married
Females. Second edition. Two parts in one volume. 356 pages.
Cloth, . * tº ſº tº º º tº tº * - . $1 5o
PETERS, DR. J. C. A Treatise on the Principal Diseases of
the Eyes. Based on Th. J. Rückert's Clinical Experiences in Ho-
moeopathy. 291 pages. 8vo. Cloth, . ſe tº tº . $1 5o
PETERS, DR. J. C. A Treatise on the Inflammatory and Or-
ganic Diseases of the Brain. Based on Th. J. Rückert's Clinical
Experiences in Homoeopathy. I56 pages. 8vo. Cloth, . $1 oo
HOMOEOPATHIC PUBLICATIONS. 13
PETERS, DR. J. C. A Treatise on Nervous Derangement and
Mental Disorders. Based on Th. J. Rückert's Clinical Experiences
in Homoeopathy. Ioa pages. 8vo. Cloth, & sº . $I oo
PHYSIcIAN's VISITING LIST AND POCKET REPER-
TORY, THE HOMCEOPATHIC. By RoBERT FAULKNER, M.D.
Second edition, . © g tº * o g © . $2 oo
“Dr. Faulkner's Visiting List is well adapted to render the details of daily work more
perfectly recorded than any book prepared for the same purpose with which we have hitherto
met. It commences with Almanacs for 1877 and 1878; then follow an obstetric calendar;
a list of Poisons and their Antidotes; an account of Marshall Hall's ready method in AS-
phyxia; a Repertory of between sixty and seventy pages; pages marked for general memo-
randa; Vaccination Records; Record of Deaths; Nurses; Friends and others; Obstetric
Record, which is especially complete; and finally pages ruled to keep notes of daily visits,
and also spaces marked for name of the medicine ordered on each day. The plan devised
is so simple, so efficient, and so clear, that we illustrate it on a scale just half the size of the
original (here follows illustration). The list is not divided into special months, but its use
may be as easily commenced in the middle of the year as at the beginning. We heartily
recommend Faulkner's List to our colleagues who may be now making preparations for the
duties of 1878.”—MonTHLY HomoeoPATHIc REVIEW, LONDON.
RAUE, DR. C. G. Special Pathology and Diagnosis, with
Therapeutic Hints. Io'72 pages. 8vo. Half morocco. Second
edition, g º e * tº * > * e e . $7 Oo
This standard work is used as a textbook in all our colleges, and is found in almost every
physician’s library. An especially commendable feature is that it contains the application
of nearly all the NEw REMEDIES contained in Dr. Hale's work on Materia Medica.
REIL, DR. A. ACONITE, Monograph on, its Therapeutic and
Physiological Effects, together with its Uses and Accurate
Statements, derived from the various Sources of Medical
Literature. By A. REIL, M.D. Translated from the German by
H. B. Millard, M.D. Prize essay. 168 pages, . * . 68 cts.
“This Monograph, probably the best which has ever been published upon the subject,
has been translated and given to the public in English, by Dr. Millard, of New York.
Apart from the intrinsic value of the work, which is well-known to all medical German
scholars, the translation of it has been completed in the most thorough and painstaking way;
and all the Latin and Greek quotations have been carefully rendered into English. The
book itself is a work of great merit, thoroughly exhausting the whole range of the subject.
To obtain a thorough view of the spirit of the action of the drug, we can recommend no
better work.”—NORTH AMERICAN JOURNAL.
RUDDOCK, DR. Principles, Practice, and Progress of Homoe-
opathy. 5 cts. ; per hundred, $3 ; per thousand, $º . $25 Oo
RUSH, DR. JOHN. Veterinary Surgeon. The Handbook to Vet-
erinary Homoeopathy; or, the Homoeopathic Treatment of Horses,
Cattle, Sheep, Dogs, and Swine. From the London edition. With
numerous additions from the Seventh German edition of Dr. F. E.
Gunther’s “Homoeopathic Veterinary.” Translated by J. F. SHEEK,
M.D. 150 pages. 18mo. Cloth, ſº * & gº . 5o Cts.
SCHAEFER, J. C. New Manual of Homoeopathic Veterinary
Medicine. An easy and comprehensive arrangement of Diseases,
adapted to the use of every owner of Domestic Animals, and especially
designed for the Farmer living out of the reach of medical advice, and
showing him the way of treating his sick Horses, Cattle, Sheep, Swine,
14 BOERICKE & TAFEL's
and Dogs, in the most simple, expeditious, safe, and cheap manner.
Translated from the German, with numerous Additions from other
Veterinary Manuals, by C. J. HEMPEL, M.D. 321 pages. 8vo.
Cloth, . © & & * tº g * • e . $2 oo
SCHWABE, DR. WILLMAR. Pharmacopoeia Homoeopathica
Polyglottica. Second edition. Cloth, ſº * ſº . $3 Oo
SHARP’S TRACTS ON HOMCEOPATHY, each, . . 5 CtS.
Per hundred, {} g g ſº * © e g . $3 oo
No. 1. What is Homoeopathy P No. 7. The Principles of Homoeopathy.
No. 2. The Defence of Homoeopathy. No. 8. Controversy on & 8
No. 3. The Truth of & 6 No. 9. Remedies of 6 &
No. 4. The small Doses of “. No. Io. Provings of £6
No. 5. The Difficulties of 6 & No. 11. Single Medicines of “
No. 6. Advantages of & 6 No. I2. Common-sense of &6
SHARPS TRACTS. Complete set of Twelve Numbers, . 50 cts.
Bound, e © o iº : ; tº & e e . 75 CtS.
SMALL, DR. A. E. Manual of Homoeopathic Practice, for the
use of Families and Private Individuals. Fifteenth enlarged edition.
831 pages. 8vo. Half leather, . tº o ſº © . $2 5o
SMALL, DR. A. E. Manual of Homoeopathic Practice. Trans-
lated into German by C. J. HEMPEL, M.D. Eleventh edition. 643
pages. 8vo. Cloth, . o ū © * . $2 5o
SMALL, DR. A. E. Diseases of the Nervous System, to which
is added a Treatise on the Diseases of the Skin, by Dr. C. E. Tooth-
AKER. 216 pages. 8vo. Cloth, tº gº & o . $I oo
This treatise is from the pen of the distinguished author of the well-known and highly
popular work entitled, “Small's Domestic Practice.” It contains an elaborate description of
the diseases of the nervous system, together with a full statement of the remedies which have
been used with beneficial effect in the treatment of these disorders.
STAPF, DR. E. Additions to the Materia Medica Pura. Trans-
lated by C. J. HEMPEL, M.D. 292 pages. 8vo. Cloth, . $1 5o
This work is an indispensable appendix to Hahnemann's Materia Medica Pura. Every
remedy is accompanied with extensive and most interesting clinical remarks, and a variety of
cases illustrative of its therapeutical uses.
VERDI, DR. T. S. Maternity; a Popular Treatise for Young
Wives and Mothers. By TULLIo SUZZARA VERDI, A.M., M.D., of
Washington, D. C. 450 pages. I2mo. Cloth, . te ... $2 oo
“No one-needs instruction more than a young mother, and the directions given by Dr.
Verdi in this work are such as I should take great pleasure in recommending to all the young
mothers, and Some of the old ones, in the range of my practice.”—GEORGE E. SHIPMAN,
M.D., Chicago, Ill. -
“Dr. Verdi’s book is replete with useful suggestions for wives and mothers, and his
medical instructions for home use accord with the maxims of my best experience in prac-
tice.”—JOHN F. GRAY, M.D., New York City. -
VERDI, DR. T. S. Mothers and Daughters; Practical Studies for
the Conservation of the Health of Girls. By TULLIo SUzzARA VERD1,
A.M., M.D. 287 pages. I2mo. Cloth, . g º • $I 5o
HOMOEOPATHIC PUBLICATIONS. 15
“The people, and especially the women, need enlightening on many points gonnected
with their physical life, and the time is fast approaching when it will no longer be thought
singular or ‘Yankeeish’ that a woman should be instructed in regard to her sexuality, its or-
gans and their functions. . . . . Dr. Verdi is doing a good work in writing suéh books,
and we trust he will continue in the course he has adopted of educating the mother and
daughters. The book is handsomely presented. It is printed with good type on fine paper,
and is neatly and substantially bound.”—HAHNEMANNIAN MONTHLY.
VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan-
grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, $1 25
“Von Tagen was an industrious worker, a close observer, an able writer. The essays
before us bear the marks of this. They are written in an easy, flowing, graceful style, and
are full of valuable suggestions. While the essay on perineorrhaphy is mainly of interest to
the surgeon, the other essays concern the general practitioner. They are exhaustive and
abound in good things. The author is especially emphatic in recommending the use of bro-
mine in the treatment of hospital gangrene, and furnishes striking clinical evidence in Sup-
port of his recommendation.
“The book forms a meat volume of 150 pages, and is well worthy of careful study.”—
MEDICAL COUNSELOR.
wiLLIAMSON, DR. w. Diseases of Females and children,
and their Homoeopathic Treatment. Third enlarged edition.
256 pages. 12mo. Cloth, . $º & * e * . $1 oo
This work contains a short treatise on the homoeopathic treatment of the diseases of fe-
males and children. the conduct to be observed during pregnancy, labor, and confinement,
and directions for the management of new-born infants.
WINSLOW, DR. W. H. The Human Ear and Its Diseases.
A Practical Treatise upon the Examination, Recognition, and Treat-
ment of Affections of the Ear and Associate Parts, Prepared for the In-
struction of Students and the Guidance of Physicians. By W. H. WIN-
SLow, M.D., Ph.D., Oculist and Aurist to the Pittsburg Homoeopathic
Hospital, etc., etc., with one hundred and thirty-eight illustrations.
Boericke & Tafel: New York and Philadelphia. Pp. 526. 8vo.
Cloth, . te * te e gº tº & º tº . $4 5o
“ . . . We hail with pleasure the advent of this work. There is perhaps no branch
in the science of medicine in which there has been so little advance as in that of otology.
Our author has treated his subject very systematically, giving first the anatomy, then the
physiology, as at present understood, methods of examination, morbid changes and injuries,
and finally the therapeutics. This last is of especial value to us, as our provings are singu-
larly deficient in reference to symptoms of the ear. . . . This book is a move in the
right direction, and we earnestly hope it will prove a stimulus ſor other specialists of our
school.”—NEW ENGLAND MEDICAL GAZETTE.
“ . . . Moreover, he has literally crammed the work with thoughts and suggestions
of a practical kind, such as could only be the outgrowth of a large personal experience and
long-continued habits of close and careful observation. . . . The work is thoroughly
practical throughout; theories are left iu the background, and the hard facts of the business
of the otologist are portrayed with a distinctness and force which characterize all the writings
of this author.—HAHNEMANNIAN MONTHLY.
WORCESTER, DR. S. Repertory to the Modalities. In their
Relations to Temperature, Air, Water, Winds, Weather and
Seasons. Based mainly upon Hering's Condensed Materia Medica,
with additions from Allen, Lippe, and Hale. Compiled and arranged
by SAMUEL WoRCESTER, M.D., Salem, Mass., Lecturer on Insanity and
its Jurisprudence at Boston University School of Medicine, etc., etc.
188o. 160 pages. I2mo. Cloth, e 4. & º • $1 25
16 BOERICKE & TAFEL's HOMOEOPATHIC PUBLICATIONS.
r—
“This “Repertory to the Modalities’ is indeed a most useful undertaking, and will,
without question, be a material aid to rapid and sound prescribing where there are promi-
nent modalities. The first chapter treats of the sun and its effects, both beneficial and hurt-
ful, and we see at a glance that Strontium carb., Anacardium, Conium mac., and Kali bich.
are likely to be useful to patients who like basking in the sun. No doubt many of these
modalities are more or less fanciful; still a great many of them are real and of vast clinical
range.
“The book is nicely printed on good paper, and strongly bound. It contains only 160
pages. We predict that it will meet with a steady, long-continued sale, and in the course of
time be found on the tables of most of those careful and conscientious prescribers who admit
the philosophical value of (for instance) lunar aggravations, effects of thunder-storms, etc.
And who, being without the priggishness of mere brute science, does not?”—HOMCEO-
PATHIC WORLD.
WORCESTER, DR. S. Insanity and Its Treatment. Lectures
on the Treatment of Insanity and Kindred Nervous Diseases. By
SAMUEL WoRCESTER, M.D., Salem, Mass. Lecturer on Insanity, Ner-
vous Diseases and Dermatology, at Boston University School of Medi-
cine, etc., etc., . sº e G e e e e . $3 5o
Dr. Worcester was for a number of years assistant physician of the Butler
Hospital for the Insane, at Providence, R. I., and was appointed shortly
after as Lecturer on Insanity and Nervous Diseases to the Boston University
School of Medicine. The work, comprising nearly five hundred pages, will
be welcomed by every homoeopathic practitioner, for every physician is called
upon sooner or later to undertake the treatment of cases of insanity among
his patrons' families, inasmuch as very many are loth to deliver any afflicted
member to a public institution without having first exhausted all means within
their power to effect a cure, and the family physician naturally is the first to
be put in charge of the case. It is, therefore, of paramount importance that
every homoeopathic practitioner's library should contain such an indispensa-
ble work.
“The basis of Dr. Worcester’s work was a course of lectures delivered before the senior
students of the Boston University School of Medicine. As now presented with some altera-
tions and additions, it makes a very excellent text-book for students and practitioners. Dr.
Worcester has drawn very largely upon standard authorities and his own experience, which
has not been small. In the direction of homoeopathic treatment, he has received valuable
assistance from Drs. Talcott and Butler, of the New York State Insane Asylum. It is not,
nor does it pretend to be, an exhaustive work; but as a well-digested summary of our present
knowledge of insanity, we feel sure that it will give satisfaction. We cordially recommend
it.”—NEW ENGLAND MEDICAL GAZETTE.
JUST ISSUED
THE AMERICAN HOMOEOPATHIC. PHARMACOPOEIA.
Compiled and Published by Boericke & Tafel. Pp. 523, 8vo. Cloth, $3.50.

No physician, busy or otherwise, can afford to neglect a correct knowledge of the forms
and preparations of his armament against disease. This knowledge is as necessary in con-
trolling legitimate operations on part of the pharmacist, as in preparing remedies individually.
In point of general information and especially of minute and unmistakable directions, the
work stands alone among the recent publications on this subject. Special attention is given
toºnym. in the body of the book, besides being fully represented in a large and copious
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