CHAPTER XV.

PUERPERAL MANIA.

_Inflammatory or phrenitic form.--Treatment.--Gastro-enteric form.--Treatment.--Adynamic form.--Causes and symptoms.--Treatment._

There are many points of similarity between puerperal convulsions, and the disease which we are now about to consider, so that an acquaintance with the nature of the one, will greatly assist the reader in his study of the other: the same causes which induce the one, will, with trifling modification, induce the other; the different species of puerperal mania, will, therefore, resemble more or less those of puerperal convulsions.

Disorder of the mind, which comes under the head of puerperal mania, is rarely met with before labour; for when it occurs during pregnancy it is usually referrible to causes unconnected with that state, as to hysteria; or is, a form of ordinary mania arising from hereditary predisposition, cerebral diseases, &c. It is true these are conditions which will render the patient exceedingly liable to an attack of derangement during labour, and especially during the puerperal state; but the identity of the affections cannot well be carried farther.

According to our own experience puerperal mania may occur under one of the three following conditions, viz.--

1. Where it is attended with, and probably depends upon, cerebral congestion or inflammation.

2. Where it arises from gastro-enteric irritation.

3. Where it is the result of general debility and anæmia.

The last two rather deserve the title of melancholia.

_Inflammatory or phrenitic form._ We shall divide the inflammatory form into two species: first, where it is wild and furious delirium with phrenitis; secondly, where it is connected with, and is the result of, puerperal fever. The first, usually comes on during labour: the patient is attacked with violent pain, heat, and throbbing of the head, which are greatly increased by her efforts during the throes; the pulse becomes quick and hard; the face flushed and crimson; the eyes wild, and the manner more and more unnatural: if this state be not promptly checked, the cerebral excitement becomes more intense, furious delirium follows, which in its turn is succeeded by coma, effusion and paralysis.

On examination after death the ordinary appearances of fatal phrenitis manifest themselves, viz. preternatural fulness of the cerebral vessels, thickening and opacity of the different membranes, softening or even suppuration of the substance of the brain, extravasation of blood, or effusion of serum into the cavities or substance of the brain, or between its membranes.

The other form of inflammatory puerperal mania, is only seen _after_ labour, and is invariably connected with, and preceded by, symptoms of puerperal fever. These are the cases of puerperal mania, where the disease comes on with a rigour, a quick pulse, violent headach, and abdominal pain. In some, the attack has appeared from the very commencement to concentrate itself upon the brain; but in others, it more frequently appears in a day or two afterwards, when, from the subsidence of the abdominal pain, we are beginning to hope that the disease has been more or less controlled. The patient is suddenly seized with intense headach, and other symptoms of cerebral congestion, accompanied by disordered mind; but there is not that degree of furious delirium which is seen in the acute phrenitis; there is less excitement, but there is also, less strength; the powers of the system are rapidly giving away, not so much under the effects of the local disease, as under those of the general affection by which the local disease has been produced. The patient is frequently both violent and obstreperous; but we seldom see that state of wild and furious raving which is observed in acute phrenitis. The former of these two species is of very rare occurrence, but from not being complicated with puerperal fever, it is perhaps not so dangerous, if promptly treated, as the other. Dr. Ferguson, has correctly observed, in puerperal fever, that "any cerebral disturbance diminishes the chances of recovery," and that "the presence of delirium in any case is almost always followed by a fatal result." (_Op. cit._ p. 49, 50.)

The patient in whom we have chiefly observed phrenitic symptoms during labour were stout, robust, short-necked women, with black oily hair, and a swarthy complexion: from an early stage they had exerted themselves during the pain in a most violent and unnecessary degree, and had gradually worked themselves into that state of excitement, which was followed by the symptoms above-mentioned: in two instances, it was ascertained that the patient had received a violent blow on the head, either during pregnancy, or on some previous occasion. In similar habits the same symptoms have been observed occasionally to accompany the first appearance of the milk, or to follow its sudden suppression when established, or a similar state of the lochia.

_Treatment._ The treatment differs but little from that of the congestive epileptic convulsions, already described: she must be bled to fainting, leeches must be applied to the temples, the head shaved and cold applied to it, the feet should be put into hot water, and the bowels opened by an active purge of calomel. If the child be not delivered, and the passages are sufficiently dilated, the forceps should be applied to shorten the labour.

In the other case, which is accompanied with puerperal fever, the propriety of bleeding to any considerable extent will be more questionable; it has probably been already employed in the early part of the original disease, and her powers more or less reduced by it: we must here rather trust to leeches and cold to the head, and bringing the system as soon as possible under the influence of calomel and opium. Whether or not the improvement which follows in some cases of puerperal fever has resulted from the use of saline medicines, we will not pretend to determine; but as, on more than one occasion, we have seen calm and refreshing sleep succeed their exhibition, it is not improbable that they might prove useful in this form of the disease.

We presume that these are the cases to which Dr. Gooch has referred, when he described them as being "attended by fever, or at least, the most important part of it--a rapid pulse;" and that the majority of them prove fatal: their unfavourable result, however, is not so much from the local affection, as from the puerperal fever under which the patient sinks.

Pure phrenitis, which is a rare disease during labour or the puerperal state, is by no means difficult to control by active antiphlogistic treatment, if taken in sufficient time, before the brain has suffered any serious injury; nor is there much danger of her continuing deranged even after the inflammatory symptoms have been reduced. This appears to be also the case in that form which attends puerperal fever; but here the danger to life is so much greater, that we rarely have an opportunity of ascertaining the duration of the mental disorder after the symptoms of cerebral inflammation have been subdued, since most of these cases terminate fatally.

_Gastro-enteric form._ In the gastro-enteric form, the cerebral symptoms are of a much milder character: the head is perhaps warmer than natural, and it aches a good deal across the forehead and eyes; the face is seldom flushed, but it is sallow, the eye is yellow, the tongue is foul, the breath offensive, and if any evacuations have been passed, they are excessively unhealthy; the abdomen feels full and loaded, the pulse is irritable, but devoid of strength; the patient is seldom violent, and if so, can usually be restrained by the mildest measures. Her previous history will also assist us in our diagnosis; we shall, probably, find that she has for some time suffered from constipation and deranged bowels, or is known to have greatly neglected them before her confinement.

Puerperal mania from this cause is a result of cerebral irritation, not inflammation, and is a state which will generally cease the moment the cause is removed. As is the case with puerperal convulsions from gastro-enteric irritation, so here the moment we break the chain of morbid sympathies, upon which the disease depends, the symptoms disappear, and are instantly followed by a clearing up of the mental disorder. It usually comes on during the first few days after labour, before the patient has taken the laxative medicine which is customary at this time, and seems to be excited to an outbreak by any little source of mental annoyance or irritation. At first, it appears to be little else than giving way to caprice and temper, but by degrees her manner becomes more changed; and ultimately she grows violent and unmanageable. The state of mind, however, is very different to that of the inflammatory form of puerperal mania; there is no raving delirium, and but a slight degree of incoherence; she understands what is said to her, but reasons erroneously under the influence of a false impression. This state rarely proves dangerous either to her life or her reason, if the proper treatment has been promptly had recourse to; but where it has been allowed to run on for some time, or she has been reduced by antiphlogistic treatment under an erroneous fear of cerebral congestion or inflammation, there may be reason to fear that she will ultimately sink, or at any rate, that the derangement will become permanent.

_Treatment._ As the pulse scarcely ever betrays a febrile or inflammatory condition of the system, for although quick, it is seldom observed to be full and hard, bleeding is rarely required in this form of puerperal mania, leeches and cold applications being almost sufficient to control any symptoms of determination to the head which may be present: it is upon purgatives that we must place our chief hope in this disease, for until the bowels have been thoroughly and effectively cleared, there will be little chance of the symptoms being alleviated. In some cases it is scarcely credible to what an extent this may be carried; day after day sees the patient relieved of copious, dark, and offensive evacuations, which are evidently not merely the result of enormous accumulations in the bowels, but of excrementitious matters, which are thrown off by the secreting vessels of the liver and alimentary canal. So far from producing debility, the pulse rises with each relief and becomes fuller and slower, the face resumes a healthier aspect, the tongue becomes cleaner, the headach subsides, reason regains its ascendancy, and this favourable change is followed by calm and refreshing sleep. We could quote several cases of our own, in illustration of this form of puerperal mania and its treatment, where the symptoms have quickly yielded, as soon as the source of irritation had been removed from the system; the patient has recovered favourably, although in most instances she has retained a sufficient recollection of what had passed to feel much vexed and even shocked at, what she was aware had been, very strange and unruly conduct; but we prefer selecting Dr. Gooch's thirteenth case, of which the details are given so graphically, as not a little to enhance the value of it.

"A lady, twenty-two years of age, clever, susceptible, and given to books, was confined with her first child at ----, -- miles from town: she was anxious to nurse it; but several days passing with little appearance of milk, doubts began to be entertained whether she would be able: _she_ thought she would, her nurse and surgeon thought she would not: this led to irritating discussions; her manner became sharp, quick, and unnatural; and at the end of a few days she was decidedly maniacal. I and another physician were now sent for; we found her in a straight waistcoat, incessantly talking and reciting poetry; her skin was hot, her pulse full, and much above 100; her tongue covered with a dark thick fur; her bowels were confined, and her stools excessively dark and offensive; she took a dose of calomel and jalap, followed by small doses of sulphate of magnesia; these produced a few evacuations, but they were followed by no relief; she talked almost incessantly, scarcely ever slept, and was so violent that it was impossible to keep her in bed without the straight waistcoat. Thus three days passed from our first consultation. The physician who attended with me, thinking the case would be protracted, withdrew, and I was directed to take Dr. Sutherland down with me. As the purgative had operated very moderately, and the tongue and stools were as unnatural as at first, he proposed a more active purge. The next morning, therefore, she took a strong dose of senna and salts, made still more active by the addition of tincture of jalap; after this had been taken about three hours, it procured a very large evacuation, nearly black, and horribly offensive; this was as usual discharged into the bed without any notice on the part of the patient; it acted again an hour or two afterwards; but now the nurse, who was sitting by her bed-side, was surprised to see her turn round, and in a calm and natural manner request to be taken up, as her medicine was going to operate; her waistcoat was immediately loosened, and she was taken out of bed, when she voided a stool of prodigous size, as dark and offensive as the first, and then walked back to her bed calm and collected. We saw her not many hours afterwards; her waistcoat was off, she was lying on her sofa perfectly tranquil, answered questions correctly, manifested no vestige of her complaint, excepting some strangeness in the expression of her countenance, and a timidity and abstinence from conversation which was not natural to her: she recovered rapidly and uninterruptedly." (_Account of some of the most important Diseases peculiar to Women_, by Robert Gooch, M. D. p. 156.)

The chances of recovery in puerperal mania, from, gastro-enteric irritation are as great as they are small in the inflammatory form connected with puerperal fever: the danger is more from erroneous practice on the part of the medical attendant, who either prostrates the powers of life by active depletion, under the supposition that he is treating a case of cerebral congestion, or aggravates the disorder of the mind into wild delirium, by the exhibition of opium, to procure sleep. It is in these cases that we occasionally see so much relief procured by the action of emetics, as at one time to have been considered nearly specific in this disease, by some of the French practitioners. If the powers be good, we cannot agree with Dr. Gooch, in objecting to the use of antimony; when in a sufficient dose, and combined with ipecacuanha, it is too speedy in its operation to depress the patient much by nausea, and has the additional advantage of acting as a rapid and effectual purge: when its action is over, she usually falls into a sound sleep, perspires freely, and wakes greatly refreshed.

The indiscriminate use of emetics in puerperal mania, is not less mischievous than that of bleeding; they are chiefly indicated in those cases, where, in addition to the symptoms above-mentioned, there are signs of a foul and oppressed stomach, and where the patient either complains of nausea, or has already made several attempts to vomit. As soon as the offending cause is removed, the bowels should be kept open by mild alterative and laxative medicine, as equal parts of blue pill, compound extract of colocynth, and extract of henbane, in two pills at night, and a mineral acid in some bitter infusion during the day. The food should be bland but nutritious, the mind quietly but agreeably occupied, and all excitement carefully avoided. In this form of puerperal mania, it is not only a rare occurrence to find that the disordered state of the mind continues, when the cause which had produced it no longer exists, but it is scarcely ever known to return in the patient's subsequent confinements. In the case which has been so ably recorded by Dr. Gooch, the patient has since had a very large family, her labours have all been perfectly favourable, and without the slightest symptom of her former disease.

The _adynamic form of puerperal mania_ is by far the most common species of the disease, and like the adynamic puerperal convulsions, arises from causes which produce exhaustion and collapse in the general powers of the system. It is to Dr. Gooch that we are indebted for a masterly exposition of this disease, and for having been one of the first to point out its real character.

_Causes and symptoms._ This form of disordered mind is a disease of true debility, and is closely allied to delirium tremens, and convulsions produced by anæmia. It can scarcely be said to deserve either the terms "puerperal," or "mania," for we frequently see a very near approach to it in females who are much weakened by hæmorrhage, either from menorrhagia, malignant disease of the uterus, or abortion; and from being a disease which arises from great exhaustion, it rather deserves the name of melancholia, than of mania. In lying-in women, "there are two periods at which this is chiefly liable to occur; the one soon after delivery, when the body is sustaining the effects of labour, the other several months afterwards, when the body is sustaining the effects of nursing." (Gooch, _op. cit._ p. 109.) In the one case, it is usually the result of profuse hæmorrhage, in the other, it is produced by suckling her child when she is not strong enough for this purpose. "I have repeatedly seen the commencement of mental derangement in women who had recovered from their confinement and had been suckling several months. Nearly all these cases were instances, not of mania but of melancholia. They occurred in women who had been debilitated by nursing. The disease at this period has been attributed to weaning; but, in all cases, I have seen, the disease has begun before the weaning, and this measure has been resorted to, because the patient had neither milk nor strength to fit her for a nurse. There was a peculiarity about the commencement of the disease which I have seldom or never noticed at the commencement of mania; there was an incipient stage in which the mind was wrong, yet right enough to recognise that it was wrong." (Gooch, _op. cit._ p. 114.)

This half-way state of mind between reason and derangement is frequently seen in women who have been exhausted by menorrhagia, leucorrhoea, &c., or who have been drained by nursing. We confess that we can see but little difference in the effects of anæmia upon the brain and nervous system, whether it be in the unimpregnated or puerperal state, beyond that, on account of the great changes which have taken place in the system by the process of labour, by the secretion of milk, &c., the system is probably more irritable, and susceptible than it would otherwise be. Nothing is more common than to see, in cases of menorrhagia, the mind becoming enfeebled, the memory impaired; the patient begins to find that she can no longer control her thoughts in the ordinary manner, but that strange trains of ideas will pass through her mind, the source of which she cannot explain, and frequently so unaccountably, as to cause her serious uneasiness: "If this goes on so, I shall lose my senses," is almost a never failing observation; and the dread that this will be the case, tends to depress the system still more. The sleep is disturbed by frightful dreams, or she passes night after night in wakeful restlessness; she worries herself about trifles, her manner changes, and the mind at length is quite disordered. The same train of symptoms is a frequent result of over-suckling, and as Dr. Gooch has justly observed, is not the result of weaning. "In all the cases which I have seen, months after delivery, the weaning has been the consequence of the disease, not the disease the consequence of the weaning. The patients had been reduced in health by nursing, their memories had become enfeebled, their spirits depressed, and their minds ultimately disordered; they were directed to wean their children, because they had neither milk nor strength to enable them to nurse." (_Op. cit._ p. 130.)

A similar state of mind may be induced at an earlier period and more suddenly, by the effects of a profuse hæmorrhage, by serious discharges, which occasionally take place shortly after labour, or even by mental depression; in fact, by whatever lowers the vital powers to a considerable extent. In these cases, the very history and appearance of the patient are sufficient to explain the nature of the disease: her hollow eyes, pale face, and blanched lip, show distinctly how her strength has been reduced. The source and extent of her debilitated state will in great measure determine the degree of danger, and the chances of her recovery. In ordinary cases of this form there is not much to fear, as far as the life of the patient is concerned; and the cases which have come under our own notice confirm the excellent remark of Dr. Gooch, "that mania is a less durable disease than melancholia; it is more dangerous to life, but less dangerous to reason." But if the disordered mind has come on shortly after labour, in consequence of profuse flooding; if the powers of the system have rallied but imperfectly, and from the tinnitus aurium, strabismus, half vision, &c., it is evident that the cerebral functions are greatly impaired; if the nights are passed without sleep, and the days in continued and exhausting excitement; if the pulse be feeble and rapid, the skin cold and clammy, the face covered with perspiration, and there is a disposition to colliquative diarrhoea, we shall have but too much reason to fear an unfavourable issue; every symptom denotes that the powers of the system have received a fatal blow, and she either sinks exhausted, or dies in a state of coma, probably from serous effusion upon the brain. On the contrary, if in addition to a general improvement, she has enjoyed some hours of refreshing sleep, there is every prospect, not only of returning health, but also of reason. A mere gleam of returning reason without a corresponding improvement of health, will afford but little satisfaction to the mind of a discerning practitioner, for it gives no assurance that the danger of fatal sinking is at all diminished.

Disordered mind coming on some weeks after delivery from the effects of over-nursing, when the patient has been unable to afford the necessary supply to her child, is seldom attended with so much danger to life, as where suddenly induced immediately after labour by hæmorrhage: the intermediate stage between reason and derangement is more distinctly marked, and is of considerable duration; and the gradually increasing affection of the mind frequently warns even the patient herself to seek medical advice before the symptoms become more serious.

We believe that the proportion of patients in whom the mind continues deranged after their health has been restored, is very small, and feel convinced that the results afforded by the practice of lunatic hospitals are far from giving a correct estimate. A large majority of the cases of derangement in lying-in women are of such short duration that they never come even under the notice of those members of the profession whose attention is particularly devoted to this branch of medical practice, still less do they require to be removed into asylums for lunatics. "The records of hospitals contain an account of cases which have been admitted only because they were unusually permanent; they are the picked obstinate cases, and can afford no notion of the average duration of all kinds; the cases of short duration, which last only a few days or a few weeks, which form a large proportion, are totally lost in the estimate of a lunatic hospital." (Gooch, _op. cit._ p. 125.) The results of Dr. Gooch's practice, which is known to have been very extensive, and especially in consultation, shows that out of a considerable number of cases only two of his patients remained disordered in mind, "and of these, one had already been so before her marriage." There are two classes of patients in whom disordered mind is not only much to be apprehended during their lying-in, but in whom there will be some reason to fear that it may become permanent; first, in those who have already been deranged, independent of the puerperal state, or who inherit a strong predisposition to mental disease; and secondly, in those where hysteria has existed in an unusual degree during the latter part of pregnancy. These circumstances justify us in using every precaution in their lying-in to avoid any thing which may excite the disease; but, as already stated, not only is the disorder of the mind rarely of any duration, but it is seldom known to recur on any subsequent occasion.

_Treatment._ Our indications of treatment are two-fold, viz., to rouse and support the powers of the patient, and to allay as far as possible the irritability of the brain and nervous system.

If the patient has been prostrated by hæmorrhage, not only a nutritious, but even a cordial and stimulant diet will be necessary: the emulsion of egg and brandy, which we have before recommended in anæmic puerperal convulsions, will here prove very useful; and it must be given in small but frequently repeated doses, until an improvement is observed in the pulse and in her general appearance. Under all circumstances, it will scarcely ever be proper or even safe to confine her to low diet: beaf-tea, veal-broth, &c. should be given in considerable quantities during the twenty-four hours; and it is surprising what improvement will even take place merely from the administration of this bland nutriment. If the face be pale and the pulse low, wine may be given according to the circumstances of the case.

To calm the cerebral excitement and procure sleep, sedatives will prove of the greatest value, and require to be repeated until the nervous system is fairly under their influence. The intense pain at the vertex, which of itself is sometimes quite sufficient to produce delirium, the tinnitus aurium, &c., all cease; the pulse becomes softer, fuller, and slower; and, even if sleep be not immediately induced, a state of calm tranquillity follows, in which the mind becomes more composed. The Liquor Opii Sedativus may be given in a dose of twenty-five minims, and repeated in an hour or so according to circumstances. The combination of camphor with morphia, or extract of henbane, is an excellent form, and may be given with perfect safety to a considerable extent.

The bowels should be opened by the mildest laxatives, such as castor oil, rhubarb and manna, &c., medicines which will neither act violently, nor weaken by producing watery evacuations; and, once in every few days, it will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, with extract of hop or gentian. To assist still farther in restoring her health and strength, she should take an infusion of a vegetable bitter with a mineral acid. As soon as her strength will permit, a change of residence may be recommended, and she should remove to some quiet watering-place, where invigorating air and agreeable scenery and occupations will assist in completing her recovery.

"The constant attendants on the patient ought to be those who will control her effectually but mildly, who will not irritate her, and will protect her from self-injury. These tasks are seldom well performed by her own servants and relatives.

"If the disease lasts more than a few days, and threatens to be of considerable duration, her monthly nurse and own servants ought to be removed, and a nurse accustomed to the care of deranged persons placed in their stead. Such an attendant will have more control over the patient, and be more likely to protect her from self-injury." "With regard to the removal of her husband and relations, this also will be a question; if the disease threatens to be lasting, it is generally right. Interviews with relations and friends are commonly passed in increased emotion, remonstrance, altercation, and obviously do harm: large experience also is decidedly favourable to separation as a general rule; yet there may be exceptions, which the intelligent practitioner will detect by observing the effect of intercourse." (Gooch, _op. cit._ p. 158.)

INDEX.

_Abdomen_ of the foetus, labour obstructed by depositions in the, 284. Pendulous, 308. Management of the, 309.

_Abdominal_ muscles, faulty action of the, obstructing labour, 336.

_Abnormal_ Parturition, divisions and species of, 263. See _Dystocia_.

_Abortion_, 141. Explanation of the term, 141. Period at which it is most common, 142. Causes of, 142. Death of the embryo, 142. External violence, 143. Mental emotions, 143. Irritable uterus, 144. Symptoms of, 144. Treatment of, 146. Prophylactic, 146. In the attack, 149. After expulsion, 155.

_Abscess_, mammary, 191. Treatment of, 192.

_Absorption_ of retained placenta, 358.

_Adynamic_ puerperal fever, 450. See _Puerperal Fever_. Mania, 473. See _Puerperal Mania_.

_After-pains_, 197. Causes of, 197. Utility of, 198.

_Age_, rigidity of the passages from, obstructing labour, 314. Influence of, on the contractile power of the uterus, 327.

_Allantoidis_ Liquor, situation of the, 54.

_Allantois_, mode of its formation, 70. Its existence in the human embryo, 70. Functions of the, 70.

_Amnii_ Liquor spurius, situation of the, 54. Characters of the, 55. Source of the, 55. Use of the, 55. Formation of the bag of the, 162. Excessive quantity of, 287.

_Amnion_, description of the, 54. Formation of the, 69. Dropsy of the, 287.

_Anatomy_ of utero-gestation, 15. Of the pelvis, 15. Of the sacrum, 16. Of the coccyx, 17. Of the ovaria, 22. Of the Fallopian tubes, 28. Of the uterus, 30. Comparative, of the, 34. Of the external organs of generation in the female, 45.

_Anæmic_ puerperal convulsions, 387.

_Anchylosis_ of the foetal joints, obstructing labour, 284.

_Anteversion_ of the uterus, 309.

_Apoplectic_ puerperal convulsions, 387.

_Areola_ of the breasts, 86.

_Arm_, presentation of the, 272. See _Labour_. With the head, 273. See _Presentation_.

_Arthritic_ inflammation supervening upon puerperal fever, 456.

_Artificial_ premature labour, 250.

_Atony_ of the uterus, 324. Causes of, 325. Debility, 325. Derangement of the digestive organs, 326. Mental affections, 326. Age and temperament, 327. Plethora, 327. Rheumatism of the gravid uterus, 328. Inflammation of the uterus, 329. Treatment of, 339.

_Auscultation_ in the diagnosis of pregnancy, 89. Uterine souffle, 90. Funic souffle, 93. Mode of ascertaining twin pregnancy by means of, 100. During the pains, 159.

_Axes_ of the pelvis, 21.

_Ballottement_, method of performing, 94.

_Bladder_, distended or prolapsed, obstructing labour, 322. Stone in the, 323.

_Blastodermic_ Membrane, 65. See _Egg_.

_Blood-vessels_, uterine, enlargement of, during pregnancy, 38. Their connexion with the placenta, 57, 58.

_Breasts_, changes which they undergo during pregnancy, 86. Abscess of the, 191.

_Breech_, presentation of the, 210. See _Nates_.

_Brim_ of the pelvis, situation of the, 17.

_Bronchial_ Processes, description of the, 71.

_Cæsarean_ Operation, 243-278. Indications for its performance, 243. Different modes of performing it, 246. History of the, 248.

_Canalis_ venosus, situation of the, 78.

_Caput_ succedaneum, in what it consists, 165.

_Carunculæ_ myrtiformes, how produced, 46.

_Cerebral_ tumours in the foetus, obstructing labour, 283.

_Chest_, morbid depositions in the foetal, obstructing labour, 284.

_Child_, size of, at birth, 281. Its influence on the duration of labour, 282. Unnatural form of the, 282. See _Foetus_.

_Chorion_, description of the, 52. Changes which it undergoes during pregnancy, 53.

_Cicatrices_ in the vagina obstructing labour, 315. Treatment of, 316. Of the os uteri, 311.

_Circulation_, foetal, 77. See _Foetus_.

_Clitoris_, anatomical description of the, 46.

_Coccyx_, anatomical description of the, 17.

_Colic_, occurring during pregnancy, 104. Treatment of, 104.

_Colostrum_, nature and use of the, 190.

_Conception_, false, 112. See _Mole_.

_Constipation_ during pregnancy, 104. Treatment of, 104.

_Contagious_ nature of adynamic puerperal fever, 458.

_Contracted_ vagina, obstructing labour, 315.

_Contractile_ power of the uterus, derangement of the, 324. Causes of, 325. Treatment of, 329.

_Contraction_, hour-glass, of the uterus, 354. See _Placenta, encysted_.

_Convulsions_, puerperal, 376. Epileptic, 377. Causes of, 377. Symptoms of, 377. Tetanic, 381. Diagnosis of labour during, 382. Prophylactic treatment of, 383. Treatment during the attack of, 383. Apopletic, 387. Anæmic, 387. Symptoms of, 388. Treatment of, 388. Hysterical, 390. Symptoms of, 390.

_Copulative_ Organs, 22.

_Cord_, umbilical description of the, 63. Vessels of the, 63. Length of the, 63. Round the neck of the child, 183. Ligature of the, 184. Rupture of the, 364. Prolapsus of the, 368. Diagnosis of, 368. Causes of, 368. Treatment of, 372. Reposition of the, 373. Unusual shortness of the, 288. Knots upon the, 290.

_Corpus_ Luteum, nature of the, 25. Appearance of, at different periods after conception, 25.

_Cotyledons_ of the placenta, situation of the, 56.

_Cough_, spasmodic, occuring during pregnancy, 104. Treatment of, 104.

_Cranium_, presentation of the, 200. See _Presentation_.

_Crotchet_, mode of its application, 260.

_Death_ of the foetus, signs of the, 107. See _Foetus_.

_Debility_, insufficient uterine action from, 325.

_Decidua_ membrana, description of the, 48. Its connexion with the uterus, 49. With the ovum, 50. With the placenta, 51-55. With the Fallopian tubes, 51. Vera, 51. Reflexa, 51.

_De Graaf_, vesicles of, 24.

_Delirium_ occurring during labour, 167.

_Depositions_, morbid, in the foetal cavities, obstructing labour, 284.

_Development_ of the ovum. See _Ovum_.

_Diagnosis_ of pregnancy, 80. See _Pregnancy, signs of_. Of twin Pregnancy, 100.

_Diameters_ of the pelvis, 19.

_Diarrhoea_ during pregnancy, 105. Treatment of, 105.

_Diet_ during labour, 179. Lactation, 195.

_Dilatation_ of the perineum during labour, 166.

_Distended_ bladder, obstructing labour, 322.

_Dropsy_ of the amnion, 287.

_Ductus_ arteriosus, situation of the, 78.

_Duration_ of pregnancy, 136. Causes which determine the, 139. Of labour, prognosis as to, 178. Wigand's views, 178.

_Dystocia_, 263. Divisions and species of, 263. Malposition, 264. Faulty form and size of the child, 281. Faulty condition of the parts which belong to the child, 282. Abnormal state of the pelvis, 292. Faulty condition of the soft passages, 308. Faulty condition of the expelling powers, 324. Inversion of the uterus, 345. Encysted placenta, 354. Precipitate labour, 361. Prolapsus of the umbilical cord, 368. Puerperal convulsions, 376. Placenta prævia, 393. Puerperal fevers, 415. Phlegmatia dolens, 463. Puerperal mania, 473.

_Dystocia_ epileptica, 381. See _Convulsions, puerperal_.

_Eclampsia_ parturientia, 376. See _Convulsions, puerperal_.

_Egg_, bird's, its analogy with the human ovum, 64. Blastodermic membrane, 65. Vitelline membrane, 65. Yelk bag, 65. Germinal vesicle, 65.

_Embryo_, development of the, 64.

_Embryulcia_, 261. See _Perforation_.

_Encysted_ Placenta, 354. See _Placenta_.

_Epileptic_ Convulsions, puerperal, 376. See _Puerperal Convulsions_.

_Eutocia_, 156. See _Labour, natural_.

_Evolution_, spontaneous, of the foetus, 270.

_Examination_ during labour, mode of its performance, 174.

_Exostosis_ of the pelvis, 300. Prognosis in, 305.

_Expelling_ powers, faulty state of the, after the birth of the child, 337.

_Expulsion_, spontaneous, 270. Of the child, 166. Delirium accompanying the, 167. Of the placenta, 167.

_External_ organs of generation in the female described, 45.

_Extirpation_ of the uterus, 332. See _Inversion_.

_Extraction_, method of performing, after turning the child, 239. After perforation, 259.

_Extra-uterine_ pregnancy, 117. Varieties of, 117. Tubarian, 118. Ovarian, 118. Ventral, 119. In the substance of the uterus, 117. Symptoms of, 118. Causes of, 119. Treatment of, 120. Case of, 120.

_Eye_, rheumatic inflammation of the, after puerperal fever, 456.

_Face_ Presentation, 206. See _Presentation_.

_Fallopian_ Tubes, description of the, 28. Their agency in impregnation, 29. Changes which they undergo during pregnancy, 29. Pregnancy of the, 117.

_Febris_ lactea, 191. See _Milk Fever_.

_Feet_, rules for finding the, in the operation of turning, 237. Presentation of the, 273. See _Presentation_.

_Female_ Pelvis, distinction between it and the male, 17. Organs of generation described, 22.

_Fever_, milk, 192. See _Milk Fever_. Puerperal, 415. See _Puerperal Fever_.

_Fibrous_ structure of the uterus described, 32.

_Flatulence_ during pregnancy, 104. Treatment of, 104.

_Flooding_, 338. See _Hæmorrhage_.

_Foetus_, characters of a full-grown, 75. Nutrition of the, 75. Circulation in the, 77. Changes which it undergoes at the moment of birth, 78. Signs of the death of the, 107. Premature expulsion of the, 141. See _Abortion_. Size and form of the, at birth, 281. Morbid depositions in the cavities of the, 284. Anchylosis of the joints of the, 284. Spontaneous evolution of the, 270.

_Foramen_ ovale, situation of the, 77.

_Forceps_, description of the, 216. Varieties of the, 217. General indications for their use, 221. Mode of applying the, 222. History of the, 227.

_Formative_ Organs, 22.

_Fracture_ of the parietal bone of the foetus from pelvic deformity, 302.

_Funic_ Souffle, 93. See _Auscultation_.

_Funis_, 63. See _Cord, umbilical_.

_Funnel-shaped_ Pelvis, 298.

_Gastro-bilious_ puerperal fever, 444. See _Puerperal Fever_.

_Gastrotomy_, 243. See _Cæsarian Operation_.

_Generation_, internal organs of, described, 22. External organs of, 45.

_Germinal_ Vesicle, 65. See _Egg_.

_Graafian_ Vesicles, description of the, 25.

_Hæmorrhage_, uterine, after the birth of the child, 338. Treatment of, 339. In placental presentation, 399. Treatment of, 406.

_Hand_ and feet, presentation of the, 274. See _Presentation_.

_Headach_ during pregnancy, treatment of, 104.

_Heartburn_ during pregnancy, 103. Treatment of, 103.

_Hour-glass_ Contraction, 354. See _Placenta, encysted_.

_Hydrocephalus_, obstructing labour, 282.

_Hymen_, description of the, 45. Unruptured, impeding labour, 316.

_Hysterical_ puerperal convulsions, 390. See _Convulsions_.

_Hysterotomy_, 243. See _Cæsarian Operation_.

_Inclination_ of the pelvis, 21.

_Indusium_, 23. See _Ovaria_.

_Inflammation_ of the uterus, affecting its contraction, 329.

_Inversion_ of the uterus, 345. Causes of, 345. Diagnosis of, 346. Symptoms of, 346. Treatment of, 347. Chronic, 351.

_Joints_, anchylosis of the foetal, obstructing labour, 284.

_Kiesteine_, 96.

_Labia_, anatomical description of the, 47. Varicose and oedematous swellings of the, 317.

_Labour_, premature. See _Premature Expulsion of the Foetus_. Natural, 156. Preparatory stage of, 157. First contractions, 157. Action of the pains, 158. Auscultation during the pains, 159. Effects of the pains on the pulse, 160. Symptoms during and between the pains, 160. Characters of a true pain, 161. Formation of the bag of liquor amnii, 162. Rigour at the end of the first stage, 162. Show, 163. Duration of the first stage, 163. Second stage of, 164. Straining pains, 165. Dilatation of the perineum, 166. Expulsion of the child, 166. Third stage of, 167. Expulsion of the placenta, 167. Twins, 168. Treatment of, 169. State of the bowels, 170. Management of the first stage, 174. Examination of the patient, 174. Position of the patient, 176. Diet during labour, 179. Supporting the perineum, 179. Perineal laceration, 181, 182. Cord round the child's neck, 183. Ligature of the cord, 184. Passage of the shoulders, 184. Management of the placenta, 186. After treatment, 188. Lactation, 189. Milk fever and abscess, 191. Excoriated nipples, 193. Diet during lactation, 195. Management of the lochia, 196. After-pains, 197. Mechanism of, 199. See _Parturition_. Abnormal, 263. Precipitate, 361. See _Precipitate Labour_.

_Laceration_ of the perineum, 181, 182. Of the uterus, 274. See _Rupture_.

_Lactation_, management of, 189. Diet during, 195.

_Ligaments_ of the uterus, 31.

_Ligature_ of the funis, 184.

_Liquor Amnii._ See _Amnii Liquor_.

_Lochia_, management of the, 196.

_Malacosteon._ See _Mollities Ossium_.

_Male_ and female pelves, distinction between the, 17.

_Malposition_ of the child in utero, 264. Rareness of its occurrence, 265. Causes of the, 266. Symptoms of, 268. With deformed pelvis, 272. With rigidity of the uterus, 272. See _Presentation_.

_Mamma._ See _Breasts_.

_Mammary_ Abscess, 191.

_Mania_ connected with precipitate labour, 366. Puerperal. See _Puerperal Mania_.

_Mechanism_ of parturition, 199. See _Parturition_.

_Membrana_ decidua, 48. See _Decidua Membrana_.

_Membrane_, blastodermic, 65. Vitelline. See _Egg_.

_Membranes_, formation of the, 48. Premature rupture of the, 287.

_Menses_, cessation of the, in pregnancy, 83.

_Mental_ affections, impairing uterine contraction, 326.

_Midwifery_, explanation of the term, 13. Operations of, 216. Forceps, 216. Turning, 230. Cæsarian operation, 243. Artificial premature labour, 250. Perforation, 161.

_Milk_ Fever, 191. Treatment of, 192.

_Miscarriage_, 141. See _Abortion_.

_Mole_ pregnancy, 112. Nature and origin of, 112. Diagnostic symptoms of, 114. Treatment of, 116.

_Mollities_ Ossium, 295. Causes of, 296. Pelvic deformity from, 296. Varieties of pelvic deformity from, 296.

_Monsters_, difficult labour in cases of, 284.

_Movements_ of the foetus, value of, as a sign of pregnancy, 88-94.

_Nates_, presentation of the, 210. Modifications of, 210. Varieties of, 210. Mechanism of labour in, 211. Diagnosis of, 213. Management of, 213. Comparative frequency of, 215.

_Navel-string._ See _Cord, umbilical_.

_Nutrition_ of the foetus, 75. See _Foetus_.

_Nymphæ_, anatomical description of the, 47. Varicose and oedematous swellings of the, 317.

_Nipples_, excoriated, 193. Treatment of, 194.

_Oedematous_ swellings of the labia and nymphæ, 317.

_Operations_ in midwifery. See _Midwifery_.

_Operation_, Cæsarian. See _Cæsarian Operation_. For Inducing premature labour, 253.

_Organs_ of generation, internal, in the female, 22. External, 45.

_Ossa_ innominata, description of the, 15.

_Ossium_, Mollities, 295. See _Mollities_.

_Os Uteri_, rigidity of the, 310. Adhesion of the edges of the, 311. Cicatrices of the, 311. Agglutination of the, 312.

_Ovaria_, description of the, 22. Situation of the, 22. Arteries of the, 23. Tunica albuginea of the, 23. Graafian vesicle, 24. Appearance of the, during childhood, 28. Diseases to which they are liable, 28.

_Ovarian_ Pregnancy, 118. See _Extra-uterine Pregnancy_.

_Ovaries._ See _Ovaria_.

_Ovum_, development of the, 48. Membrana decidua, 48. Chorion, 52. Amnion, 54. Liquor Amnii, 55. Placenta, 55. Umbilical cord, 63. Analogy between the human, and the bird's egg, 64. Order of development, 66.

_Pains_, labour, action of, 158. Auscultation during, 159. Effects of, on the pulse, 160. Symptoms to be observed during and between, 160. Characters of true, 161. Straining, 165. Spurious, 172. Causes of, 172. Diagnosis of, 172. Treatment of, 173.

_Palpitation_ during pregnancy, 104. Treatment of, 104.

_Parietal_ Bone, fracture of the foetal, from pelvic deformity, 302.

_Parturition_, mechanism of, 199. Cranial presentations, 200. Face, 206. Nates, 210. See _Presentation_; _Labour_.

_Pelvis_, anatomy of the, 15. Brim of the, 17. Distinction between the male and female, 17. Diameters of the, 19. Before puberty, 20. Axes of the, 21. Inclination of the, 21. Malposition of the child with deformed, 272. Abnormal state of the, 292. Equally contracted, 292. Unequally contracted, 293. Causes of, 293. Symptoms of, 298. Funnel shaped, 298. Obliquely distorted, 299. Exostosis of the, 300. Diagnosis of contracted, 300. Treatment of, 303. Prognosis of, 304.

_Pendulous_ Abdomen, obstructing labour, 308. Management of, 308.

_Perforation_, 256. History of, 256. Instruments employed in the operation of, 256. Indications for its performance, 257. Extraction after, 259. Embryulcia, 261.

_Perforators_, different kinds of, 250.

_Perineum_, obstructing labour, 317. Dilatation of the, 166. Mode of supporting the, in labour, 179. Laceration of the, treatment of, 181.

_Peritonitis_, puerperal, 420. Symptoms of, 420. Anatomical characters of, 430. Treatment of, 431. False, 441. Symptoms of, 441. Treatment of, 443.

_Phlebitis_, uterine, 436. Symptoms of, 436. Anatomical characters of, 437. Treatment of, 438. Crural, connexion of, with phlegmasia dolens, 465.

_Phlegmasia_ dolens, 463. Nature of, 463. Definition of, 463. Symptoms of, 464. Duration of, 465. Connexion of, with crural phlebitis, 465. With puerperal fever, 467. Causes of, 466. Anatomical characters, 467. Treatment of, 469.

_Physiology_ of utero-gestation, 15.

_Placenta_, description of the, 55. Cotyledons of the, 56.

_Placenta_, decidua of the, 51-56. Circulation of the uterine blood through the, 57-61. Sulci of the, 57. Foetal surface of the, 60. Expulsion of the, 167. See _Labour_. Management of the, 186. In twin cases, 187. Prævia, 393. History of, 393. Symptoms of, 402. Comparative frequency of, in different years, 405. Treatment, 406. Partial presentation of the, 413. Treatment of, 414. Retention of the, 337. Encysted, 354. Situation of, 354. History of, 354. Adherent, 356. Treatment of, 356. Left in the uterus, 357. Absorption of retained, 358.

_Plethora_, effects of, on uterine contraction, 327.

_Plug_, utility of the, in restraining hæmorrhage, 410. Best means of applying, 152.

_Position_ of the patient during labour, 176.

_Precipitate_ labour, 361. From violent uterine action, 361. From deficient resistance, 363. Effects of, 363. Treatment of, 365. Connexion of, with mania, 366.

_Pregnancy_, changes induced in the uterus by, 36. Seat and appearance of the uterus in the different stages of, 39. Signs of, 80. General, 81. Cessation of the menses, 83. Areola, 86. Movements of the foetus, 88-94. Auscultatory signs, 89. Ballottement, 94. Urinary deposites, 96. Purple hue of the vaginal entrance, 97. Diagnosis of twin, 100. Treatment of, 101. Morning sickness, 101. Heartburn, 103. Constipation, 104. Flatulence, 104. Colicky pains, 104. Headach, 104. Spasmodic cough, 104. Palpitation, 104. Toothach, 104. Diarrhoea, 105. Pruritis pudendi, 105. Salivation, 106. Mole, 112. See _Mole Pregnancy_. Extra-uterine, 117. See _Extra-uterine Pregnancy_. Duration of, 136.

_Premature_ expulsion of the foetus, 141. See _Abortion_.

_Premature_ Labour, 141. Artificial, 250. History of, 250. Period for inducing, 253. Mode of operating, 253. Rupture of the membranes in, 287.

_Presentation_, cranial, 206. First species of, 200. Second species of, 203. Of the face, 206. Of the nates, 210. See _Nates_. Of the arm, 272. Of the arm with the head, 273. Of the hand and feet, 273. Of the head and feet, 274. Of the placenta, 393. See _Placenta Prævia_.

_Prolapsus_ of the umbilical cord, 368.

_Pruritis_ pudendi occurring during pregnancy, 105. Treatment of, 106.

_Puberty_, state of the pelvis before, 20.

_Puerperal_ Convulsions, 376. See _Convulsions_.

_Puerperal_ Fevers, 415. Nature of, 418. Varieties of, 418. Pathology of, 418. Peritonitis, 420. See _Peritonitis_. Uterine phlebitis, 436. See _Phlebitis_. Gastro-bilious, 444. Causes of, 444. History of, 444. Symptoms of, 445. Anatomical characters of, 446. Treatment of, 446. Adynamic, 450. Symptoms of, 450. Anatomical characters of, 455. Supervention of arthritic or rheumatic inflammation, 456. Contagious nature of, 458.

_Puerperal_ Mania, 473. Inflammatory form of, 473.

_Puerperal_ Mania, treatment of, 474. Gastro-enteric form of, 475. Treatment of, 476. Adynamic form of, 478. Causes of, 478. Symptoms of, 478. Treatment of, 481.

_Quickening_, 88.

_Retained_ Placenta, absorption of the, 358.

_Retention_ of the placenta, 337, 356.

_Retroversion_ of the uterus, 126. History of, 126. Causes of, 127. Symptoms of, 129. Diagnosis of, 130. Prognosis of, 131. Treatment of, 131.

_Rheumatic_ inflammation after puerperal fever, 456.

_Rheumatism_ of the gravid uterus, 328. Symptoms of, 328. Treatment of, 333.

_Rickets_, a cause of deformity of the pelvis, 294.

_Rigidity_ of the uterus, malposition with, 272. Of the os uteri, 310. Treatment of, 310. From age, 314.

_Rigour_ after the first stage of labour, 162.

_Rupture_ of the uterus, 274. Seat of the laceration, 274. Causes of, 275. Symptoms of, 276. Treatment of, 277. Gastrotomy, 278. During the early months of pregnancy, 278. Premature, of the membranes, 287. Of the umbilical cord, 364.

_Sacrum_, anatomical description of the, 16.

_Salivation_ during pregnancy, 106. Treatment of, 106.

_Show_, 163. See _Labour_.

_Sickness_, morning, in pregnancy, 101. Treatment of, 102.

_Signs_ of pregnancy, 80. See _Pregnancy_. Of the death of the foetus, 107.

_Size_ of a child at birth, 281.

_Spasmodic_ cough during pregnancy, 104. Treatment of, 104.

_Spontaneous_ evolution, 270. Expulsion, 271.

_Stone_ in the bladder, obstructing labour, 323.

_Stricture_ of the uterus, 335. Symptoms of, 335. Effects of, on labour, 335. Causes of, 336. Treatment of, 336.

_Stroma_, 23. See _Ovaria_.

_Structure_, fibrous, of the uterus, 32.

_Sulci_ of the placenta, how formed, 57. Their connexion with the uterine vessels, 59.

_Tampon_, 410. See _Plug_.

_Temperament_, influence of, on uterine contractions, 327.

_Tetanic_ puerperal convulsions, 381. See _Convulsions_.

_Toothach_ during pregnancy, 104. Treatment of, 104.

_Tumours_, obstructing labour, 320.

_Turning_, 230. Indications for, 231. Mode of performing the operation of, 232. Rules for finding the feet, 237. Extraction of the child, 239. With the nates foremost, 240. With the head foremost, 241. History of, 242.

_Twins_, 168. Management of the placenta of, 168, 187.

_Umbilical_ Cord, 63. See _Cord, umbilical_.

_Unruptured_ Hymen impeding labour, 316.

_Urinary_ deposites in pregnancy, 96.

_Uterine_ Souffle, 90. See _Auscultation_. Action, violent, 361. Phlebitis, 436. See _Phlebitis_.

_Utero-gestation_, anatomy and physiology of, 15.

_Uterus_, description of the, 30. Ligaments of the, 31. Structure of the, 32. Comparative anatomy of the, 34. Changes in the, during gestation, 36. Situations and appearances of the gravid, 39. Condition of the gravid, after delivery, 44. Blood-vessels of the, connected with the placenta, 57, 61. Retroversion of the, 126. See _Retroversion_. influence of the form and size of the, on parturition, 266. Rigidity of the, 272. Anteversion of the, 309. Derangement in the contractile power of the, 224. Rupture of, 274. Rheumatism of the gravid, 328. Effects of uterine inflammation in labour, 329. Stricture of the, 335. Atony of the, 324. Inversion of the, 345. Extirpation of the, 352. Hour-glass contraction of the, 354.

_Vagina_, anatomical description of the, 45.

_Vagina_, contracted, obstructing labour, 314. Cicatrices in the, 315.

_Varicose_ swellings of the labia and nymphæ, 317.

_Ventral_ Pregnancy, 119. See _Extra-uterine Pregnancy_.

_Vesicle_, germinal, of the egg, 65. See _Egg_.

_Violent_ uterine action, precipitate labour from, 361.

_Wigand's_ views as to the duration of labour, 178.

_Womb_, 30. See _Uterus_.

_Yelk-bag_, 65. See _Egg_.

THE END.

FOOTNOTES:

[1] On the Ova of Man and Mamiferous Animals, &c.: by T. Wharton Jones. (_Med. Gaz._)

[2] "Inde vero cum viderum viviparorum testes ova in se continere, cum eorundem uterum itidem in abdomen, oviductus instar apertum notarim, non amplius dubito quin mulierum testes ovario analogi sint, quocunque demum modo ex testibus in uterum, sive ipsa ova, sive ovis contenta materia transmittatur, ut alibi ex professo ostendam, si quando dabitur partium genitalium analogiam exponere, et errorem illum tollere quo mulierum genitalia genitalibus virorum analoga creduntur." (_Nicolai Stenonis Elementorum Myologiæ Specimen, &c._ Amst. 8vo. p. 145.)

[3] "Ova in omni animalium genere reperiri confidenter asserimus, quandoquidem ea non tantum in avibus, piscibus tam oviparis quam viviparis, sed etiam quadrupedibus ac homini ipso evidentissime conspiciantur." (_Regner de Graaf de Virorum et Mulierum Organis Generationi Inservientibus._ Lugd. B. and Roterod. 1668. 8vo. p. 299.)

[4] Anat. Descript. of the Human Gravid Uterus: by W. Hunter, M. D.

[5] An Exposition of the Signs and Symptoms of Pregnancy, &c.: by W. F. Montgomery, M. D. p. 226.

[6] Phil. Trans. 1797.

[7] Purkinje and Valentin, de Phoenomeno generali Motus vibratorii. Wratisl. 1825.

[8] W. Hunter, Anatomical Description of the Human Gravid Uterus, &c. p. 13.

[9] Vesalius, Malpighi, Morgagni, Diemerbroeck, Vieussens, Ruysch, Monro, Heister, Haller, Roederer, Meckel, Hunter, Wrisberg, Lobstein, C. Bell. (_Meckel's Anat._ vol. iv.)

[10] C. Bell, On the Muscularity of the Uterus. (_Med. Chir. Trans._, vol. iv.)

[11] Leroux, Sur les Pertes de Sang.

[12] The tortuous serpentine course which the arteries of the uterus take, is not, as has been generally supposed, a provision of nature against the increase of size which the uterus has to undergo during pregnancy, but is the result of the structure in which they ramify, having already undergone these changes during a previous pregnancy.

[13] Anatomical Description of the Human Gravid Uterus, &c.: by W. Hunter, M. D.

[14] The axis of the brim of the pelvis runs in such a direction, that if a line were drawn from its centre, it would pass upwards and forwards through the umbilicus: the gravid uterus has its axis rarely or never inclined less than this, and usually much more, especially in multiparæ in whom the fundus is occasionally inclined so strongly forwards as to receive the name of pendulous belly.

[15] We are inclined to think that the soft feel of the portio vaginalis is one of the earliest signs of pregnancy which can be detected by examination. Our attention was first drawn to it in an obscure case of early pregnancy, complicated with extensive disease, which we examined with Mr. Ingleby of Birmingham, and where we gave a wrong diagnosis, not considering the patient to be pregnant. If we had placed as much confidence in this symptom as we are now inclined to do, we should probably have formed a more correct view of the case. Since this we have, on several occasions, found that attending to this circumstance has considerably assisted us in determining cases of doubtful pregnancy at an early period.

[16] This description is given according to the lunar not calendar months, of which there are necessarily ten during the forty weeks of pregnancy.

[17] We are aware that the plan which we follow, in considering the development of the ovum, is very different to that usually adopted, and will probably be open to some objections on the score of defective arrangement; but it must be remembered that this is a work intended for students, where complete and perfect arrangement must, to a certain extent, be sacrificed in order to place an acknowledged difficult and complicated subject in the clearest and most intelligible light. We have, therefore, preferred describing first the coverings of the ovum during those periods of pregnancy at which they are most frequently seen, and shall delay its minute consideration until we come to the description of the foetus itself, the development of the one being so essentially connected with that of the other, as to render a separate description of them impossible. By this means the reader, by having the general details first brought under his notice, will be enabled to enter with more ease and advantage upon the consideration of those which are obscure and difficult.

[18] Siebold's Journal für Geburtshülfe, vol. xiv. heft. 3. 1835.

[19] On the Signs and Symptoms of Pregnancy, p. 133.: by W. F. Montgomery, M. D. In a note to the above quotation, the learned author very properly calls them _decidual cotyledons_, "for to that name their form, as well as their situation, appears strictly to entitle them: but from having, on more than one occasion, observed within their cavity a milky or chylous fluid, I am disposed to consider them reservoirs for nutrient fluids, separated from the maternal blood, to be thence absorbed for the support and development of the ovum. This view seems strengthened when we consider that, at the early periods of gestation, the ovum derives its support by imbibition, through the connexion existing between the decidua and the villous processes covering the outer surface of the chorion."

[20] Observations by Dr. Baillie, in the posthumous work of Dr. W. Hunter, on the Anatomy of the Gravid Uterus.

[21] Observations on Certain Parts of the Animal Economy, p. 134.

[22] It has lately been supposed that the irregular nodules of wax in the Hunterian preparations were merely the result of extravasation, a rather hazardous conclusion against the authority of such men as the Hunters. Mr. J. Hunter has, however, expressly met this objection in the following observation:--"this substance of the placenta, now filled with injection, had nothing of a vascular appearance, or that of extravasation; but had a regularity in its form which showed it to be a natural cellular structure, fitted to be a reservoir for blood." (_Observations on Certain Parts of the Animal Economy_, p. 129.)

[23] In offering these observations on the placenta, we have purposely quoted, wherever it was possible, from the admirable essays of the Hunter's, on this subject. These works, more especially that of Dr. W. Hunter, are becoming too scarce to be easily attained by the student; and yet it is more peculiarly important to this class of our readers, that they should not only be aware how much we are indebted to these illustrious men for what we know upon the subject; but also that they should be as familiar as possible with their very words and expressions. The essays in question are master-pieces of original observation and correct description, and we may safely assert, that the one by Dr. Hunter is so complete, as to leave us little or nothing more to be wished for on this subject. With such feelings we cannot conceal our surprise, to find that an author like Dr. Burns should have passed over the whole subject of the placenta without once alluding to the name of Hunter; this omission is the more marked in the last editions of his work, where he has furnished the reader with copious references, &c. in the notes. One would have thought that Dr. Burns would have felt pride in acknowledging the merits of his distinguished countrymen.

[24] We said, "_one_ of the earliest changes." Mr. Jones considers that "the breaking up of the surface of the yelk into crystalline forms," is the first change which he has observed.

[25] Allen Thomson on the Development of the Vascular System in the Foetus of Vertebrated Animal. (_Edin. New Philosop. Journ._ Oct. 1830.)

[26] Pander. Beiträge zur Entwickelungs-gesechichte des Hünchens im Eie. Würzburg, 1817.

[27] In making these observations upon the formation of the ductus arteriosus, we must request our readers to consider this as still an unsettled question.

[28] The vernix caseosa is a viscid fatty matter of a yellowish white colour, adhering to different parts of the child's body, and in some cases in such quantity as to cover the whole surface; it seems to be a substance intermediate between fibrine and fat, having a considerable resemblance to spermaceti. From the known activity of the sebaceous glands in the foetal state, and from this smegma being found in the greatest quantity about the head, arm-pits, and groins, where these glands are most abundant, there is every reason to consider it as the secretion of the sebaceous glands of the skin during the latter months of pregnancy.

[29] Fourcroy, it is true, has shown that the foetal blood is not only of a darker colour, but incapable of becoming reddened by the contact of atmospheric air, and that it coagulates very imperfectly. Others have shown that there is no perceptible difference in the colour of the blood of the umbilical arteries from that of the umbilical vein. Still, however, this by no means disproves what we have now stated, and which is now generally allowed to be the office of the placenta during the latter periods of pregnancy.

[30] "A gentleman," says Dr. Montgomery, "lately informed me that, being afflicted with a stepmother naturally more disposed to practise the _fortiter in re_ than to adopt the _suaviter in modo_, he and all the household had learned from experience to hail with joyful anticipations the lady's pregnancy, as a period when clouds and storms were immediately changed for sunshine and quietness." (_Exposition of the Signs and Symptoms of Pregnancy_, p. 9.)

[31] _Dionis_ says, that "women of a sanguine complexion, who form more blood every month than is necessary for the nourishment of the foetus whilst it is small, discharge the overplus by the vessels which open into the vagina during the first months."

[32] The menstrual blood is more pale and sparing: it usually comes from the hæmorrhoidal vessels of the vagina, or at most, from those of the cervix uteri. (Levret, _Art des Accouchemens_, § 233.)

[33] Should the vessels of the cervix uteri take upon them the secretion of the menses, this discharge can thus continue through pregnancy. (Carus, _Lehrbuch der Gynakologie_, bd. ii. p. 67.)

[34] L'Art d'Accouchemens, § 369. (note;) also Deventer, Novum Lumen Obstet. chap. xv.; Perfect's Cases of Midwifery, vol. ii. p. 71. [Meurer, American Journ. Med. Sc., April 1841, p. 494.]

[35] This fact was observed so long ago as by Aristotle, also by Schenk, as quoted by Mauriceau, lib. i. chap. 1. Mauriceau himself mentions having seen several cases, one of which forms the subject of his 393d observation. "Le 8 Juin, 1685. J'ai vu une jeune femme agée seulement de seize ans et demi, marié depuis un an qui était grosse de cinq mois ou environ, quoiqu'elle n'eut jamais eu ses menstrues, à ce qu'elle me dit aussi bien que son marie, qui ne pouvait pas se persuader qu'elle cût pû devenir grosse, n'ayant pas encore eu ce premier signe de fécondité; m'alleguant, pour soutenir son opinion, qu'on ne voyait jamais de fruit d'un arbre qui n'eut été précédé de sa fleur. Mais je lui dis qu'il était certain, comme il reconnut bien par sa propre experience en voyant accoucher sa femme d'un enfant vivant quatre mois ensuite, que les jeunes femmes pouvaient bien quelquefois devenir grosses, ainsi qu'il était arrivé à sa femme, sans avoir jamais eu leur menstrues, si elles usaint du coit dans le temps méme quelles étaient sur le point d'avoir effectivement cette evacuation naturelle pour le premier fois."

[36] Roederer, Elm. Art. Obst. p. 46. The original is a masterly specimen of description, not less remarkable for its singular comprehensiveness than the beauty of the style. "Menstruorum suppressionem mammarum tumour insequitur, quocirca mammæ crescunt, replentur, dolent interdum, indurescunt; venæ earum coeruleo colore conspicuæ redduntur; crassescit papilla, inflata videtur, color ejusdem fit obscurior; simili colore distinguitur discus ambiens qui in latitudinem majorem expanditur, parvisque eminentiis quasi totidem papillulis tegitur."

[37] "In women with dark eyes and hair, this discolouration is very distinct; in women with light hair and eyes, it is often so slight that it is difficult to tell whether it exists or no."... "In brunettes who have already borne children, the areola remains dark ever afterwards, so that this ceases to be a guide in all subsequent pregnancies." (Gooch, _on some of the more important Diseases of Women_, p. 201 and 203.)

[38] We had, at the moment of writing the above, a patient just recovered from her first labour, in whom the discolouration extended nearly over the whole breast: it was darker in some spots than in others, and presented a variety of shades not unlike a large bruise of some days' standing. Dr. Montgomery mentions a case where the areola was almost black, and upwards of three inches in diameter. A similar case occurred not long since.

[39] Bibliothèque Universalle, t. ix. p. 248; also in the Isis for 1819,