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NATIONAL LIBRARY OF MEDICINE




          Bethesda, Maryland 
Mf&VtfUj?r+*5

u 
 
THE
PRINCIPLES

MIDWIFERY;
INCLUDING TOE
DISEASES
WOMEN AND CHILDREN.
           BY JOHN  BURNS, M. D.
LECTURER OK MIDWIFERY, AVD MEMBER OF THE FACULTY OF PHYSICIANS
               AND SURGEONS, GLASGOW.
THE FOURTH AMERICAN, FROM THE THIRD LONDON EDITION,
                GREATLY ENLARGED.
         WITH IMPROVEMENTS AND NOTES,
      BY THOMAS  C. JAMES, M. D.
professor of midwifery is the university of Pennsylvania.

                  VOL. I.
     k            PHILADELPHIA:

PUBLISHED BY BENJAMIN WAfclTER, EDWARD & RICHARD PARKER, MATIIKW
   CARE If & SON, BENJAMIN & THOMAS KITE, SOLOMON W. CONRAD,
            ANTHONY FINLKt,\AM> MOSES THOMAS.
                 J. R. A*Skeyrett, Printer.
1817. 
003
 B33
DISTRICT OF PENNSYLVANIA, TO WIT:
    Be it remembered, That on the seventh day of September, in the
thirty-eighth year of the Independence of the United States of America,
A. D. 1813, Benjamin and Thomas Kite, Johnson and Warner, Edward
Parker, Kimber and Conrad, Mathew Carey, Moses Thomas, Anthony
Finley, and Redwood Fisher, of the  said  District, have deposited in
this office the title of a Book, the right whereof they claim as Proprie-
tors, in the words following, to wit:
  " The Principles ofMidwifery; including the diseases of Women  and
   " Children.  By John Burns,  Lecturer on Midwifery, and Member of
   " the faculty of Physicians and Surgeons, Glasgow.  The third Ameri-
   " can, from the second London Edition, much enlarged.  With Improve-
   " ments andJVotes, by Thomas  C. James, M. D. Professor of Midwifery
   "in the University of Pennsylvania."
  In conformity to the Act of the Congress ofthe United States, intituled,
" An Act for the Encouragement of Learning, by securing the Copies
of Maps, Charts and Books, to  the Authors and Proprietors of such
copies during the times therein mentioned."—And also to the Act, en-
titled, " An Act supplementary to an Act, entitled' An Act for the En-
couragement of Learning, by securing the Copies of Maps, Charts and
Books, to the Authors and Proprietors of such copies during the times
therein mentioned,' and extending the benefits thereof to the Arts of
designing, engraving, and etching historical and other Prints."
                                       D. CALDWELL,
                              Clerk of the District of Pennsylvania.
   6  76/
/3~fi(o-Vt 
PREFACE OF THE AUTHOR.
  IN preparing this work, I have endeavoured to pro-
ceed as much as possible upon the method of induction.
I have collected with care the  different cases which
have been made public, as well as my own private ob-
servations.  To these I have added the opinions and
advices given by others, in so far as they seemed to be
founded on facts, and supported by experience. From
the whole I have deduced, in the different parts of my
subject, both the symptoms and the practice.
  The anatomical descriptions, I have given from dis-
sections and preparations before me whilst writing.
  I intended to have added to the text, copious re-
ferences to the opinions and cases contained in systems,
or scattered through other publications.  This would
have rendered  the present book, in some manner,  an
index  to  those already published, and been  of con-
siderable  service to  practitioners, who wished to con-
sult them  upon any particular point.  But in spite of all
my endeavours, this work has extended  to a length
which rendered it  necessary to strike out many re-
ferences, and shorten the account of  cases, to  prevent
it from swelling to a size which would have rendered
it less generally useful.
   Whilst I thus state the plan on which I have pro-
ceeded, I acknowledge myself deeply sensible, that its
execution does not  bear any proportion to the impor- 
IV
tance of the subject.   Should this work fall only into
the hands of those, competent to judge on their profes-
sion, it would, if  faulty or deficient, do  little harm :
but should it ever be circulated more extensively,  it
must  like other systems and elements,  have an in-
fluence on the opinions and future practice of the stu-
dent of midwifery; and  will prove useful or injurious
to society, according to the correctness of the principles
it contains.  When I consider how important the dis-
eases of women  and children are, and how much de-
pends on the prudent management of parturition, I feel
the high responsibility which falls on those who pre-
sume to  give lessons  in midwifery.  I do, however,
sincerely trust, that the precepts I have inculcated will,
in general, be found  agreeable to the experience and
practice of our best teachers ; and, on a review of the
whole, I  cannot say that I have  either wasted the
reader's time in  idle theory,  or misled his opinion by
mere speculation.
   In  preparing  a third  edition for the press, I  have
carefully revised the whole work, and have made many
additions, which I hope will prove useful.

    Glasgow.  October. 1814. 
PREFACE OF THE EDITOR.
  IT is not the intention of the present editor to incur
the fault so sharply reprehended by Johnson, and "re-
tard the instruction" contained in the ensuing volumes,
by an unnecessary and prolix preface.  He will only
briefly mention, that our author, " equally experienced
as a teacher and practitioner,"  has, from the  acknow-
ledgement of the most competent judges,* "by a judi-
cious  arrangement, by a faithful exposition of facts and
observations, and by a methodical induction of the prin-
ciples and practice of the art, accomplished in this work
all that could be  expected, in the  present state of the
science, to give a new interest to the subject.
  " The prominent advantage, that confers upon it a
decided preference to  all others, as a System or Class-
book,  is, that every subject, directly or indirectly con-
nected with the  practice of the accoucheur, is here
brought into one connected view.
  " But what we are most disposed to recommend in
this volume,! is the  pathological  department, and the
descriptions and treatment of the diseases of puerperal
women, and of children.   A more copious, scientific,
and judicious account  of these diseases, is perhaps no
where to be met with."  Thus far the editors  of the
Edinburgh  Medical and Surgical Journal.
• Edin. Med. and Surg. Journal, for 1810.
f The work was originally published in one volume. 
VI
  One great advantage of this work to the student soli-
citous of full and accurate information on the subjects
of which it treats, is to be experienced in the very valu-
able notes and  references of the  author, to almost all
that has been communicated by practitioners of deserv-
ed  celebrity, on parallel subjects  or  cases.   In this
point of view, it  may be considered as the Common-
place Book of  an immense fund of the most  useful
practical knowledge, indispensable as a guide to the in-
experience of the student, and earlier practitioner, and
of no ordinary  utility and aid, to the maturer  acquire-
ments of advanced and established professional skill.
  This edition has been considerably enlarged and im-
proved  by the author.   The sections  on abortion and
uterine  hemorrhage, will be found to have been very
considerably extended, and rendered of far greater va-
lue •—indeed, they may now be considered, as contain-
ing the essence of his separate Treatises on those very
interesting subjects, which have for some time enjoyed
the approbation of the public.
   The new articles, totally omitted in the former edi-
tion,  but by the  author introduced  into this, are those
on pneumonia, on ephemeral fever, on weed or intesti-
nal fever, and on diarrhoea, as existing in the puerpe-
ral state, and on chorea, on  bronchitis, and on  peri-
tonitis, as the  diseases of the infantile age.   These, it
is presumed, will not fail to give additional interest  to
 the work.
    The editor has taken the liberty of introducing into
 the text,  a section on  the difference between the male
 and female pelvis; which as he conceived, the author
 ought not to have omitted; and Dr. Clarke's account of
 the cauliflower excrescence of the os  uteri.  Whether 
Vll
this is only a variety of the spongoid tumour, he  will
leave to the reader to decide.  It appears to assume
some difference in its form and train of symptoms.  The
history is from the pen of an accurate observer of na-
ture, and a judicious and experienced practitioner.
   As Baudelocque has explained the mechanism of
parturition, more fully and  minutely than almost any
other writer, and as his work on midwifery has obtain-
ed considerable reputation with the  medical  public of
the United States, it has been judged proper, occasion-
 ally, to  give a general view of  his divisions of labour,
 together with the several species  of presentations,
 which it may be useful to keep in recollection in actual
 practice.  Some tables, relative to this part of our sub-
 ject, from the last edition of his valuable work that
 have not, as far as we know, been hitherto translated,
 will also be given in the appendix.  These, it is hoped,
 will not be entirely devoid of interest, either to the stu-
 dent or practitioner.
    The  chief mass of the notes in Dr. Chapman's edi-
 tion of  our author s production, have been, by permis-
 sion retained in this ; these are marked with the letter
 C. The notes added by the present editor have alpha-
 betical  references, and are thus sufficiently distinguish-
 ed from those of the author, and of the intelligent editor
 of whose information we have availed ourselves, and to
 whom we have just alluded. These will be found to be
 altogether of a practical nature, and are intended solely
 to explain, or illustrate the text; as it has been found
 rarely  necessary to differ in sentiment from one. whose
  opinions seem generally to be founded on the solid basis
  of practical truth. Auy additions made  to the text, or
  Author's notes, are included between brackets. 
Vlll
  The Author has rendered this last edition more in-
teresting, by some valuable additional matter, and the
Editor has subjoined a few notes, which he hopes will
not be found entirely nugatory.
Philadelphia, July 1st, 1817. 
CONTENTS.
                      BOOK I.

Of the Structure, Functions, and Diseases of the Pelvia
   and Uterine System,  in  the unimpregnated state,
   and during Gestation.

                    CHAPTER I.
               Of the  Bones of the Pelvis.
   Section 1. General view      ...      Page 1
   Section 2. Ossa innominata     ...         2
   Section 3. Sacrum and coccyx -                     5

                    CHAPTER II.
Of the Articulation of the  Bones of the Pelvis,  and  their occa-
                    sional separation.
   Section 1. Of the symphysis pubis   ...      f
   Section 2. Sacro-iliac  junction       -    -    -    8
   Section 3. Vertebral junction, and obliquity of the
       pelvis......-9
   Section 4. Separation of the bones   -                9
   Section 5. Difference of female from male  pelvis      14

                    CHAPTER  III.
          Of the soft parts which line the Pelvis.
   Section 1. Muscles.....16
   Section 2. Arteries......17
   Section 3. Nerves.....18
\$*Section 4. Lymphatics.....19 
X
                    CHAPTER IV.
             Of the Dimensions of the Pelvis.
   Section 1. Brim and outlet     -     -     -     Page 20
   Section 2. Cavity.....21
   Section 3. Pelvis above the brim      -     -     -    23
   Section 4. Axis of the brim and outlet   -            24

                    CHAPTER V.
Of the Head of the Child, and its progress through the  Pelvis in
                        Labour.
   Section 1. Bones of the head     -                 24
   Section 2. Size of the head      ....    26
   Section 3. Passage of the head     -                 27

                    CHAPTER VI.
    Of Diminished Capacity and Deformity of the Pelvis.
   Section 1. Deformity from rickets        -     -    29
   Section 2. Deformity  from  malacosteon      -       31
   Section 3. Deformity from exostosis and tumours     33
   Section 4. Means of ascertaining the dimensions
       and size of the head when broken down      -     35-

                    CHAPTER VII.
           Of Augmented Capacity of the Pelvis,         36

                   CHAPTER VIII.
           Of tlie external Organs of Generation.
    Section 1.  General view     -                      37
    Section 2.  Labia and nymphw    ...         38
    Section 3.  Clitoris.....38
    Section 4.  Urethra         ....        39
    Section 5. Orifice of vagina and hymen      -      41

                     CHAPTER IX.
            Of the Internal Organs of Generation.
    Section  1. Vagina.....        42 
XI
Section 2. Uterus and its appendages      -     Page 43

                 CHAPTER X.
     Of the Diseases of the Organs of Generation.
Section 1.  Abscess in the labium       -      -    47
Section 2.  Ulceration of the labia    -       -      48
Section 3.  Excrescences on the labia          -    51
Section 4.  Scirrhous tumours        -        -      51
Section 5.  Polypous  tumours          -       -    52
Section 6.  OSdema     -            -       -      53
Section 7.  Hernia, laceration, &c.     -      -    53
Section 8.  Diseases  of the nymphse          -      54
Section 9.  Diseases  of the clitoris     -      -    55
Section 10. Diseases  of the hymen    -       -      56
Section 11. Laceration of the perinseum        -     57
Section 12. Imperfection of the vagina        -       59
Section 13. Inflammation and gangrene  of the
     vagina      -       -      -       -       -     59
Section 14. Induration, ulceration, and polypi        60
 Section 15. Inversion         .       -       -       60
 Section 16. Watery tumour     -       -       -     61
 Section 17. Hernia          -        -        - ...     61
 Section 18. Encysted tumour and varices       -    62
 Section 19. Spongoid tumour         -       -       63
 Section 20. Erysipelatous inflammation         -    63
 Section 21. Fluor albus       .       -       -       65
 Section 22. Affections of the bladder    -      -    70
 Section 23. Excrescences in the urethra      -       74
 Section 24. Deficiency and inal-formation of uterus   76
 Section 25. Hysteritis       .       -       -      77
 Section 26. Ulceration  of the uterus     -      -    78
 Section 27. Scirro-cancer      -     -      -      80
 Section 28. Tubercles     -      -      -      -    84
 Section 29. Spongoid tumour        -      -       86
 Section 30. Cauliflower excrescence  from oa  uteri     87
 Section 31. Calculi          .       -       -        89
 Section 32. Polypi       -       -       -       -    90
 Section 33. Malignant polypi        -      -       95
vol. i.                           2 A 
XII
Section 34. Moles         -      -       -     Page 96
Section 35. Hydatids         - '     -       -       97<
Section 36. Aqueous secretion          -       -     99
Section 37. Worms          -       -       -       10°
Section 38. Tympanites       -                   10°
Section 39. Prolapsus  uteri         -       -       101
Section 40. Hernia     -     '-      -       -    107
Section 41. Dropsy of the ovarium           -       108
Section 42. Other diseases of the ovarium      -    114
Section 43. Deficiency      -      -       -       115
Section 44. Diseases of the tubes and ligaments      115

                 CHAPTER  XI.
                 Of Menstruation,         -        116

                 CHAPTER XII.
      Of Diseased States of the Menstrual Action.
Section 1. Amenorrhea       ...    121
Section 2. Formation of an organized substance     129
Section 3. Dysmenorrhoea          -       -       129
Section 4. Copious Menstruation      -       -    131
Section 5. Menorrhagia      -      -      -       131

                CHAPTER XIII.
           Of the Cessation of the Menses,      -    137

                CHAPTER XIV.
   Of Conception, and the term of Gestation,      -    139

                 CHAPTER  XV.
               Of the Gravid Uterus.
Section 1. Size and position        -       -      143
Section 2. Developement of the uterus, and state
     of its cervix       -                          144
Section 3. Muscular fibres           -       -      145
Section 4. Ligaments          -                   146
Section 5. Vessels          -                       147
S otion 6. Of the foetus        -       -       -     148
Section 7. Its peculiarities          -      -       153 
Mil.
Section 8.  Umbilical cord
Section 9.  Placenta
Section 10. Membranes and liquor amnii
Section 11. Decidua      ...

                CHAPTER XVI.
                   Of Sterility,

                CHAPTER XVII.
           Of Extra-uterine Pregnancy.
Section 1. Symptoms, progress, and species
Section 2. Treatment

              CHAPTER XVIII.
           Of the Signs  of Pregnancy.

                CHAPTER XIX.
        Of the Diseases of Pregnant  Women.
Section 1.  General effects     -       -      -    177
Section 2.  Febrile state     -       -       -       179
Section 3.  Vomiting     -    -       -      -    181
Section 4.  Heartburn       -       -       -       183
Section 5.  Fastidious taste    -       -      -    183
Section 6.  Spasnj of stomach and  duodenum        184
Section 7.  Costiveness      -       -       -       184
Section 8.  Diarrhoea         -       -      -    186
Section 9.  Piles    -       -       -       -       187
Section 10. Affections of the bladder          -    188
Section 11. Jaundice    -   -              -       190
Section 12. Coloured spots     -       -           190
Section 13. Palpitation      -       -       -       190
Section 14. Syncope      -            -      -    191
Section 15. Dyspnoea and cough      -       -       192
Section 16. Hemoptysis and haematemesis      -    193
Section 17. Head-ache and convulsions       -       193
Section 18. Tooth-ache        -       -           195
Section 19. Salivation       -       -       -       195
Section 20. Mastodynia        -       -       -    196
Page 157
     160
     163
     164
166
168
172
17 
XIV
 Section 21. ffidema          -       -        Page  196
 Section 22. Ascites        -       -       -          197
 Section 23. Redundance of liquor amnii      -       199
 Section 24. Watery discharge     -       -          201
 Section 25. Varicose veins          -       -       20S
 Section 26. Muscular pain      -      -           203
 Section 27. Spasm of ureter          -       -       204
 Section 28. Cramp       -                         204
 Section 29. Distension of the  abdomen       -      204
 Section 30. Hernia       ...          205
 Section 31. Despondency     -       -       -      206
 Section 32. Retroversion of uterus       -          206
 Section 33. Antiversion       -       -       -      213
 Section 34. Rupture of uterus     -      -          214
 Section 35. Abortion, and treatment of pregnant
  women         -                                217
 Section 36. Uterine hemorrhage      -       -      255
 Section 37. False pains     -       -               298
Notes       -       -      .       .       .      501 
          THE

    PRINCIPLES

           OF

MIDWIFERY.-
                       BOOK I.

OF THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE PELVIS
      AND UTERINE SYSTEM, IN THE UNIMPREGNATED
             STATE, AND DURING  GESTATION.
                       CHAP. I.

                Of the Bones of the Pelvis.

                   § I. GENERAL VIEW.    . -•■ *

  THE  practical precepts,  and rules  in  Midwifery, are
easily understood, and readily acquired.  They arise evident-
ly from the structui'e and actions of  the  parts concerned in
parturition; and whoever is well acquainted with this struc-
ture and these actions, may, from such  knowledge, deduce
all the valuable and important directions which constitute
the Practice of Midwifery.
  One of  the first, and not the least important, of the parts
concerned in parturition,  is  the pelvis,  which must be exa-
mined, not only on account of its connection with the uterus
and vagina, but also of its own immediate relation to the de-
livery of the child, and the obstacles which, in many instances,
it opposes to its passage.
  VOL. I.                          B 
2
  The pelvis consists,  in  the  full  grown  female, of three
large bones, two of which are very irregular, having no near
resemblance to  any other object,- on which account they have
been called the  ossa  innominata.   These form the sides and
front of the bason  or pelvis.  The back part  consists of a
triangular bone, called the os sacrum, to the inferior extremi-
ty or apex of which,  is attached, by a moveable articulation,
a small bone, which, from its supposed resemblance to the
beak of a cuckoo, has been named the os coccygis.
  The os innominatum, in infancy, consists of three  separate
pieces: the upper portion is called the ilium, or haunclfbone;
the under, the ischium, or seat bone; and the anterior, which
is the smallest of the three, is called the os  pubis, or share
bone.  These all join togetlier  in the acetabulum, or socket,
formed for receiving the os femoris, and are connected by a
very firm gristle or cartilage.  This, before the age of pu-
berty, is converted  into bone, so that the three  different
pieces are consolidated into one, though the names given to
the bones originally  are still applied to the different parts of
the united os innominatum.
   The sacrum  also,  which seems to consist only of one curv-
ed triangular  bone, is  really made up of several pieces,
which, in  the  child, are nearly as distinct as the vertebrae,
to which, indeed, they bear such  a resemblance, that they
have been considered as a continuation of them; but from
their imperfect structure, and subsequent  union, they have
been called the false vertebrae.
   The bones of the pelvis are  firmly joined together, by
 means  of ligaments and intermediate cartilages, and form a
 very irregular canal, the different parts of which  must be
 briefly mentioned.

                  § 2. OSSA INNOMINATA.

   When we look at the pelvis, we observe,  that the ossa
 innominata naturally divide themselves into two parts, the up-
 permost of which is thin and  expanded, iiTegularly convex
 on  its dorsum or outer surface, hollow on the inside, which 
3
is called the costa, and bounded by a broad margin, extend-
ing in a semicircular direction from before backwards, which
is called the crest of the ilium.  The under part of the os in-
nominatum is very irregular, and  forms,  with the  sacrum,
the cavity of the pelvis.  The upper expanded part has little
influence on labour, and serves, principally, for affording
attachment to muscles.  In the under part, we have several
points to attend to.
  1st. The upper and under  parts form an angle with each
other, marked by a smooth line, which is a continuation of
the margin of  the  pubis, or  anterior part of the bone.  It
extends from the symphysis pubis, all the way to  the junc-
tion of the os innominatum with the sacrum, and is called the
linea iliopectinea.  It is quite smooth and obtuse at the sides,
where the two  portions form an angle; but at the anterior
part, where the upper portion is wanting, it is sharp, and
sometimes is elevated into a thin spine  like the blade of a
knife.
  2d. The  upper portion is  discontinued exactly about the
middle of this line, or just over the acetabulum; and at the
termination, there is from this portion an obtuse projection
overhanging the  acetabulum, which is  called the inferior
spinous process of the ilium,  to distinguish it from a similar
projection about half an inch higher, called the  superior
spine.
   3d. The under part of the bone is of the greatest import-
ance, and in it we recognise the following  circumstances.
Its middle is large,  and forms on the outside a deep cup or
acetabulum, for the reception of the head of the  thigh  bone.
On the inside, and just behind this  cup,  it forms a smooth
polished plate  of bone within the cavity of the pelvis, which
is placed obliquely with regard to the pubis, and has a gen-
tle slope forward.  The cone of the  child's head, in labour,
moves downwards, and somewhat forwards,  on this,  as on
an inclined plane; it may be called the plane of the  ischium,
although a part of it be formed by the ilium.
  4th.  Standing off from the back  part of this, about two
inches beneath the linea iliopectinea, is a short projection, 
4
called the spine of the ischium, which seems to encroach a
little  on the  cavity of the pelvis, and is placed, with regard
to the pubis, still more obliquely than the plane of the is-
chium.   It must, consequently, tend to direct the vertex, as
it descends, still more towards the pubis.
  5th. Beneath  this, the ischium becomes narrower, but not
thinner; on the contrary, it is rather thicker, and terminates
in a rough bump, called, the tuberosity of the ischium.
  6th. Next, we look at the anterior part of the bone, and
find,  that just before the plane of the ischium, there is a large
hole in  the os innominatum.  This  is somewhat oval in its
shape;  and at the upper part within the  pelvis, there is a
depression in the bone, which, if followed by the finger or a
probe, leads to the face of the pelvis.  The hole is called the
foramen thyroideum.
  7th. Before this hole the two  ossa innominata join, but
form  with each other on the inside, a very obtuse angle, or
a kind  of smooth rounded surface, on which  the bladder
partly rests.   The .junction is  called the symphysis of the
pubis. t
  8th. The, two  bones, where they form the symphysis, are
Joined with each  other for about an inch  and a half;  then
they divaricate, forming  an angle,  the  limbs of which ex-
tend all the way to the tuberosity of the ischium.   This se-
paration or divarication is called the arch of the pubis, which
is principally constructed  of the anterior  boundary of the
foramen thyroideum, consisting of a column or piece of bone,
about half an inch broad, and one-fourth of an inch thick,
formed by the union of  the ramus of the pubis, and that of
the ischium.
  9th. At the upper part of the symphysis, or a very little
from  it, the os innominatum has a short obtuse projection,
called the crest of the pubis, into which Poupart's  ligament
is inserted; and from this there runs down  obliquely, a ridge
on the outside of the hone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.
  10th.  When we return to the back part of the os innomi-
natum, we find,  that just after it has formed the plane of the 
5
ischium, it extends backwards to join the sacrum; but in do-
ing so, it forms a very considerable notch or curve, the con-
cavity of  which  looks  downwards.  When" the sacrum  is
joined to the bone, this  notch  is much more distinct.   It is
called the sacro-sciatic notch or arch : for one side is formed
by the ischium, and is about two inches long; the other is
formed chiefly by the  sacrum,  and is about  half  an inch
longer.  In the recent subject, strong ligaments are extended
at the under part, from  the one bone  to the other,  so that
this notch is converted into a regular  oval hole.
   1 lth. Lastly,  this notch being formed, the  bone  expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that the
os innominatum  forms a strong, thick, projecting ridge, ex-
tending farther  back  than the spinous processes of the sa-
crum.  This ridge is  about two inches and three quarters
long, and is a continuation of the crest of  the ilium,  but is
turned downwards; whereas were  the crest continued in its
former course, it would meet with  the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle; but this ridge, if prolonged  on both sides^ would form
an acute angle, the point of junction being opposite the bot-
tom of the sacrum.   From this strong ligaments pass" to the
sacrum, to join, the two bones.

                 § 3. SACRUM AND COCCYX.

   The sacrum forms the back part of the pelvis.  It is a
triangular bone, and  gently curved;  so that, whilst  a line
drawn from the one extremity to the other, measures, if it
subtend the arch, about four inches; it will, if carried along
the surface of the bone, measure full half an inch more.  The
distance betwixt the  first or straight line, and the middle
of the sacrum is about  one  inch.   The breadth of  the base
of the sacrum,  considered as an  angular  body, is full four
inches : the centre of this base is  shaped like  the surface of
the  body of one of the lumbar  vertebrae,  with the last of
which it joins, forming, however, an angle with it, called the 
G
 great angle, or promontory of the sacrum.(a)  From this the
 bone is gently curved outward on each side, toward the sacro-
 iliac junction, contributing to  the  formation  of the brim of
 the pelvis.
   The upper half of the side of the bone is broad and  irre-
 gular for articulation with the os innominatum.  The ante-
 rior surface of the bone is smooth and concave; but often we
 observe transverse ridges, marking the original separation of
 the bones of the sacrum.  Four pair of holes  are found dis-
 posed in two longitudinal rows on the face of the sacrum,
 communicating with the canal which receives the continua-
 tion of the spinal marrow; through these  the sacral nerves
 issue.  These holes slope a little outward, and betwixt the
 two rows is the attachment  of the rectum.  The posterior
 surface of the bone  is very irregular; and,  we observe, 1st,
 The canal extending down the bone, for receiving the  con-
 tinuation of the spinal marrow. 2d. At the  upper part of
 this are two strong oblique processes, which join with those
 of the last lumbar vertebra.  3d. On a central line down the
 back of the canal, there is an irregular ridge analogous to
 the spines of the vertebrae.  4th. The rest of  the surface is
 very irregular and rough; and we observe, corresponding to
 the holes for  transmitting the sacral nerves on  the exterior
 surface, the same number of foramina on this  posterior sur-
 face, but, in the recent subject, they are covered with mem-
 brane, leaving o»ly a small opening for the exit of nervous
 twigs.
  The coccyx is an appendage to the sacrum, and as it is in-
 clined  forwards, from that bone, the point  of junction has
been called the little angle of the sacrum.   It  is, at first, al-
together  cartilaginous, and cylindrical in  its shape, but it
gradually ossifies and becomes flatter, especially at the up-
per part, which has been called its shoulder.  In men it is
generiilly anchylosed with the sacrum, or at least moves with
difficulty, but it almost always separates by maceration.  In
Women it remains mobile, and, during labour, is pressed back
(a) But more commonly the projection of the sacrum. 
7
so as to enlarge the outlet of the pelvis.  By falls or blows it
may be luxated;  and if this be not discovered, and the bone
replaced, suppuration takes place about the rectum, and  the
bone is discharged.
                       CHAP. II.

Of the Articulation of live  Bones of the Pelvis, and their occa-
                    sional separation.

               § 1. OF THE SYMPHYSIS PUBIS.

  The  bones  of the pelvis are connected  to  each other,
by intermediate cartilages, and by very strong ligaments.
The ossa innominata are united to  each other at the pubis,
in a very strong and peculiar manner.   It was supposed that
they were joined together by one intermediate cartilage; but
Dr. Hunter* was, from his observations, led to conclude, that
each bone was first of all covered at its extremity with carti-
lage, and then betwixt the two was interposed a medium, like
the intervertebral substance, which united them.  This sub-
stance consists of fibres disposed in a transverse direction.
  M. Tenonf has lately published an account of this articu-
lation ;  and is  of opinion, that sometimes the one mode and
sometimes the other obtains.  I am inclined to  think, that
Dr. Hunter's description is applicable to the most natural
state of the part; but we often, in females^nd that the in-
termediate fibrous substance, especially at the posterior part,
is absorbed, and its place supplied  with  a more fluid  sub-
stance ; or, on the contrary, anchylosis may sometimes  take
place; a circumstance which Dr. Hunter says he never saw,
but which I  have met with.   Besides this mode of connec-
tion, there is also in addition  a very strong capsule to the
articulation, the symphysis being covered on every side with

  • Vide Med. Obs. and Inq. Vol. II. p. 333.
  7 Vide Mem. de PInslitutdes Sciences, Tome VI. p. 1T2. 
                             8

  ligamentous fibres, which contribute greatly to the strength
  of the parts.

                  § 2. SACRO-ILIAC JUNCTION.

    The  ossa innominata  are  joined  to the  sacrum  bj
  means of a thin layer of cartilaginous substance, which covers.
  each bone;  that belonging  to the sacrum is the thickest:
  both are rough, and betwixt them is  found a  soft yellowish
  substance  in small quantity.   The connection of the two
  bones therefore, so far as it depends on this medium,  cannot
  be very  strong; but it is exceedingly  strengthened by liga-
  mentous fibres,  which  serve  as a capsule;  and  behind,
  several strong bands pass from the ridge of the ilium to the
  back of  the sacrum; sometimes the/bones are united  by  an-
  chylosis.  At the lower part, additional strength is obtained
  by  two  large and strong ligaments,  which pass from  the
  ischium to  the sacrum, and  therefore  are called the sacro-
  sciatic ligaments.  The innermost of these arises from the
  spine of the ischium, is very strong, but at first not above  a
  quarter of an inch  broad; it gradually  expands, however,
  becoming at its  insertion about an inch and a quarter in
  breadth. It passes on to the sacrum, and is implanted into the
  lower part of the side of that bone, and the upper part of the
" coccyx. It converts the sacro-sciatic notch into a regular oval
  hole, the inferior end of which, owing to the neat expansion of
  the ligament, is as round and exact as the upper. As it makes
  a similar expansion downwards, there is a kind of semilunar
  notch formed betwixt it and the  coccyx.  The outer liga-
  ment may  be said to arise from the side of  the sacrum, and,
  like the other, is broad at that part.  It runs for some time
  in  contact with  the inner ligament, and parallel to it; but
  afterwards  it separates, passing down to be inserted in tho
  tuber ischii; and, when the ligaments separate, their surfaces
  are no  longer  parallel to each  other.  There  is, in conse-
  quence of this separation, a small triangular opening formed
  betwixt the ligaments; or rather there is an aperture like a
   bow, the string being formed by the under ligament,  and the 
9
arch partly by the spine of the ischium, and partly by the
upper ligament.

 § 3. VERTEBRAL JUNCTION AND OBLIQUITY OF THE PELVIS.

  The pelvis  is  joined to  the trunk above, by  means of
the last lumbar vertebra; to the extremities below, by the
insertion of the thigh bones into the acetabula;  and it is so
placed, that when the body is  erect, the upper part of the
sacrum and the acetabula are nearly in the same line.   The
brim of the pelvis, then, is neither horizontal nor perpendi-
cular to the  horizon, but oblique, being placed at an angle of
35 or 40 degrees.  Were the ligaments of the pelvis loosened,
there would, from this position, be a tendency in the sacrum
to fall directly towards the pubis, the ossa innominata reced-
ing on each side.  But the structure of the part adds greatly
to the power of the ligaments; for it is to be observed, that in
standing, and in various exertions of the body, the limbs re-
act on the pelvis; and the heads of the thigh bones pressing
on the two acetabula, force the ossa innominata more closely
on each other at the symphysis, and more firmly on the sacrum
behind.   It  is not possible,  indeed, to separate the bones of
the pelvis, unless the connecting ligaments be  diseased, or
external violence be applied, so as to act partially or  une-
qually on the pelvis.                          .  '"■

              § 4. SEPARATION OF THE BONES.

  By external violence, the symphysis has been wrench-
ed open,  as was the case with Dr. Greene*; or the sacro-
iliac  junction may be separated, as in the case of the young
peasant, related by M. Louis.f
  By some  morbid affection of the symphysis, it may yield
and become loosened during  pregnancy, or may be  separated
during labour.   Some have been inclined to consider this as
an uniform operation of nature, intended to facilitate the birth

  * Phil. Trans. No. 484.
  f Vide Mem. de l'Acad. de Chir. Tome IV. p. 63.
  VOL. I.                           C 
10
  of the child.   Others, who cannot go this length, have never-
  theless  conjectured, that the ligaments  do  become  some-
  what slacker;  and have grounded this opinion on the sup-
  posed fact of the pelvis of quadrupeds undergoing this  relax-
  ation.  But the truth is, that this separation is not an advan-
  tage, but  a serious evil;   and in cases of  deformed  pelvis,
  where we would naturally look for its operation, did it  really
  exist, we do not observe it to take place.(6)
    When a person stands, pressure is made upon the symphy-
  sis, and therefore, if it be tender, pain will then be felt.   In
  walking, pressure is made  on the two  acetabula alternately,
  and the ossa innominata are acted on by  the strong  muscles
  which pass from them to the thighs, so that there  is  a ten-
  dency to  make the one os  pubis rise  above  the other;  but
  this, in a sound state  of the parts, is sufficiently resisted by

   (6)  There is an animal however, in which this separtion of the bones of the
 pelvis during pregnancy and parturition does really take place, and in whom
 it appears to be an operation of nature to facilitate the latter process.—This
 animal is the Guinea Pig.
   Le Gallois says, that upon comparing the pelvis of the female of the Guinea
 Pig with the head of a full grown Foetus, it appears utterly impossible, that the
 latter  should pass through the former, if the pelvis constantly preserved the
 state and dimensions at any other time than that of gestation.
   •When the female Guinea Pig is alive, the diameter of the pelvis is asserted
 to be but about one half of the head of the Foetus ;  and nevertheless, Guinea
 Pigs are delivered with much ease.
   The duration of gestation in these animals being about 65 days.—About 3
 weeks before delivery, the symphysis pubis is observed to acquire more thick-
 ness and a slight mobility; these are continually increasing. Eight or ten days
 before delivery, the two ossa pubis begin to separate from each  other.  This
 separation increases slowly at first, and only begins to go on rapidly  for the
 three or four days which precede  delivery.—At the moment of parturition,
 according to Le Gallois, it is such as readily to admit the middle finger, and
 sometime beth the middle and forefinger together.
   The delivery being accomplished, the bones of the pubis soon close.
.Twelve hours after, the distance of the separation has lessened more than one
Jhalf; and 24 hours after, they are in contact at their anterior extremity; and
 i^ less than three days they are perfectly so through the whole extent of their
 symphysis, which, then only presents a slight thickness and mobility.  A few
 days after, nothing is to be seen.  But when the females are old or sick, the
 union takes place more slowly.  Vide Le Gallois's Experiments.  Note at the
 end of the Vol. 
11
the ligaments.  In a diseased state, however, or in a case of
separation of the bones, there is not the same obstacle to this
motion: and hence, walking must give great pain, or be alto-
gether impossible : even attempts to raise the one thigh above
the other, in bed, must give more or less pain,  according to
the sensibility or laxity of the symphysis.  Standing has also
an effect on the symphysis, as I have mentioned ; but some-
times the person can, by fixing one  os innominatum, with all
the muscles connected with it, and throwing the chief weight
of the body to that side, stand, for a short time, easier on one
leg than on both.  This is the case when one os  innominatum
has been more acted on than the other, at the sacro-iliac junc-
tion.  The person can stand easiest on the soundest side.
The patient also, especially if the relaxation be accompanied
with  any degree of relaxation of  uterine  attachments in-
stinctively crosses her legs when standing, thereby obtaining
relief.
   From these observations, we may learn  the mischievous
consequences of a separation of the bones, and also the cir-
cumstances which will lead us to suspect that it has happened.
If the bones be fully disjoined, then, by placing the finger on
the inside  of  the  symphysis, and  the  thumb on the outside,
we can readily perceive a jarring, or motion, on  raising the
thigh.
   It is well known  to every practitioner, that owing to the
 distension of the  muscles  during pregnancy, very consider-
able  pain  is  sometimes felt at the insertion,  of  the  rectus
muscle into the pubis; and it is also known, that sometimes,
 in consequence of pregnancy, the parts about the.pelvis, and
 especially the bladder and urethra, and even the whole vulva,
 may become very irritable.  This tender state may bo com-
 municated to the symphysis; or some irritation,  less  in de-
 gree than that I  have mentioned  may exist, which, in par- <jf^
 ticular cases, seems to extend to the articulation, producing;'"
 either an increased effusion of interstitial fluid in the inter**
 mediate cartilage, and thus loosening  the  firm adhesion  of
 the bones, or a tenderness and sensibility of the part, render-
 ing motion painful.   In cither case, exertion may  produce a 
12
separation:  and certainly, in some instances, has  done so.
The separation is  always attended with inconvenience, and
often with danger, especially when it occurs during parturi-
tion ; for abscess may take place, and the patient sink under
hectic fever; or inflammation may be  communicated to the
peritoneum,  and the patient die in great pain.
  When the accident happens during gestation,  it some-
times takes place gradually, in consequence of an increasing
relaxation of the articulation, from slow but continued irrita-
tion.   In the other  instances, it happens  suddenly after
some exertion.   It may occur so early as the second, or so
late as the ninth month, and is discovered by the symptoms
mentioned above; such  as pain at the pubis, strangury, and
the effects of motion.  In some instances, considerable fever
may take place,  but in  general, the  symptoms are not dan-
gerous, and  I do not know any case which  has terminated
fatally before delivery.  A state of strict rest, the applica-
tion of  a broad  firm bandage round the pelvis, to keep the
bones steady, and the use of the lancet and antiphlogistic re-
gimen, if there be fever or much pain,  are  the  chief points
of practice.  Nor must it  be forgotten, for a moment, that
although by these  means, the symptoms are removed, the
patient is liable,  during the remaining term of gestation, or
at the time of  delivery, to a renewal of the relaxation or se-
paration, from causes which,  in other circumstances, would
have had no effect.   So far as I have been able  to learn, a
woman  who  has  had this separation in one pregnancy, is not,
in general, peculiarly liable to a return of it in a subsequent
pregnancy, though there may be particular exceptions to this
observation.1
  When it happens during parturition, it  sometimes takes
place in a pelvis apparently previously sound; but in  most
instances, we have,  during some period of gestation, symp-
toms of disease about the symphysis; and so far from mak-
ing labour easier,  the woman often  suffers more,  when the
symphysis is previously relaxed.  The primary and imme-
diate effects  are the same as w hen the accident happens dur-
ing pregnancy; but the subsequent symptoms  are frequently 
13
much more severe and dangerous, the tendency to inflamma-
tion being strong.   The  pain  may be either  trifling or ex-
cruciating at the moment, according  to the sensibility of the
parts.  But even in the mildest case, great circumspection
is required, violent  inflammation having come on so late as a
fortnight after the accident.   The means used in the  former
case are to be rigidly employed, and the woman should keep
lu?r thighs together, and  lie chiefly on her back.   If the se-
paration  have been slight, re-union may take place in a few
weeks, sometimes in a month;2 but  if a great injury have
been sustained, it may be many months, perhaps years before
recovery be completed; and, in such cases, it is probable, that
at last, an anchylosis is sometimes formed.
  Either owing to the violence of the accident, or the pecu-
liar state of the parts, it sometimes happens, that inflamma-
tion takes place to a very  considerable degree in the symphy-
sis ;  but  it is  to be remarked, that the symptoms are by no
means uniformly proportioned  in their severity to the degree
of the separation.   Inflammation is known by the accession
of fever,  with acute pain about the lower part of the  belly,
greatly increased by motion,  succeeding to the primary ef-
fects ; or,  sometimes, from the first, the pain is very great,
and  not  unfrequently  it is   accompauied by  sympathetic
derangement of the stomach and bowels,  such  as vomiting,
nausea, looseness, &c.   Presently  matter forms, and a well
marked hectic state takes place.  The patient is to be treat-
ed, at first, by the  usual remedies for abating inflammation,
such as general and local evacuation of blood, fomentations
and laxatives.  When  matter  is formed,  we  must carefully
examine  where it is most exposed, and let it out by a small
puncture.3
  The inflammation may  be communicated to the peritoneum,
producing violent pain in the lower belly, tumefaction and
fever, and almost uniformly proves fatal; though frequently
the patient lives until abscess takes place in the cellular sub-
stance within the pelvis.   If any thing can save her,  it must
be the prompt use of blood-letting and blisters.
  In almost every case of separation of the pubis, consider- 
11
able pain is felt in the loins, even although the junction at
the sacrum be entire, and the ossa pubis be very little asunder.
But when the separation is complete, and in any way exten-
sive, then the articulation  of the sacrum  with the ossa inno-
minata,4 especially with one of them,  is more injured,5 and
the person is lame in one or both sides, and  has acute pain
about the posterior ridge of the ilium6, and in  the course of
the psoas and glutei muscles.   The  mischief may also com-
mence in the saoro-iliac articulation, and the symphysis may
be little affected.  The general principles of treatment arc
the same as in the former case.  When suppuration takes
place about the sacro-iliac articulation, the danger is greatly
increased.
   In all cases of separation, when the patient has recovered
so far as to be able to move, the use of  the  cold bath acce-
lerates the cure; the general health is to be carefully attend-
ed to, and any urgent symptom supervening, is to be obviated
by suitable remedies.

  § 5. DIFFERENCE OF THE FEMALE FROM THE MALE PELVIS.

   [A slight inspection  is  sufficient to  show the difference
 in form and proportions, between  the  female and the  male
 pelvis.
    The crista;, as well  as the  anterior and  superior  spinous
 processes of the ossa ilia, are farther separated in the female
 pelvis, hence affording a greater concavity to the iliac fossae,
 and greater capacity to the large or superior pelvis.   The
 two straits which terminate the cavity of the pelvis, differ
 also considerably in the two  sexes.  The circumference, or
 brim of the superior strait is larger and more rounded in the
 female, the sacro-vertebral projection is less prominent; the
 two tuberosities of the ischia  are also less  rough, less  pro-
 jecting, and farther separated, than in the male; and finally,
  the extremity of the os coccygis does not approach so near to
  the  arch of the pubis, which affords to  the inferior strait,
  greater extent from its anterior to its posterior termination.
    With regard to  the excavation  of the pelvis,  it  is  more 
15
»      concave in the posterior part in the female, because the sa-
      crum has greater height and curvature; the arch of the pu-
      bis is broader,(c) and its branches are also turned more out-
      ward and  forward.  The region of the pubis is less convex,
      and the cartilage, which forms the symphysis, is thicker and
      shorter, offering towards the interior of the pelvis a promi-
      nence more remarkable than in the male.
         But in this  very conformation,  which nature  appears to
      have intended to render labour more easy, there are certain
      circumstances  exposing  the female to peculiar  inconveni-
      ences, which in men are more rarely observed; thus the su-
      perior  spinous  processes  which   anteriorly terminate the
      cristas, or spine  of the ilium, could not he separated to  a
      greater distance, without increasing the length of Poupart's
      ligament, forming the crural arch; from thence it follows,
      that the intestine and epiploon, finding in this part less re-
      sistance and a larger aperture, must more frequently pass
      down and  produce femoral hernia.
         Again, women having their hips  farther separated, must
      necessarily step  with less firmness than  men:  for in pro-
      gressing, when one leg is elevated, the centre of gravity of
      the body is less  readily thrown upon  the other,  which rests
      on the ground; from hence results  a species of clandication
      or vacillating  gait, in which the trunk and the inferior ex-
      tremities,  instead of advancing directly or in  a straight line,
      describe greater or smaller arches of circles.](rf)  '

        (c) Soemmering observes, that the angle between the diverging branches
      ef the pubis, is in the male an acute one ; but in the female forms an angle
      of from 80 to 90 degrees, and hence approaches nearer to the figure of an
      arch, from which  it  receives its name.
        (</) Vide Capuron. cours theorique et practique, &c. Soemmering Tabula
      Sceleti feminini juncta descriptione. 
id
                       CHAP. III.

           Of the soft Parts which line the Pelvis.

                      §1. MUSCLES.

   Various strong, and large muscles, pass from the spine
 and pelvis to  the thigh bones, and act as powerful  bands,
 strengthening, in a very great degree, the articulations of the
 pelvis.  These it is not requisite to describe, but it  will be
 useful, briefly to notice the soft parts which line the pelvis,
 and which may be  acted on by  the child's  head during
 labour.
   1st. When  we remove the  peritoneum from the cavity of
 the pelvis, we first of all are led to observe, that all the under
 portion  of the os innominatum, and part of the sacrum, are
 covered with a layer of muscular fibres, which arises at the
 brim of the pelvis, and can be traced all the way down to the
 extremity of the rectum.  This is  the levator ani;  it is  a
 strong muscle, with many glossy tendinous fibres, especially
 at the fore part, where it  lines the  ossa pubis.   Under the
 symphysis, it is pierced by the urethra and vagina; and dur-
 ing the  passage of  the child's head, those fibres which sur-
 round the vagina must be considerably distended; and this
 is more readily effected, as the anus  is  brought forwards
 when  the perinaeum is distended.
   2d. Under this,  on each side, we have arising from the
 membrane that fills up the thyroid  hole, and also from the
 margins of the hole  and the inner surface of the ischium, the
 obturator  internus, which forms at that part a soft cushion of
flesh, the fibres running backwards and downwards, and ter-
 minating  in  a tendon, which passes  over the sacro-sciatic
notch, running on it as on a pully, in order to reach the root
of the trochanter.
   3d. We find the pyriformis arising from the under part of
the hollow of the sacrum,  and also passing out at the notch,
 to be  inserted witli the obturator; and in  laborious parturi- 
                            17

tion, the injury or pressure which these muscles sustain, is
one cause of the uneasiness felt in moving the thighs.
  4th. From the spine of the ischium, originates the coccy-
geus, which runs backward to be inserted into the side of the
coccyx, in order to move and support it.  This gradually be-
comes broader, as we recede from its origin, and is spread on
the inside of the sacro-sciatic ligament.  Thus the cavity of
the pelvis is lined  with muscular substance, whose fibres are
disposed in a very regidar order, and  which  are exhibited
when the peritoneum and its cellular substance are removed.
  5th. When we look  at the upper part of the os innomina-
tum, we find all the hollow of the ilium occupied with the ilia-
cus internus, the tendon of which passes over the fore part of
the pelvis, to reach the trochanter of the thigh.  Part of this
muscle  is covered by  the psoas which arises from the lum-
bar vertebrae, and passes  down by the side of the brim of  the
pelvis to go out with the former muscle: though just upon
the brim, it does not encroach on it, so as perceptibly to lessen
the cavity.  These muscles afford a soft support to the intes-
tines and gravid uterus.

                    §  2. ARTERIES.(e)

   Running parallel with the  inner  margin  of the psoas
muscle, and upon the brim of the pelvis, along the posterior
half of the linea iliopectinea, we have the  iliac artery and
vein; the artery lying, for the upper half of its course, above
the vein, and for the  under half on the outside of it; when
filled, they, especially  the vein, encroach a little  on the brim.
About three  inches from the symphysis, they quit the brim,
running rather more outward, over the part which forms  the
roof of the acetabulum, and pass out with the psoas muscle.
The great lash of arteries and veins connected with the pel-
vis, and inferior extremities, is placed on the sacro-iliac junc-
tion.   The  iliac  vessels, are  so situated, that they  escape
pressure during labour, when the  head enters the cavity of

  («?) Consult Engravings of the Arteries by C. Bell, Finley's Philadelphia
Edition. 
18
the pelvis; but the hypogastric vessels must be more or less
compressed, according to the size or position of the head, but
the circulation is never interrupted.

                      §3. NERVES.

  When we  attend to the  nerves, we  find, 1st. Upon the
ilium, at least four branches of cutaneous nerves, traversing
the iliac, and psoas muscles, in order to pass out below Pou-
part's ligament.   The  largest of these cutaneous nerves  is
the outermost, which has its  exit towards the spine  of the
ilium.   These nerves, which supply  chiefly the  skin  of the
thigh, cannot suffer during labour; but sometimes may, from
the position of the child, or the inclination of the uterus, sus-
tain pressure, during gestation, and  occasion numbness and
anomalous  sensations in the thigh.   2d. Between the two
muscles, and in part covered by the outer margin of the psoas,
is the anterior crural nerve, which is formed by the second,
third, and fourth lumbar nerves.  It is of considerable size,
and has  a  greater share than the others, in producing the
uneasy sensations I have mentioned.  3d.  Running parallel
with the brim of the pelvis, but three quarters of an inch be-
low it, in the cavity of the pelvis, is the obturator nerye, com-
ing from the  third lumbar, and which may be traced all along
the side of the ilium to the thyroid hole.  In many cases, it
cannot  fail,  during labour, to be pressed on by the head.
4th. Beneath the vessels at the sacro-iliac junction, we have
the great nerves which form the sciatic nerve, which is made
up of the fourth  and fifth lumbar nerves, and the first sacral
nerve, which is as large as either of the former:  to these are
added  the second and third sacral, which are much smaller.
The fourth lumbar nerve passes down on the sacro-iliac junc-
tion, and is quite covered  with the  vessels.   The fifth tra-
verses that curved part of the sacrum, which lies betwixt its
promontory and  side;  like the former,  it is hid by the ves-
sels.   In going to form the sciatic  nerve, the fourth lumbar
nerve passes under the gluteal artery, or the common trunk
of the gluteal and ischiatic arteries, and  the fifth passes over 
19
it.  The first sacral nerve passes along the upper margin of
the pyriform muscle, to join with these at the sacro-sciatic
notch.   There a large plexus is formed, which, uniting into
a single trunk, passes out, and is the greatest nerve in the
body. The lumbar nerves may be pressed on early in labour;
but from the cushion of vessels and cellular substance which
defends them,  they  suffer little.  When  the  head has de-
scended lower, and is beginning to  turn, the first sacral nerve
may be compressed.   Pressure of  the nerve produces pain,
numbness, and cramp in the thigh  and leg.  Different nerves
are acted on in different stages of labour.  In the very begin-
ning, the anterior crural  nerve may  be irritated or  gently
compressed, producing pain in the fore part of the thigh; next
the obturator, producing pain  in the  inside; and last of all,
the back part suffers from the pressure on the ischiatic nerve.
5th. The second and third sacral nerves are small, compared
to the first.   They  are covered by the pyriformis muscle,
but part of them pierce it, forming a plexus, which joins the
sciatic  nerve, and sends twigs to the  bladder, rectum,  &c.
This plexus may be pressed in the last stage of labour; and
the irritation thus produced may be one cause  of the passage
of the faces, which generally takes place involuntarily.
6th. The fourth sacral nerve is altogether devoted to the ex-
tremity of the rectum, and its vicinity.
   The great plexus, forming the sciatic nerve, as it lies in the
sacro-sciatic notch, yields to any pressure it may receive, and
cannot suffer in labour, at least, so as to cause inconvenience ;
but the nerves going to it may suffer, and  the person not only
 have cramp and pain during labour, but palsy and  lameness
 for a long time afterwards.  Friction, and the warm bath, at
 first, may relieve  the pain; and then, the cold bath may,
 with much advantage, be employed for perfecting the cure.

                      § 4. LYMPHATICS.

    The lymphatics  in the  upper part of  the pelvis follow
  the course of the iliac vessels, forming a large and very beau-
  tiful ple&us, from Poupart's ligament to the lumbar vertebrae. 
so
These are out of the way of pressure during labour.  Nume-
rous glands accompany them, which are sometimes enlarged
by disease, but they do not interfere with parturition.   The
lymphatics of the cavity  of the pelvis have glands in the
course of the vagina and rectum:  and these, if enlarged,
may impede delivery.
                       CHAP.  IV.

              Of the Dimensions of the Pelvis.

                § 1. BRIM AND OUTLET.

  The pelvis  has been divided  into  the great and  the
little, the first being formed by the expansion of the ilia,  and
the second, comprehending all that part which is called the
cavity of the pelvis, and which lies below the linea ilio-pec-
tinea.  The cavity of the pelvis is  the part of the chief  im-
portance in Midwifery, and consists of the brim, or entrance,
the cavity itself, and the outlet.  The brim of the pelvis has
no  regular shape, but approaches nearer the oval than  any
other.  The short  diameter of  this, extends from the sym-
physis of the pubis to the top of the sacrum.  This has been
called the conjugate, or antero-posterior diameter, and mea-
sures four inches.   The lateral diameter measures five inches
and a quarter;  and the  diagonal diameter, or a line drawn
from the sacro-iliac symphysis to  the opposite acetabulum,
measures five inches and an eighth; but as the psose muscles,
and iliac vessels, overhang the brim a very little  at the side,
the diagonal diameter, in the recent subject, appears to be the
longest.  From the sacro-iliac symphysis to the crest of the
pubis, on the same side, is four inches and a half.   From the
top of the sacrum, to that part of the brim which is directly
above the foramen thyroideum, is three inches and  a half.
The line, if drawn to the acetabulum, in place of the foramen,
is a quarter of an inch shorter; a line drawn across the fore 
%1
part of the brim, from one acetabulum to another, is nearly
four inches and a quarter.
  The outlet of the pelvis is not so regular as the brim, in its
shape, evon when the soft parts remain; but it is somewhat
oval.  The long  diameter extends from  the symphysis pubis
to the coccyx,  and measures, when that bone is pushed back,
as in labour, five inches, but an inch less when it is not.  The
transverse diameter, from the one tuberosity of the ischium to
the other, measures four inches.  The outlet of the pelvis dif-
fers materially from the brim, in this respect,  that its mar-
ginsare not all on the same level; an oval wire will represent
the brim, but,  if applied to the outlet, it must be curved. The
outlet, from the symphysis pubis  to the  tuberosity of  the
ischium, is semi-oval; but behind, it becomes more irregular,
and bends upwards and backwards.  The arch of the pubis,
or the fore part of the outlet,* is four inches broad at its base;
and a perpendicular line, dropped from its centre to the bone,
is fully two inches long.  The top of the arch will permit a
circular body  to come in contact with it, whose diameter is
an inch and a  quarter.  The length of each limb of the arch,
is three inches and a quarter.

                       § 2. CAVITY.

   The cavity  of the pelvis is the next part to be attended to;
and the most important observation to be made, is, that it is
of unequal depth.  At the back part, it measures from five to
six inches, according as the coccyx is more or less extended;
at the side, a line drawn from the brim, to the tuberosity
of the ischium, measures three inches and three-fourths.  At
the fore part, the depth of the symphysis pubis is an inch and
a half.  When the surface of the child's head, then, is paral-
lel to the lower  edge  of the symphysis, the head is still far
from having entered  fully into  the cavity of the pelvis; it
cannot be considered in the cavity, until it be  lodged fairly
in the hollow  of the sacrum.
   It may be  proper to notice  the dimension* of different
parts of the cavity itself.   An oblique line, drawn  from the 
22
sacro-iliac junction, on one side, down to the opposite tube-
rosity, measures six inches;  and the long axis of the child's
head, before it takes the turn forwards, corresponds to this
line.  From the ramus of the ischium, to the opposite sacro-
iliac junction, is five inches.  From the*top of the arch of the
pubis, or orifice of the urethra, to the  second bone  of the
sacrum, is four inches and five-eighths, to five inches.  A
line drawn from the top of the arch to the top of the sacrum,
is about a quarter of an inch  more than the antero-posterior
diameter of the brim.  From  the  top of the arch to the spine
of the ischium, is three inches and a half. From the tubero-
sity of the ischium to the centre of the sacrum is four inches.
From the back part of the tuberosity to the sacro-iliac junc-
tion on  the same side, is three inches and a half.   From the
extremity of the tuberosity to the spine of the ischium, is two
inches.   From  the spine to the sacrum is two inches, and
from  the top of the  arch of the pubis to the plane of the
ischium, is two inches.   The breadth of the plane  itself is
two inches; 30 that a line traversing  these different parts,
from  the symphysis to the sacrum, would measure, including
its slight irregularities, six inches.  From the tuberosity to
the inferior part of the thyroid hole, is an inch  and a half,
the long diameter of the sacro-sciatic notch, is two inches and
three-eighths; the short, one inch and three quarters.(/)
   In  the living subject, we can readily recognise these dif-
ferent parts of the pelvis;  and by the relation  which one
hears to the rest,  we can ascertain, by  careful examination
with  the finger, not only the relative position of the  head
with  regard to  any one spot, and consequently, its precise
situation and progress in the pelvis, but also the shape and
dimensions of the pelvis itself.(g)

  (/) There may be some variation in dimensions, as stated by different
writers;  but it is probable, the above were given by our author, from actual
measurement, of what he considered, a standard pelvis.  A similar obser-
vation may be applied to the dimensions of the child's head, as stated in the
succeeding chapter.
  (g)  The very ingenious and indefatigable Bichat has observed, that sta-
ture has no influence, or at least very little, on the dimensions of the pelvis;
and that  the individual differences which may occur, are totally independ- 
23
               § 3. PELVIS ABOVE THE BRIM.

  The shape, extent, and dimensions of the great pelvis, or
that part which is above the  brim, must he mentioned like-
wise, especially as these are of importance in estimating the
deformity of a pelvis.  From the symphysis pubis to the com-
mencement of the iliac wing, at the inferior spinous process,
is nearly four inches.  From the inferior spinous process to
the posterior ridge of the ilium, a line  subtending the hol-
low of the costa, measures five inches.  The  distance from
the superior spine is the same.  From the top  of the crest of
the  ilium  to the brim of the pelvis, a direct  line measures
three inches  and a half.  The distance betwixt the two supe-
rior anterior spinous processes  of the ilium,  is fully ten
inches.  A line drawn from the top of the crest  of the ilium
to the opposite side, measures rather more than eleven inches,
and touches, in its course the intervertebral substance betwixt
the fourth and fifth lumbar  vertebrae.  A line  drawn  from
the centre of the third lumbar vertebra, counting  from the
sacrum to the upper spine of the ilium, measures six inches
and three quarters.  A line drawn from the same vertebra to
the top of the symphysis, measures seven inches and three
 quarters,  and, when the  subject is erect, this line is exactly
 perpendicular.
   To conclude my observations on the dimensions of the pel-
 vis, I remark, that the shape is different in the child and the
 adult.   The dimensions  of the  brim  are reversed in these
 two states; the long diameter of the fatal pelvis, extending
 from the pubis to the sacrum.  By slow degrees, the shape
 changes;  and nearly about the time of puberty, the conjugate
 and lateral diameters are equal.   When  the  female  is fully
 perfected, the brim becomes more oval, the  long diameter
 extending from one side to the other.  If a girl should, very

 ent of stature. It is acknowledged, continues he, that delivery is as easy in
 small as in large women, although the first may bring forth very bulky chil-
 dren, and who, indeed, may be disproportioncd to the bulk  of their mother's
 bodies, if a comparison of size should be instituted between the two.
                              Anutoinie Descriptive, vol.  1. p. 181—2. 
m
 early, become a mother, the shape of the pelvis may occasion
 a painful and tedious labour.^)

            § 4. AXIS OF THE BRIM AND OUTLET.

   Finally, we are to remember  that the brim, and the out-
 let of the pelvis, are not parallel  to each other, but placed at
 a considerable angle.   The axis of the brim will be repre-
 sented by a line drawn from near the umbilicus, downwards
 and backwards, to the coccyx; that of the  outlet, by a line
 drawn from the orifice of the vagina to the first bone of the
 sacrum^  The precise points, however, which these lines will
touch, must vary a little,  according to the conformation and
obliquity of the pelvis,  and the prominence of the  abdomen.
Each different part of the cavity of the pelvis has its own pro-
per axis, and  the line of motion of the child's head must al-
ways correspond to the axis of that part of the pelvis in which
it is placed.   A pretty  good idea of this subject, with regard
to labour, may be obtained, by placing a small catheter,  of
the usual curvature, in the axis  of the brim, and making its
extremity pass out at the axis of the outlet.
                        CHAP. V.

 Of the Head of the Child, and its progress through the Pelvis in
                          Labour.

                 § 1. BONES OF THE HEAD.

   Tiie head of the child is made up of many different bones,
 and those of the cranium are very loosely connected together

  (A) This remarkable difference in the comparative dimensions of the fe-
male pelvis before and after puberty, has been pointed out by analogy, and
observed among  the females of quadrupeds whose pelvis does not complete.
its developement, nor acquire the form and proportions necessary for the e.\'
pulsion of the foetus until the period of puberty.  Vid. Capuron. 
85
with membrane.  The frontal, temporal, parietal, and occi-
pital bones, compose the bulging part of the  cranium and
their particular shape regulates the direction of the sutures.
The occipital bone is connected to the parietal  bones, by the
lambdoidal suture, which is readily  discovered through the
integuments, by its angular direction.   The parietal bones
are joined to the frontal bone, by the coronal suture, which
is distinguished by its running directly across the head, and
they are connected to each other by  the sagital suture, which
runs in  a direct line from the occipital,  to the frontal bone ;
as the os frontis, in  the foetus, consists of two pieces, it can
sometimes be easily  traced with the  finger, even to 'the  nose.
Let the sagital suture be  divided  into three equal parts.
From the middle one which I  call the central portion a line or
band may be drawn to the lateral part of the lower jaw, and
which will traverse the parietal protuberance and the exter-
nal ear.  As this, in labour,  is parallel to the axis of the
brim of the pelvis, until the head makes  its turn, I call  it the
line of axis.  The upper and  anterior angles of the parietal
hones, and the  corresponding  corners of the two pieces of the
frontal bone, are rounded off, so as  to leave a quadrangular
vacancy, which is filled up with tough  membrane.  This  is
 called the great, or  anterior fontanell, to distinguish it from
 another smaller vacancy at the posterior extremity of the
 sagital suture, which is called the small  fontanell.  The first
 is known by its four corners,  and by its  extending forward a
 little betwixt the frontal bones,  and  whenever it is felt, in an
 examination, we may expect a tedious  labour; for the head
 does not lie in the most favourable  position.   The little fon-
 tanell cannot, during labour,  be perfectly traced, as it is lost
 in the angular lines of the lambdoidal suture, which, however,
 ought to be readily discovered.  The head is of an oblong
 shape, and its  anterior extremity at the temples is narrower
 than the posterior, which bulges out at  the sides by  a  rising
 of the parietal bones, called the parietal protuberances: from
 these the bones slope backwards, like an obtuse angle,  to the
 upper part of  the occiput, which is  a little flattened, and is
 called the vertex.   The  general shape of the  back part is
    VOL.  I.                         T' 
26
 hemispherical.  From these protuberances,  the head  also
 slopes downwards and forwards to the zygomatic process of
 the temporal bone, becoming, at the same time, gradually
 narrower.

                   § 2.  SIZE OF THE HEAD.

    The longest diameter of the head is from the vertex to the
 chin, and this is near five inches.(i)  From the root of the
 nose to the vertex, [which is called the long diameter,] and
 from the chin to the central portion  of the  sagital suture,
 measures four inches.  From the one parietal  protuberance
 to the  other,  [which  is  called the transverse  diameter,] a
 transverse line measures from three inches and a quarter, to
 three inches and a half.   From the nape of  the neck to the
 crown of the head, is three inches and  a half, [and is called
 the perpendicular  diameter.]  From  the one temple to the
 other, is two inches and a  half.  From the occiput to the
 chin, along the base of the cranium, is four inches and a half.
 From one mastoid process to the other, along the base, is
, about two inchei; from cheek to cheek is three inches.   Al-
f though these may be the  average dimensions of the head, yet,
 owing to the nature of the sutures, they may be diminished,
 and the  sljape of the head  altered.  The one  bone may be
 pushed a Jjttle way under the  other, and, by  pressure, the
 length of the head may be considerably increased, whilst its
 breadth is diminished; but these two alterations by no means
 correspond, in a regular degree, to each other.
    The size of the  male head is generally greater than that of
 the female.  Dr. Joseph  Clarke,* an excellent practitioner,
 upon whose accuracy I am disposed fully to  rely, says, that
 it is a twenty-eighth or  thirtieth  part  larger.  It  is a well
 established fact, that owing to the greater size of male chil-
 dren, women who have the pelvis in any measure contracted,

   (l) This is termed the oblique diameter, to distinguish it from the next.
 When the  vertex is stretched  out  in laborious births,  it is sometimes ex-
 tended to six or seven inches.
   * Phil. Trans. Vol. LXXVI. 
37
have often a more tedious labour, when they bear sons than
daughters; and many who have the pelvis well formed, suffer
from the effects on the soft parts.  Dr. Clarke supposes, that
one half more males than females are born dead, owing to
tedious labour, or increased pressure on the brain;  and ow-
ing to these causes, a greater number of males than females
die, soon after birth.   In twin cases, again, as the children
are smaller,  he  calculates, that only one-fifth more males
than females  are still-born.  Dr.  Bland*  says, that out of
eighty-four still-born children, forty-nine were males, and
thirty-five, females.

                 § 3; PASSAGE OF THE HEAD. .

   By comparing the size of the head with the capacity of the
 pelvis, it is ovident that  the  one can easily pass through the
 other.  But  I apprehend that the comparison is not always
 correctly made, for the child does not pass with the long dia-
 meter of its cranium parallel to aline drawn in the direction
 of the long diameter of the brim of the pelvis;  but it descends
 obliquely, so that less room is required.  The central portion
 of the sagital suture passes first, the chin being placed on the
 breast of thechild.  Now, the length of a line drawn from the
  nape of the neck, to the crown of the head, is three inches and
  a half;  a line intersecting this, drawn from the ane parietal
  protuberance to the other,  measures no more.  We have,
  therefore, when the head passes in natural labour, a circular
  body going through  the brim, whose diameter is not above
  three inches and a half; and therefore, no obstacle or difficulty
  can arise from the size of the pelvis. There is so much space
  superabounding betwixt the pubis  and sacrum, as to  prevent
  all  risk of injury from pressure on the bladder, urethra, or
  rectum; and as the  long diameter of the head is descending
  obliquely, thesidesof the brim of the pelvis are not pressed on.
  This is so certainly the case, that the head may, and actually
   often does pass, without any great additional pain or difficulty,
* Phil Trans Vol. LXXI 
28
although the capacity of the pelvis be a little contracted. But
when the shoulders,  which measure five inches across, come
to pass, then the brim is completely occupied.  If, however,
any contraction should take place in the lateral diameter, the
child would still pass, the one shoulder descending obliquely
before the other.
   It is of great consequence to understand the passage of the
child's head in natural labour;  for upon this depends our
knowledge of the treatment of difficult labour.   The head na-
turally is placed with the vertex directed to one side,  or a
little towards the acetabulum, and the forehead, owing chiefly
to the action of the promontory of the sacrum, is turned in the
Same degree towards the opposite sacro-iliac junction. When
labour begins,- and  the head comes to  descend, the chin is
laid on the sternum, and the  central portion of  the  sagital
suture is directed downwards, nearly in the axis of the brim of
the pelvis.   When, by the contraction of the uterus, the head
is forced a little lower, its apex comes to touch the plane of
the ischium.   Upon this the posterior sloping part of the pa-
rietal bone slides downwards and forwards, as on an inclined
plane, the head being turned gradually, so that, in  a little
lime, the face  is thrown into the  hollow of the sacrum,* and
the vertex presents at the orifice of the vagina.  This is not
fully accomplished, till the cranium has got entirely into  the
cavity of the pelvis.   As the bason is shallow at the pubis, the
head is felt near  the orifice of the vagina, and even touching
the labia and  perineum, before  the turn is  completed, and
when the ear is still at the pubis.  The whole of the cavity of
the pelvis is so constructed, as to contribute to this turn, which
is further assisted by the curve of the vagina, and the action
of the lower part of the uterus, on the head of the child. The
head, whilst its long diameter lies transversely, continues to
descend in the axis  of the brim of the pelvis; but when it is
turned, it passes in the axis of the outlet.  When the turn is
making, the direction of the motion is in some intermediate
point; and this fact should, in operating with instruments.
  * Dr. Osborn attributes this turn to the action of the spines of the ischia
On the two parietal bones, but not on opposite spots. 
                           so

be studied and  remembered.   When the pelvis  is narrow
above, and the  sacrum projects forward,  the hemispherical
part of the head,  is long of reaching the inclined plane of the
ischium; and when the head is lengthened out, so as to come
in contact with it, we find, that although the projection of the
sacrum directs the vertex sometimes prematurely a little for-
ward, yet, the tendency to turn fully, is resisted by the situa-
tion of the hones above; a great part of the cranium, and all
the face, being above the brim, and perhaps in part locked in
the pelvis.  By  a continuation of the force, the shape of the
head  may be altered;  even the vertex may be turned a little
to one side, its apex not corresponding exactly to the extre-
mity of the long diameter of the head; the integuments may
be tumefied, and a bloody  serum be effused between them, so
as greatly to disfigure the presentation.  As, therefore, in
tedious labour, occasioned  by a deformed pelvis, the skull may
be much lengthened and  mishapen, we are not to judge of
the' situation of the head,  by the position  of the apex of the
tumour which it forms; but we must feel  for the  ear, which
bears a steady relation to that part of the head which presents
the obstacle.  The back and upper part of the head are com-
pressible, but the base of the skull and the face are firm.  A
line drawn from the neck to the forehead, passing over the
ear, is to be considered as the boundary betwixt these parts
of opposite character;  and therefore we attend to the relative
situation of the  ear, as it ascertains both the position of the
head, and its advancement through the brim.
                      CHAP. VI.

    Of Diminished Capacity, and Deformity of the Pelvis.

             § 1. DEFORMITY FROM RICKETS.

   The pelvis may have its capacity reduced below the na-
tural standard, in different ways.   It may be altogether upon 
80
a small scale, owing to the expansion stopping prematurely,
the different bones, however, being well formed, and correct
in their relative proportions  and distances.  This may occa-
sion painful labour, but rarely causes such difficulty as to re-
quire the use of  instruments.  Sometimes the bones  are  all
of their proper size,  but the  sacrum is perfectly straight, by
which, although both the brim and outlet are sufficiently large,
yet the cavity of the pelvis is lessened; or when all the other
parts are natural, the spines of the ischium may be exuberant,
encroaching on the lower part of the pelvis.
    Another cause of diminished capacity, is the disease called
rickets, in which the bones in infancy  are defective in their
strength, the proportion of earthy matter entering into their
composition being too  small.  In this disease, the long bones
bend, and their extremities swell out; the pelvis becomes de-
formed, the back part approaching nearer to the front, and
the relative distance of the parts being lost.   The distortion-
may exist in various degrees.  Sometimes the promontory of
the sacrum only projects forward a very little more than usual,
or is directed more to  one side than the other;1 and the cur-
vature of the bone may be either increased or diminished.  If
the sacrum project only a little, without any other change,
 the capacity of the brim alone is diminished: but if the cur-
 vature be  at the same time smaller than usual, the cavity of
 the pelvis is lessened : but unless the ischia  approach nearer
 together, or the lower part of the  sacrum be bent forward,
 the outlet is  unaffected ; and in most cases of moderate defor-
 mity, the  outlet is not materially changed.   In  greater de-
 grees of the disease, the anterior part of the brim becomes
 more flattened, the linea iliopectinea forming a small segment
 of a pretty large circle.   The sacrum forms part of a concen-
 tric circle behind ;  and thus the brim of the pelvis,  instead
 of being  somewhat oval, is rendered semicircular or crescen-
 tic, and its short diameter is sometimes reduced under two
  inches.   The promontory of the sacrum may either corres-
  pond to the  symphysis pubis, or may be directed to2 one side,
 'rendering the shape of  the brim more irregular  and the di-
  mensions smaller on one  side than the other.  In some in- 
31
stances, the shape of the brim is like an equilateral triangle;
and although the diameter from the pubis to the sacrum be
not diminished, yet the acetabula being nearer the sacrum,
the passage of the head is obstructed.

          § 2. DEFORMITY FROM MALACOSTEON.

    The pelvis is likewise, especially in manufacturing towns,
sometimes distorted by malacosteon, or softening of the bones
of the adult.   This is a disease which sometimes begins soon
after delivery, and very frequently during pregnancy.  It is,
indeed, comparatively rare in those who do not bear children,
and it is  always increased in its progress by gestation.   It
must be carefully attended to, for, to a negligent practitioner,
it has at firstNery  much the appearance of chronic rheuma-
tism.  It generally begins with  pains about the back, and
region of the pelvis.  These pains are  almost constant, or
have little remission.   They are attended  with  increasing
lameness, loss of flesh, weakness, and fever;  but the distin-
guishing mark is diminution of stature, the person gradually
becoming decrepid.  In malacosteon, the pelvis suffers,  but
the distortion is  generally different from that produced  by
rickets;  for whilst the top of the sacrum sometimes  sinks
lower in the pelvis, and always is pressed forward,3 the ace-
tabula  are  pushed backwards and inwards  towards the sa-
crum and towards  each other;4 so that, were  it compatible
with life, for the disease to  last so long, these parts would
meet in a common  point, and close up the pelvis, or at least
convert its cavity to three slits.  The ossa pubis form a very
acute angle; so that the brim of the pelvis, instead of being
 a little irregular as in slight cases of rickets, or semicircular
 as in the greatest degree of that disease, consists, when mala-
 costeon has continued long, of two oblong spaces on each side
 of the sacrum, terminating before, in a narrow slit, formed
 betwixt the  ossa pubis.'  In this narrow space, when the
 woman is advanced in her pregnancy, the urethra lies,  and
 the bladder rests upon the pendulous belly ; so that, if it be
 necessary to pass the catheter,  we must sometimes use one 
32
 made of elastic materials, or a male catheter,  directing the
 concavity of the instrument  towards  the pubis.  If the in-
 strument be large, and the ossa pubis very near each other,
 it may be  jammed betwixt them, if it be incautiously intro-
 duced.   In this disease, as well as in rickets, it is to be re-
 membered, that the promontory of the sacrum may overhang
 the  contracted brim,  so  as  more effectually to prevent the
 head from entering it.
   Rickets being a disease, which is at its greatest height in
 infancy, we have not at present to  consider the  treatment.
 Malacosteon is, on the contrary, a disease of the adult; and
 it would be of great importance to child-bearing women, to
 know  how to check its progress.  But the means capable of
 doing this with any tolerable degree of certainty, have not yet
 been discovered.   As gestation uniformly increases the dis-
 ease, it is proper that the woman should live absque marito.
 As there is evidently a deficiency of earth in the bones, it has
 been proposed to give the patient phosphate of lime, but  little
 advantage has been derived from it;  and indeed, unless we
 can change the action of the vessels, it can do no good to pre-
 scribe any of the component parts of bone.   We have, in the
 present state  of  our knowledge, no means of rendering the
 action more perfect, otherwise than by  endeavouring to im-
 prove the general health and vigour of the system, by the use
 of  tonics,  the cold bath, and attending to the state of the
 bowels.  Anodyne frictions, and small blisters,  sometimes
 relieve the pain.*(/c)
  * Upon the subject of deformity of the pelvis, and for tables of many par-
ticular instances of distortion, I have great pleasure in referring the reader
to the works of Dr. Hull, a practitioner of sound judgment, and extensive
knowledge.
  (fc) Deformity  of the pelvis,  from the above causes, may be  considered
as comparatively a rare  disease  in the United States.  In the  course
of my obstetrical practice, I can at present recollect but four or five cases,
where embryulcia and the employment of the crotchet became indispensably
necessary; and  what may be worthy of remark, these were in individuals
natives of Europe, chiefly of Ireland.  A deformed pelvis is scarcely known
among the aborigines of our country. This subject shall again be taken up
 when embryulcia is treated of; an operation, which we fear, is frequently
 resorted to very unnecessarily at least, to make use of the mildest term. 
33
      § 3. DEFORMJTY FROM EXOSTOSIS AND TUMOURS.

  The pelvis may be well formed externally, and yet its capa^
city may be diminished within, by exostosis from some of the
bones;  or it may be affected  in consequence of the fracture
of the acetabulum, from which I have seen  extensive  and
pointed ossifications stretch for nearly two inches into the
pelvis;  or steatomatous or schirrous tumours may form in the
pelvis, being attached to the bones or ligaments, of which I
have  known examples.6  An enlarged ovarium,7 or vaginal
hernia,8 may also obstruct  delivery,  even so much  as to re-
quire the  crotchet;  and therefore,  although  they be not
indeed instances of deformed pelvis, yet as they diminish the
capacity of the cavity, as certainly as any of the former causes
which I have mentioned, it is proper to notice them at this
 time.*   Enlarged glands in the course of the vagina, poly-
pous  excrescences  about the os uteri or  vagina, schirrus of
the rectum, and firm  encysted tumours  in the jiclvis, may
likewise afford an obstacle to the passage of the child.  Some
tumours, however, gradually yield to pressure, and disappear
until  the child be born ; others burst, and have their contents
eflused in the cellular substance.  A large stone in the blad-
 der may also  be so situated during labour,  as to diminish
 very much the cavity of the pelvis; and it may be even neces-
 sary to extract the stone before the child be delivered.
   Tumours in tire pelvis are produced either by enlargement
 of some of its contents, as for instance the ovarium or glands;
 or, by new formed substances.  The former  kind arc often
 moveable, the latter generally fixed; and they may consist of
 fatty, or fibrous substance, or  fluid contained in a cyst. These
 have only cellular attachments, and are rpmoved easily by
 making an incision through the vagina, and turning out the
 tumour, or evacuating its contents f other tumours are car-
 tilaginous, and these, instead of being connected only by cel-
 lular matter, are attached to  the pelvis firmly, or grow from
   * In all cases of moveable tumours, as well  as in stone in the bladder, it is
 evident, that they ought, in the very beginning of labour, to be pushed above
 the brim, and prevented from entering it before, or along with the head.
   VOL.1.                           * 
34
 it.  They adhere either by a pedicle, or by an extensive base.
 In the first case the tumour is more moveable than in the se-
 cond, where the fixture is firmer.  These can only be extir-
 pated by cutting deeply into the cavity of the pelvis, and the
 incision requires to be made through the perineum and leva-
 tor ani, like the incision in the operation of lithotomy in the
 male subject.  We are much indebted to Dr. Drew for the
 first case of an operation of this kind; and  as the tumour ad-
 hered by a neck, it was easily cut off, and the success was
 complete.
   In a dreadful case which I met with lately, the attachments
 were extensive, and the tumour so large as  to fill the pelvis,
 and permit only  one finger to be passed between it and the
 right side of the bason. It adhered from the symphysis pubis
 round to the sacrum, being attached to the urethra, obturator
 muscle and  rectum, intimately adhering to the  brim of the
 pelvis, and even overlapping it a little towards the left aceta-
 bulum. It was hard, somewhat irregular, and scarcely move-
 able. The patient was in the 9th month of pregnancy. There
•.was no choice, except  between the  cesarean operation, and
 the  extirpation of the tumour. The latter was agreed on, and
 with the assistance of Messrs. Cowper, Russel and Pattison,
 I performed it on the 16th of March, a few  hours after slight
 labour pains had  come on.   An incision was made on the left
 side of the orifice of the vagina, perineum, and anus, through
 the  skin, cellular substance, and transversalis perinei.  The
 levator ani being freely divided, the tumour was then touched
 easily with the finger.  A catheter was  introduced into  the
 urethra, and the tumour separated from its attachments in that
 quarter.  It was next separated from the uterus, vagina, and
 rectum, partly by the scalpel, partly by the finger.  I could
 then grasp it as a child's head, but it was  quite fixed to the
 pelvis.   An incision was made  into it with  the knife, as near
 the  pelvis as possible; but from the difficulty of acting safely
 with that instrument, the scissars, guided with the finger, were
 employed when I came near the back part";  and instead of
 going quite through,' I stopped  when near the posterior sur-
 Ve, lest I should wound the rectum, or a  large vessel, and 
35
completed the operation with a  spatula.   The tumour was
then removed,  and its base or attachment to the bones dis-
sected off as closely as possible.   Little blood was lost.  The
pains immediately became strong, and before she was laid
down in bed they were very pressing.  In four hours she was
delivered of a still-born child, above the average size.   Peri-
toneal  inflammation, with considerable constitutional irrita-
tion, succeeded; but by the prompt and active use of the lancet
and purgatives, the danger was soon over, and the recovery
went on well.  On the 18th of April, when this was written
to go to press, the wound was nearly healed.   On examining
per vaginam, the vagina is felt adhering as it ought to do, to
the pelvis, rectum, &c.   The side of the pelvis is smooth; and
a person ignorant of the previous history of the case, or who
did not see the external wound, would not be able to discover
that any operation had been performed.

  § 4. MEANS OF ASCERTAINING THE SIZE OF THE HEAD, &c.

  In order to ascertain the degree of deformity, and the capa-
city  of the pelvis, different instruments have been invented.-
Some of these are intended to be introduced within the pelvis,
and others  to be applied on  the outside, deducting a certain
number of inches for the thickness of the pubis, sacrum, and
soft parts.   But these methods are so very uncertain, that I
do not know any person who makes use of them  in practice*
The hand is the best pelvimeter, and must in  all cases, where
an accurate knowledge is necessary, be introduced within the
vagina.  By moving it  about, and observing the number of
fingers which can be passed'into different parts of the brim,
or the distance to which two fingers require to be separated in
order to touch the opposite points of the brim, or the space
over which one finger must move in order to pass from one
part to  another, we may obtain a sufficient  knowledge, not
only of the shape of the brim, cavity, and outlet of the pelvis,
but also of the degree to which  the  soft parts  within arc
swelled, as well as  of the position and extent of any tumour
which  may be formed  in  the  pelvis.  We may be farther 
36
assisted by observing, that in great degrees of deformity  or
contraction, the head does not enter the brim at all; in smaller
degrees it  engages slowly,  and the  bones of the cranium,
form an  angle more or less acute, according to the dimen-
sions of the brim, into which it is squeezed.
  As in many cases of deformed and contracted pelvis, it is
necessary to break down the head in  order to get it through
the cavity,  it will be proper to subjoin the dimensions of the
foetal  head when it is reduced  to its smallest size.  When
the frontal, parietal, and squamous bones are removed, which
is all that we can expect to be done in a case  requiring the
crotchet, we find that the width of the base of the cranium,
over the  sphenoid bone, is two inches and a half.  The dis-
tance from cheek to cheek is three inches.  From the chin to
the root of the nose is an inch and a half;  and by .separating
the symphysis of the jaw, the two sides of the maxilla may
recede, so as to make this distance even less.  From the chin
to the nape of the neck, when the chin  is placed  on the breast,
is two inches and three quarters.  When, on the contrary,
the chin  is raised up, and  the triangular part of the occiput
laid back on the neck, the distance  from the throat to the
occiput is two inches.  The  smallest  part of the head, then,
which can   be made to present, is the face;  and when this
is brought through the brim, the back part of  the head and
neck may,  although they measure two inches, be reduced by
pressure so as to follow the face.  The short diameter of the
chest when pressed, is an inch and a half; that of the pelvis
is the same.  The diameter of the shoulder is one inch.
                      CHAP. VII.

           Of Augmented Capacity of the Pelvis.

  A very  large pelvis,1 so far from being an advantage, is
attended with many inconveniences, both during gestation
and parturition.   The uterus, in pregnancy, does not ascend 
37
at the usual time out of the pelvis, which  produces  several
uneasy sensations;  it is even  apt, owing  to  its increased
weight, to be prolapsed: or, if the bladder be distended, it
may readily be  retroverted.   At the very end of gestation,
the uterus may descend to the orifice of the vagina; and, dur-
ing labour, forcing pains are apt to come  on  before the  os
uteri be properly  dilated, by which both  tike child  and the
uterus may be  propelled, even out of the vagina; and in
many instances, although this should  not happen,  yet the
pains are severe and tedious, especially if the practitioner  be
not aware of the nature of the case.
                     CHAP. VIII.

           Of the External Organs of Generation.

                    1. GENERAL VTEW.

  The  symphysis of the pubis, and insertion of the recti-
muscles, are  covered with a very considerable quantity of
cellular substance, which is called the mons veneris.  From
this the two external labia pudendi descend, and meet toge-
ther about an inch before the anus; the  intervening  space
receiving the  name of perinseum.  On separating the great
labia, we observe a small projecting body placed exactly on
the lower part of the symphysis.  This is the clitoris, and it
is surrounded by a duplicature of skin called  its prepuce.
From this duplicature, or rather from the point of the clitoris,
we find arising  on  each side, a small flap, which is con-
tinued down on the inside of tho labia, to the orifice  of the
vagina.   These receive the name of nymphse, or labia? mino-
res or  interiores.  On  separating them,  we observe, about
nearly an inch below the clitoris, the  extremity of the ure-
thra ; and, just under it, the orifice  of the vagina, which is
partly closed up, in  the infant state, by a  semilunar  mem-
brane called the hymen.   These parts are all comprehended 
38
 under the general  name  of vulva, or external organs  of
 generation.

                 § 2. LABIA AND NYMPHJE.

    The labia have nothing peculiar in their structure, for
 they are merely duplicatures of the skin, rendered prominent
 by a deposition of fatty matter.  Externally they have just
 the appearance of the common integuments; and at the age
 of puberty, are, together with the mons veneris, generally
 covered with hairs.  Internally they resemble the inside of
 the lips or eye-lids, and are furnished with numerous  seba-
 ceous glands.  They are placed closer together below than
 above ; and at their junction behind,  a small  bridle called
.the fourchette, extends across, which is generally torn when-
 ever a child is born.
    The nymphse at first appear to be merely duplicatures of
 the inner surface of the labia, but they are, in fact, very dif- •
 ferent  in their structure.   They are distinct vascular  sub-
 stances inclosed in a  duplicature  of the  skin.  When injected .
 by filling the pudic artery, each nympha is found to be made
 up of  innumerable  serpentine vessels, forming  an oblong
 mass.  This at the  upper part joins the  clitoris, to which,
 perhaps, it serves as an appendage; whilst the  loose dupli-
 cature of skin in  which it is lodged, by being unfolded, per-
 mits the labia to be more safely and easily distended, during
 the passage of the child.

                     § 3. CLITORIS.

    The clitoris is a small body resembling the male penis,
 but has no urethra.  It consists of two corpora cavernosa,
 which  arise from the rami of the ischia and pubis, and unite
 at the symphysis of the pubis.  These are furnished  with
 two muscles analogous to the erectores penis  of the  male.
 When the crura andnymphse are filled with wax, we find on
 each side, two vascular injected bodies, one of them  in close
 contact with the bones, the other more internal with regard 
39
to the symphysis of the pubis.  When the  one is injected,
the other is injected also, and both are connected together at
the upper part.  The clitoris, formed by the junction of its
crura, is apparently about the eighth part of an inch long, a
part of it  not being  seen,  and it is  supported by a pretty
strong suspensory ligament which descends  from the  sym-
physis.   When  distended  with blood, it  becomes  erected
and considerably longer,  and is»cndowed with great sensi-
bility.

                      § 4. URETHRA.

    On separating the nymphse, we find a smooth hollow  or
channel, extending down from the clitoris for nearly an inch;
and at the termination of  this, and just above the vagina, is
the orifice of the urethra,  which although not one of the or-
gans of generation,  deserves particular  attention.  The
bladder is lodged in the fore part of the pelvis, immediately
behind the symphysis pubis ; but when distended, it rises up»
and its fundus has been known to extend even to the umbili-
cus.  The urethra is the excretory duct of the bladder; it
is about an  inch and a half long, and passes along  the up-
per part of the vagina, through which it may be felt like a
thick fleshy cord.  The structure of the urethra is extremely
simple,  for little can be discovered except a continuation of
the  internal  coat of the  bladder, covered  with condensed
cellular substance.  On slitting up the canal, numerous mu-
cous lacunae may be  discovered  in  its  course, and two of
these at the orifice are peculiarly large.  The urethra is very
vascular, and, when injected and dried, its orifice is perfect-
ly red.  In the unimpregnated state,  it runs very much  in
the direction of the outlet of the pelvis ; so that a probe, in-
troduced into the bladder,  and pushed  on in the course of the
urethra, would, after passing  for about three inches and  a
half, strike upon the fundus uteri, and, if carried on for an
inch and a half farther, would touch  the second bone of the
sacrum.   The uterus being much connected with the bladder
at its lower part, it follows, that when it rises up  in preg- 
40
nancy, the bladder will also be somewhat raised, and pressed
rather more forwards, and the vagina being elongated, the
urethra,  which is attached to  it, is  also  carried  a little
higher, and, in its course, is brought  nearer the inside of the
symphysis pubis.  In those women who, from  deformity of
the pelvis, or other causes, have a very pendulous belly, the
bladder,  during pregnancy, is sometimes  turned  over the
pubis, the urethra curved a little, and  its opening somewhat
retracted within the orifice of the vagina.  When it  is neces-
sary to pass the catheter,  it is of great consequence  to be
able to do it readily, and this is by no means difficult to do.
The woman ought to be placed  on her back, with her thighs
separated, and the knees drawn a little up: a bason is then
to be  placed betwixt the  thighs, or  a bladder may be tied
firmly to  the extremity of the catheter to receive the urine.
The instrument is then  to be conveyed under the thigh, and
the labia  separated with the finger.  The clitoris is next to
be touched, and the finger run gently down  the  fossa  that
leads to the orifice of the urethra,  which  is  easily distin-
guished, by its resemblance to an irregular dimple, situated
just above the entrance to the vagina.  The point of the in-
strument is to be moved lightly down the fossa after the fin-
ger, and it will readily slip into the  urethra.   It is then to
be carried on in the direction of the axis of the outlet of the
pelvis, and the urine drawn off.  This operation ought al-
ways  to  be performed in bed, and the patient is never to be
exposed.   In cases of  fractures, bruises, &c.  where the
woman cannot turn from her side to her back, the catheter
may he introduced from behind, without moving her.  When
the bladder is turned over  the pubis, as happens in cases of
great deformity of the pelvis, it is sometimes requisite to use
either a flexible catheter, or a  male catheter, with its  con-
cavity directed forward.  When the uterus is retroverted,
if we  cannot use a female catheter, we may employ a male
catheter,  directing the  concavity backwards.   When the
head of the child in labour has entered the pelvis, the urethra
is pushed close to the symphysis of the pubis ; then  the flexi-
ble or flat catnetcr must be introduced parallel to the sym- 
11
physis, and the head of the child may be raised up  a little
with the finger.   This, indeed, of itself, frequently permits
the urine to  flow; and when the urine is retained after  de-
livery, it is often sufficient to raise up  the uterus a little with
the finger.

           § 5. ORIFICE OF VAGINA AND  HYMEN.

   The orifice of the vagina is situated nearly opposite to the
anterior part of the tuberosity of the ischium, about an inch
and a half below the symphysis of the pubis,  and in the di-
rection  of the axis of the outlet of the pelvis.  It is, in all
ages, but more  especially in infancy, considerably narrower
than the canal itself,  and is surrounded  by a sphincter mus-
cle, which arises from the sphincter ani, and is accompanied
with a vascular plexus, called plexus retiformis.  In children,
it is always shut up by a membrane called the hymen, which
consists of four angular duplicatures of the membrane of the
vagina; the union of which maybe discovered by correspond-
ing lines on the hymen.  At the upper part there is a semi-
lunar vacancy, intended  for the transmission of the menses.
 Sometimes it is imperforated, or partially or totally absorbed.
 When the hymen is  ruptured, it is  supposed to shrivel into
 three or four small excrescences at the orifice of the urethra,
 called the carunculae  myrtiformes.(f)
   Immediately below the orifice of the vagina, there is a short
 sinus within the labia, which  extends farther back than the
 vagina. This has been called the fossa navicularis, and reaches
 to the fourchette.

   (I) Haller, in his Elementa Physiologic, asserts  that the hymen is peculiar
to the female of the human species; but Duverney, in a Memoir read  before
the Institute and the School of Medicine, at Paris, asserts, that it is common to
 others of the mammalia.
VOL. I.
R 
42
                      CHAP.  IX.

            Of the Internal Organs of Generation.

                       § 1. VAGINA.

  The internal organs of generation consist of the vagina,
with the uterus and its appendages.
  The vagina is a  canal, which extends from the vulva to
the womb.   It consists principally of a spongy cellular sub-
stance, endowed with some elasticity, and having an admix-
ture of indistinct muscular fibres.   It is lined by a continua-
tion of the cutis from the inner surface of the labia ; and this
lining, or internal coat, forms numerous wrinkles, or trans-
verse rugse, on the anterior and posterior sides of the vagina.
They are peculiar to the human  female, and are most dis-
tinctly seen in the virgin state; but after the vagina has been
distended, they are more unfolded, and sometimes  the sur-
face is  almost smooth.  In the whole course of this coat,
may be observed the openings of numerous glandular follicles,
which secrete a mucous fluid.  In  the fcetus this is white and
milky; in the adult  it is  nearly colourless.   The vagina is
very vascular; and when the parts are well injected, dried,
and put in oil of turpentine, the vessels are seen  to be both
large and numerous.  Just below  the symphysis  pubis, we
observe a great congeries of vessels surrounding the urethra
and upper part of the vagina.
  The vagina forms a curved canal, which  runs  very much
in the course of  the axis of the  outlet and cavity of the pel-
vis.  It is not round, but considerably flattened; it is wider
above than below, being in young  subjects much contracted
about the orifice.  At its upper part, it does not join the lips
of the os uteri directly, but is attached  a little above  them,
higher up behind than before, so that the posterior lip of the
uterus is better felt than the anterior.   In the infant, the va-
gina is .-tttached still higher up,  so that the lips of the uterus
project in it something like a penis* 
43
  The inner coat of the vagina  is reflected over the lips of
the uterus, and passes into its cavity, forming the lining of
the uterus.  The junction  of the uterus and vagina is so inti-
mate, that we cannot make an accurate distinction betwixt
them; but may say, that the one  is a continuation of the
other.   The  vagina adheres before very intimately to the
urethra, behind, it comes gradually to approach to the rec-
tum, and at its upper part it is pretty firmly connected to it.
This union forms the recto-vaginal septum.  These connec-
tions of the  vagina are formed by cellular substance, there
being only a very small part of its  upper extremity covered
with peritoneum.
   When the finger is introduced into the vagina in situ, the
urethra is felt on its fore part, resembling a firm fleshy cylin-
der.  Behind, the rectum can be traced down to the point
of the coccyx.  At the side, the ramus of the ischium and of
the pubis, together with the obturator interims muscle are to
be distinguished.   In a well formed pelvis, the finger cannot
easily reach beyond the lower part of the sacrum; during
labour, however, the parts being more relaxed, the bone may
be felt  more easily, but its promontory cannot be touched
with the finger.

             § 2. UTERUS AND ITS APPENDAGES.

   The uterus is a flat body somewhat triangular in its shape,
 being  considerably broader at  its upper than at its  under
 part.   It is scarcely three inches in length, about two  inches
 broad  above, and one below.  It is divided by anatomists
 into the fundus or upper part, which is slightly convex, and
 lies above the insertion of the fallopian tubes;  the cervix or
 narrow part below; the  body,  which comprehends  all the
 space betwixt the fundus and cervix ; and last  of all, the os
 uteri, which is the termination of the cervix, and consists of
 a small transverse chink, the two sides  of which have been
 called the lips of the uterus.   The  uterus contains a small
 cavity of a triangular shape, which opens into a narrow chan-
 nel formed in the cervix, and is continued down to the os 
u
uteri.  At the upper angles may be perceived the openings of
the fallopian tubes.  Both the cavity  and the channel are
lined with a continuation of the inner coat of the vagina, but
it has a very different appearance from that which it exhibits
in the vagina. The surface of the triangular cavity is smooth,
and the skin which covers it is very soft and vascular.  The
surface of the  cervical  channel again is rugous, and  the
rugae are disposed in a beautiful manner, so as to have some
resemblance to  a palm tree.   This part is by no  means so
vascular as the  cavity above; but it contains betwixt the rugse
several lacuna?, which secrete a mucous fluid.  Where the
cavity of the uterus terminates in the channel of the cervix,
there is sometimes a slight contraction of the passage.
   The substance  of the uterus  is made up  of  numerous
fibres,(m) disposed very  irregularly, and having a considera-
ble quantity of  interstitial fluid interposed, with many vessels
ramifying amongst them. A dense succulent texture is thus
formed, which  constitutes the substance of the  uterus.  On
cutting open the womb, we observe that its sides are about a
quarter of an inch thick,  but are rather thinner at the fundus,
than elsewhere, though the difference is very trifling.  Several
irregular  apertures may be  perceived on the  cut surface:
these are the veinous sinuses.  The fibres which we discover
are muscular; but we cannot, in the unimpregnated state, ob-
serve them to follow any regular course.
   The arteries  of the uterus are four in number,  with corres-
ponding veins.   The two uppermost arteries arise either high
up from the aorta, or from the emulgent arteries.  They de-
scend, one on each side,  in a serpentine direction behind the
peritoneum, and are  distributed on the ovaria, tubes, and up-
per part of the  uterus.   These are called spermatic arteries.
The two lowermost, which are called uterine, arise from the
hypogastric arteries.  They run, one on each side, toward
the ceivix uteri, and  supply it and the upper part of the vagi-
na.  Thus the fundus uteri is supplied by the spermatic arte-
  (wi) The reader is referred to a very interesting paper " on the muscularity
of the uterus, by Charles Bell, Esq. F. R. S. Ed. &c." published in the 5th
vol. of the Eclectic Repertory,  p. 37, and § 9. 
45
lies, and the cervix, by the uterine arteries; and these, from
opposite sides, send across branches which communicate one
with the other.   But besides this distribution, the uterine ar-
tery is continued up the side of the uterus, and meets with the
spermatic, so that, at the two sides, we have arterial trunks,
from which  the  body of the uterus is liberally supplied with
blood.   The veins correspond to  the arteries.   The nerves
of the uterus, like the blood vessels, have also a double origin,
and follow nearly the same course. Those which come from
below are derived from the sacral nerves, especially from the
fourth pair.   Those  from above come chiefly from the meso-
colic plexus, and trunk of the intercostal.  The renal plexus
furnishes nerves to the ovarium.
   The lymphatics, in the unimpregnated state of the uterus,
are small, and not easily discovered.  Those from the upper
part of the womb, and from the ovaria,  run along with the
spermatic vessels, terminating in glands placed by the side of
the lumbar vertebrae. Hence, in diseases  of the ovaria, there
may be both pain and swelling of the glands.  But the greatest
number of lymphatics run along with the uterine arfery, seve-
ral of them  passing to the iliac and sacral glands, and some
accompanying the round ligament.  This may explain why,
in certain conditions of the uterus, the inguinal glands swell.
Others run  down through the  glands of the vagina; and
hence, in cancer of the womb, we often feel those glands hard
and swelled, sometimes to such a degree, as almost to close up
the vagina.
   The uterus is covered with the  peritoneum,  which passes
off from its sides, to reach the lateral part of the pelvis, a little
before the sacro-iliac  symphysis; and  those  duplicatures,
which, when the uterus is pulled  up, seem to divide the cavity
of the pelvis into two chambers, are called very improperly
the broad ligaments  of the uterus.
   When the uterus is raised, and those lateral duplicatures of
the peritoneum are stretched out, we observe, that at the up-
per part they form two transverse folds or pinions, one before,
and the other  behind.   In the  first of  these,  the fallopian
tubes are placed; in the second, the ovaria. 
                           46

  Besides these duplicatures, we likewise remark other two
which extend from the sides of the fundus uteri to the linea
ilio-pectinea at the side of the pelvis, and then run on to the
groin.  These  contain, on each side, a pretty thick cord,
which arises from the fundus uteri, and passes out at the in-
guinal canal, being then lost  in the  labia pudendi.  These
cords, which are called the round ligaments of the uterus,
consist  of  numerous  blood-vessels, some lymphatic, small
nerves,  and fibrous matter.
  The fallopian tubes, in quadrupeds, are merely  continua-
tions  of the horns of the uterus;  but in the human female,
they are very  different  in their structure  from the womb.
They appear to consist in a great measure of spongy fibrous
substance, which, as  Haller observes, may  be inflated  like
the clitoris.  This is hollow, forming a canal of about three
inches long, lined with a continuation of the internal coat of
the uterus; and as they lie in the anterior pinion of the broad
ligaments of the uterus, they are covered of necessity with a
peritoneal coat.  They  originate from the  upper corners of
the uterine cavity by very small orifices, but terminate at the
other extremity in an expanded opening with ragged margins,
which are called the fimbriae of the tube.  The internal  sur-
face of the canal is plaited, the plicae running longitudinally.
  The ovaria1 lie in the posterior  pinion of the broad liga-
ment.  They are  two  oval flattened bodies, of a  whitish
colour, and grandular consistence. They  are cellular, but
not very vascular, although vessels run to their coat.  After
puberty, they contain numerous minute vesicles, the largest of
which are near the surface, and even form slight projections
from it.  These are the ova of the female, and are filled with
a coagulable lymphatic matter.  Their number is uncertain,
but Haller says he never saw above fifteen in one woman.  In
old women they disappear,  or shrivel.
  The ovarium is covered  with the peritoneum;  but when
the ovum is impregnated and becomes prominent, the peri-
toneum which covers it is absorbed, the ovum passes into the
fallopian tube, and the little scar which remains on the sur-
face of the ovarium, is called corpus luteum. 
47
  In the foetus, the ovaria and tubes are placed on the psoas
muscles; but in the adult, they lie loosely in the pelvis, and
the uterus sinks within the cavity.  The os uteri is directed
forward, and the fundus backward, being in general found
opposite to, or resting on the second bone of the sacrum.
                       CHAP. X.

        Of the Diseases of the Organs of Generation.

               § 1. ABSCESS IN THE LABIUM.

  The  labia are subject to several diseases:  of these, the
first which  I shall mention, is  phlegmonoid  inflammation.
This may occur at any period of life, and under various cir-
cumstances ; but frequently it takes place  in the pregnant
state, especially  about the sixth and seventh month of gesta-
tion.  Sometimes it appears suddenly, and oftener than once
in the same pregnancy.  Occasionally it makes its  attacks
in childbed, in consequence of the violence which the parts
may have sustained in labour.   It  is marked by the usual
symptoms of inflammation,  namely, heat, pain, throbbing,
and more or less  swelling, not unfrequently attended with
fever.   The swelling is sometimes  hard and  moveable, like
a gland, especially when the progress  is slower than usual.
In general, the course  of the disease is rapid, the pain, and
inflammation are at first very  acute, and the part  swells
speedily.  In a few hours, especially if a poultice have been
applied, the abscess begins to point at the inside of the labium,
and the  nympha is  either lost, or if it remain, appears pushed
out of its place.  Sometimes it bursts within thirty-six hours
from its appearance.   By means of cold saturnine applica-
tions, and gentle laxatives,  the inflammation may sometimes
be resolved,  but most frequently it ends in  suppuration,
which is to be  promoted  by fomentations and warm cata-
plasms.   If necessary, an opiate may be given to abate the 
48
pain, and a pillow must be placed between the knees, to keep
the part from pressure.   If possible, the abscess ought not to
be punctured, but, if the pain  and tension be unbearable, we
must indulge the patient by making  a small opening;  a
good deal  of blood will in this case come  with the matter.
After the abscess bursts, the parts may be dressed with any
mild ointment.   Should the opening of the abscess be higher
than its bottom, it will  be necessary, if the discharge con-
tinue,* to lay it open, after which it will speedily heal.

              § 2. ULCERATION OF THE LABIA.

    The internal surface of the labia is often the seat of ulce-
ration and excoriation, which may generally be  avoided by
the daily  use of the bidet.  The general form under which
excoriation appears, is that of a raw surface, as if the cuticle
had been  peeled from a blistered part.   Most  frequently
these sores are the consequence  of acrimony, produced by
inattention to  cleanliness, especially  in  children;  and  in
their case the labia, if care be not taken, may  cohere.  The
treatment  consists in keeping the parts clean, bathing the
sore .with a weak solution oT  sulphate of zinc, and prevent-
ing cohesion.  Should the parts not heal readily, they may
be washed with brandy, or  a very weak solution of  nitrate
pf silver,  or touched with  caustic.  When adhesion takes
place, it may, if slight, be destroyed,  by gently pulling the
one labium from the other; if firmer, the parts  must be se-
parated with the knife.   In either case, reunion must be pre-
vented, by washing the surface frequently with  solution of
alum, and applying a small piece of lint spread with simple
ointment.  Simple itching of the parts may be removed by
the tepid bath, a dose of castor oil, and fomenting the parts
with milk and water.
    Sometimes we meet with deeper ulcerations,  which it  is
of great importance to the domestic happiness  of individuals
to  distinguish from  chancre.  Nothing seems easier in  a

           * Vide Mr. Hey's Surgical Observations, p. 188. 
49
 book, than to make the diagnosis, but in practice it is often
 very difficult.  A well marked  chancre begins with circum-
 scribed inflammation of the part; then a small vesicle forms,
 which  bursts, or is removed by slough, and  displays a hol-
 low ulcer,  as if the skin  had been scooped away or nibbled
 by a small animal; its surface is not polished,  but rough,
 and covered with pus, which is  generally of a buff or dusky
 hue; the margins are red, and  the general  aspect  of the
 sore is angry.   But the most distinguishing character  of
 the chancre,  is considered to be a thickening or  hardness  of
 the base and edges of the ulcer.   The progress of the sore is
 generally slow*, either towards recovery or augmentation.
 When  remedies are used, the first effect produced is remov-
 ing the thickening by degrees, and lessening the discharge, or
 changing its  nature, so that the surface of the sore can be
 seen;  it has  then  in general a  dark fiery look, which con-
 tinues  until all the diseased substance be removed, and the
 action  of the part be completely changed.  Now, from this
 description, we should, it  may  be supposed, be at no loss in
 saying, whether a sore were venereal; but in  practice, we
 find many deviations from this  description.  The thickening
 may be less in one case than another, and may not be easily
 discovered, yet the sore may be  certainly venereal.  Pecu-
 liarity of constitution, or of the part affected,  can modify
 greatly the effects of the vims.   There may be extensive in-
 flammation, or  phagedenic ulceration: and  yet the  action
 may be venereal.   It  is,  however, satisfactory  to  know in
these cases, that in a  little time, unless extensive sloughing
have taken place, the  appearance  of  the sore becomes more
decided,  the  proper character of  chancre  appears,  and the
usual remedy cures the patient.
   Phagedena is a very troublesome, and sometimes  a for-
midable  disease,  especially of  infants.   I shall here only
 notice that form which appears  in adults,  and which, as it  is
 infectious,  may be mistaken for  syphilis.   It  commences
 with a livid redness of the part, succeeded speedily  by vesi-
cation  and  ulceration, which extends laterally, and  some-
 times penetrates deep.  The ulcer has an eating appearance,
  vol. i.                          h 
50
is painful, discharges a great quantity of matter, and very
often is attended with fever.   A  variety  of this  disease
is attended  with superficial  sloughing, which may be fre-
quently repeated, and is  generally preceded  by a peculiar
appearance of cleanness in the sore.  This  is not to be con-
founded with sloughing, produced by simple inflammation or
irritation of the parts, which is similar in its nature and treat-
ment to common gangrene.  We must foment the sore with
decoction of camomile flowers, mixed with  a  little tincture
of opium, and then apply mild dressings.  Rest is essential
to the cure: and if a febrile state exist,  it is to be obviated
by laxatives, acids, mild diaphoretics, and decoction of bark.
If there be no fever, mercury, or the nitrous acid, often effec-
tually change the action of the parts.
  Sometimes irritable sores appear on different parts of the
labia, or orifice of the vagina, in succession, healing slowly
one after another.  These have an  inflamed appearance, the
margins are sometimes tumid, and the surface is at first irre-
gular and depressed, but afterwards it forms  luxuriant granu-
lations.  There is another sore met with on the inside of the
labium, and which  generally spreads to the size of a  six-
pence.  The surface is quite  flat, and sunk a little below the
level of the surrounding parts.   The margins are thickened,
and sometimes callous, the discharge thin, and the ulcer not
in general painful, the surface soft and spongy without a hard
base.  These sores  generally agree best  with stimulants,
especially caustic and escharotics.  When they do not yield
to this treatment, it will be proper to have recourse to a cau-
tious course of mercury.  Some of these, like the phagedena,
are infectious.
   Some of these sores are  occasionally productive of second-
ary symptoms, such as ulcers  in  the throat.  When these
succeed a sore,  which has run its course differently from
chancre, and been healed without  the use of mercury,  it is
allowable to suppose, that they also may be cured, merely by
attending to the general health, and perhaps by local applica-
tions.  But if they continue without amendment, or threaten 
51
 danger to any important part, we must not delay making trial
 of mercury.

             § 3. EXCRESCENCES ON THE LABIA.

   Sometimes after a slight degree of inflammation, producing
 heat and itching of the parts, numerous excrescences appear
 within the labia.  These are either soft and fungous, or hard
 and warty.  Both of these states may be induced by previous
 venereal inflammation; but they may also occur independent-
 ly of that disease.  Even where there is an offensive discharge
 from the fungi or warts, we are not always to conclude that
 they are syphilitic, but be  guided in our judgment by conco-
 mitant circumstances.  Warty excrescences are most readily
, removed, by the application  of  savin  powder by  itself,  or
I mixed with  red precipitate; and during its operation, the
 parts  may be washed with lime water.  The powder must be
 aSplied to the roots of the warts, for their  substance is al-
 m tst insensible.   Fungous excrescences may sometimes be
 removed by ligature;  but  when the parts are sensible, they
 mus \ be destroyed, by applying a strong solution of caustic
 with % pencil, or sprinkling them with escharotic substances.
 If thesv  cannot be borne,  we  must first abate the sensibility
 by tepit- fomentations with decoction of poppies,  or  water
 with a little tincture of opium, or decoction of cicuta, or weak
 infusion of ^elladona.   Should there be ground for suspecting
 a syphilitic action, mercury must be given, at the same time
 that we make suitable local applications; but  in doubtful
 cases, I have seen this medicine given without any benefit.
 These excrescences, from their appearance, their great pain,
 and foetid discharge, may suggest an opinion  of their  being
 cancerous; but thej begin in a different way, and generally
 yield, though sometimes slowly, to proper applications.

                 § 4. SCIRRHOUS TUMOURS.

    Solid tumours may form in the labia,  and are distinguished
 by their hardness, and by their moving under the skin, until
                          **                 '            v*

                             ■*■  *                       ,«# 
52
    adhesion from inflammation takes place.  These tumours arc
    sometimes scrophulous and have little pain, even when they
    have gone on to suppuration.  Oftener,  however, they are
    cancerous; and these are distinguished from the former, by
    their great hardness and inequality, and by their shooting
    pain.  If they are not removed, the cancerous abscess points
    to the inner surface of the labium, its  top becomes  dark co-
    loured, sloughs off,  a red fluid is discharged,  and presently
    fungus appears.  Soon after this the glands at the top of the
*v   thigh, and sometimes those in the course of the vagina, swell.
    If all the diseased parts can be removed, an operation must be
    performed.  If they cannot, we  must  palliate symptoms by_
    proper dressing and opiates.(n)

                      §5. POLYPOUS  TUMOURS.

       Soft fleshy appendiculae,  or firm polypous  tumours some^
    times spring from  the labia.  Both of these,  especially tb<6
    latter, may give trouble by their weight or size.   They may
    also, by being fretted, come to ulcerate, and the ulceration is
    always of a disagreeable kind.   They ought to be therefore,
    early removed  by the knife or the ligature.   If the base be
    broad, the double ligature must be employed; but  should

      (n) An immense tumour was successfully extirpated from the labia of a ne-
    gro woman by Dr. Hartshorne at the Pennsylvania Hospitalin December, 1815,
    said to be produced by the kick of a horse, and of upwards of' en years stand-
    ing.                                            '
      In this case, the labia were much enlarged,  and almost a* hard as cartilage.
    The hardness and enlargement of the integuments extended  anteriorly three
    inches above the pubis, and posteriorly to within two inches of the anus.  The
    patient walked with great difficulty, as the circumference of the middle of the
    tumour was at least twenty inches, and its  lower partalmost reached the knees.
    The weight of the tumour removed, was upwards t)f eleven pounds.
      On the eveningtif the 3d day after the operation, unequivocal symptoms of
    Tetanus appearing, and the violence of the sppsms increasing, caustic potash
    was freely applied to the neck, over the cervical vertebrae.  The effect of this
    application in lessening the convulsive action of the muscles was very evident.
      The woman was discharged well, on the 6tft  of April, ensuing.
      In Larrey's Memoirs, vol. 1. p. 299. will ^e found a description of a similar
 
5.3
there be any hardness about the part where the ligature would
be applied, it is best to dissect the whole growth out.
  Encysted tumours may form in the labia.  They are elas-
tic, and contain a glairy fluid.  A seton may be passed, or the
cyst may be laid open.(o)

                       § 6. CEDEMA.

  OEdematous tumour of the labium is either a consequence of
pregnancy, or a symptom of general dropsy.   The tumour is
variable  in its size.   When it  depends on pregnancy, it is
seldom necessary to do any thing; and even in time of labour,
although  the tumour be great, we need be under little appre-
hension, for it will yield to the pressure of the child's head.
But if at any time, during gestation, the distension be so great
as  to  give  much pain, then  one  or two punctures  may be
made, in order to let out the fluid, but this is very rarely ne-
cessary.  Gentle laxatives  are generally  useful.  Blisters ap-
plied to the vicinity of the part  have been proposed, but they
are painful and even dangerous.  When the swelling depends
on  dropsy, diuretics are to be employed; but if the woman be
pregnant, they must be used cautiously.

               § 7. HERNIA, LACERATION, &c.

   Pudendal hernia is formed in the middle of the labium. It
may be traced into the cavity of the pelvis, on the inside of
the ramus of the  ischium, and can be felt as far as the vagina
extends.   It differs farther from inguinal hernia, which also
lodges in the labium, in this, that there is no tumour discover-
able in the course of the round ligament from the groin.  It
sometimes goes up in a recumbent posture, or it may by pres-
sure be  returned.  A pessary has little effect in keeping it
up, unless it be made inconveniently large.  It is not easy to
 adapt a truss to it, but some good is done with a firm T-band-

  (o) vVould it not be more eligible, when practicable, to extirpate the cyst
completely by the knife, to prevent the risk of its sloughing away I 
54
age, or one similar to that used for prolapsus ani.  If it can-
not be reduced, we must support it by a proper bandage, which
is not to be drawn tight.
  Sometimes the labia are naturally  very small,  at  other
times uncommonly large; one  side may be  larger than  the
other.
  Laceration of the labia is to be treated like other wounds.
WThen the hemorrhage is great, the vagina must be plugged,
and a firm compress applied externally, with a proper band-
age.

             § 8. DISEASES OF THE NYMPHJE.

  The most frequent disease to which the nympha is subject,
is elongation.   When the part protrudes beyond the labia, it
becomes covered with a white and more insensible skin. But
sometimes  it is fretted, on which account, or from  other
causes, women  submit to have the nympha cut away. This is
done at once by a simple incision; but,as the partis exceed-
ingly vascular,  we must  afterwards restrain the hemorrhage,
either with a ligature or by pressure. By neglect, the patient
may lose blood, even ad deliquium.  In some countries, this
elongation  of the nympha is very common.1  In others, the
nymphae, together with the preputium clitoridis, are removed
in infancy.2  The nymphae are subject to ulceration, tumour,
and other diseases, in common with the labia.
  Sometimes by falls, but oftener3 in labour, the vascular
structure of the nympha  is injured, and a great quantity of
blood is poured out into the cellular substance of the labia,
producing  a black and  very  painful  tumour.4  This  may
take place even before the child is expelled;  and, in a case
of  this kind, the  midwife, mistaking the swelling  for  the
protruded membranes, actually perforated  the  labium,  and
caused a considerable discharge of blood.5   More frequently,
however, the tumour appears immediately after delivery,6
and the attention is directed to it both by its magnitude  and
its sensibility, which is sometimes so great as to cause syn-
cope.  It is tense, throbbing, and may also be  accompanied 
                           55

by severe pain in the legs, and violent bearing-down efforts,'
as if another child were to be born, or, as if the womb were
inverted. It has, however, been known to advance so slowly,,
as not  to attract attention  for two days.  There  are also
instances where the inflammation runs high, and the recto-
vaginal  septum sloughing,  faeces  are discharged by  the
vagina.8
  In the course of a short time the tumour bursts, and clotted
and fluid blood is discharged.  This process should be hast-
ened by  fomentations and poultices, and the pain be abated
by opiates;  but if it be very great, relief may be obtained, by
making  a small puncture in  the inside of the labium.9  Whe-
ther the  tumour burst, or be punctured, the previous inflam-
mation may close the vessels so as to prevent hemorrhage ;  but
if it do not, the vagina is to be gently filled with  a soft cloth to
prevent  the fluid from extending along the sides of the pelvis.
A compress is also to be firmly retained externally, to check
all hemorrhage from the aperture.  If inflammation run high,
it is to be abated by the usual means.

               §9. DISEASES OF THE CLITORIS,

   The clitoris may become scirrhous, and even be affected
 with  cancerous ulceration.  In  this disease, it is generally
 thickened, enlarged,10  and  indurated, and the patient com-
 plains of considerable pain.  Presently  ulceration takes place,
 and fungus shoots out.  In no case of this kind that I have
 met with, has an  operation been submitted to; and, indeed,
 unless the whole of  the  diseased  part, can be removed, we
 must  be satisfied with palliating  symptoms.  In one case,
 however, related by Kramer,11 where the clitoris was  en-
 larged, with cauliflower-like excrescences, and the right nym-
 pha indurated, the parts were  successfully removed by the
 knife, after failing with the ligature, which produced insup-
 portable pain.
    The clitoris sometimes becomes prcternaturally elongated ;
 and if this take place in infancy, and be accompanied with
 imperfect or confused structure of the other parts, the per- 
56
 son  may  pass for an hermaphrodite.12   This is said to be
 most frequent in warm climates; and in these, extirpation is
 sometimes  performed.  Haller assigns a cause for the en-
 largement.


                § 10. DISEASES OF THE HYMEN.

   The most frequent disease of the hymen is imperforation;
 in consequence of which the menses are retained,13 the uterus
 is distended, and the orifice of the vagina protruded, so as
 sometimes to resemble polypus, or a prolapsus uteri ;14 or it
 becomes fretted and covered with scabs. Even the perineum
 may  be  stretched,  as if  the head of  a child rested on it.15
 Menstruation is generally painful, and  the uterus becoming
 enlarged, contraction at  last takes place, and pains like those
 of labour come on, especially about the menstrual  period ;16
 such  a case may, therefore, by inattention, be mistaken for
 parturition.1'   Whe sufferings of  the patient are, in some in-
 stances, increased by the addition of suppression of urine,18
 or pain in passing the feces,19 or convulsions.*  Imperforated
 hymen is by no means uncommon, and the treatment is very
 simple, for the  part is  easily divided.20   The retained fluid
 is thus evacuated, sometimes in very great quantity.  It has
 very  rarely the appearance of blood, being generally dark
 coloured, and pretty thick,  or even like pitch.   Febrile and
 inflammatory symptoms may follow the  operation.21
   The  hymen  is sometimes perforated as usual, but very
strong, so as to impede the  sexual intercourse;  yet in those
 cases  impregnation  has taken place, and the hymen has been
 torn,22 or cut in the  act of parturition. It is asserted that con-
ception may take place, although the hymen be imperforated.!
   When the hymen is torn in coitu, some blood is  evacuat-
ed, wiiich, in many countries, is considered as a  mark of
virginity.  But as even the  presence or absence of a hymen
cannot be looked upon as  affording any certain proof relative

  * Vide Case by Mr. Fynney,in Med. Comment. Vol. HI. p. 194.
  ■J- Vide Ambrose Pare, Hildanus, cent. III. ob. 60.—Ruysch, ob 22.—
 Mauricean, ob. 439. 
57
 to chastity, this test must he considered as altogether doubt-
 ful.   When the  hymen is ruptured, and there is an inflam-
 mation about the external  parts, some have,  in cases of al-
 leged  rape considered the crime as proven.  But whoever
 attentively examines the subject  must admit, that these are
 very  fallacious  marks;  that they may exist without any
 violence having been  employed; and that  a woman may
 have, if previously stupified, been violated without exhibiting
 any mark of injury.  Practitioners  therefore ought, in a
 legal question of this  nature, to  be cautious  how they give
 any opinion, especially if they have not seen the person im-
 mediately after the crime has been committed.*

           § 11. LACERATION OF THE PERIX.EUM.

    The perineum may be torn during the expulsion  of the
 head  or arms  of the child.  In  many cases, the laceration
 does not extend  farther back than to the ants, 'nor even so
 far.  This is a very simple accident, and requires  no other
 management thaa rest,  and attention to cleanliness.  But
 as the recto-vaginal septum is carried forwards  and down-
 wards, when the perineum is put on the stretch previous to
 the expulsion of the head,  it sometimes happens, that  the
 laceration extends along this septum,  and a communication
 is formed betwixt the rectum and  vagina.   In some cases,
 the sphincter  ani remains  entire, although the  rectum be
 lacerated ; in others it also is torn.   This accident is  at-
tended with considerable pain and hemorrhage, and  suc-
ceeded by an inability to retain the  feces, which pass rather
by the vagina than the rectum.   Prolapsus  uteri is also, in
some instances, a consequence of this  laceration.  This ac-
cident is  sometimes produced by  attempts to distend  the
 parts  previous to delivery, or by the  use of instruments;
but it may also take place, even to  a great  degree, in a  la-
 bour otherwise natural and  easy, and in  which no  attempts

   * Vide Baudelocque, 1'Art, &c. sec. 342, et Fodere Med. Legale, Tome
 II. p- 3.
  VOL. I.                         I 
05
have been made to accelerate  delivery.  The most effectual
way to prevent laceration  is by supporting the perineum
with the hand, when it is  stretched, and keeping  the head
from being suddenly forced out.   When the parts have been
actually torn,  our first attention  is to be  directed to the re-
pressing of  the hemorrhage, which is sometimes considera-
ble ; and this is best effected  by  compression  and rest,
which  favour  the formation  of  coagula.   Next,  we are to
consider how  the divided parts may be united.  Rest,  and
retaining the  thighs as much  together as  possible, together
with frequent  ablution, in order to remove the urine, which
sometimes, for a few days  flows  involuntarily, or the lochia
and stools,  are requisites in every mode  of treatment.  As
there is nothing in the structure of the parts to prevent their
re-union, it has very feasibly been proposed to induce a state
of costiveness, and prevent a stool  for  many  days.    But
with only one or two exceptions,  this method has failed ;
the subsequent expulsion of the indurated feces tearing open
the parts, if adhesion had  taken place.  An  opposite prac-
tice, that of keeping the  bowels open, and the stools soft or
thin, by gentle laxatives,  has been much  more successful,
the parts in some instances  healing in a few weeks.  During
this period, the stools are, at least for a time, passed some-
times  involuntarily ; but in  other instances, they can from
the first he retained, if the patient  keep in bed.  Sutures
have been  also employed, and ought certainly to  be had re-
course to, if re-union cannot otherwise be effected.^)   If ne-
cessary, the edges of the divided parts  must be made raw.
It would appear that there is  no occasion for putting  a liga-
ture in the recto-vaginal septum.   It is sufficient to place
two in the perineum. When the sphincter ani remains en-
tire, but the septum is torn, some have considered it neces-
sary to divide that  muscle; hut  others, with more reason,
omit this practice.  During the cure, some introduce a canula
into the vagina, to support the parts, and others apply com-
presses dipped in balsams; but it  is better to apply  merely
  (/>) Sutures should be very rarely had recourse to, as they give  great
irritation, and are subject to be torn out 
59
 a pledget, spread  with simple ointment, to the part.   If the
 radical cure fail, the patient must use a compress, retained
 with a T-bandage.23


            § 12. IMPERFECTION OF THE VAGINA.

   The vagina may be unusually small.   I have known it not
 above three inches long, and sometimes it is very narrow.
 The size, if  necessary, may be enlarged with a tent of pre-
 pared sponge.*  Should pregnancy take place before it be
 fully  dilated, we need be under no apprehension with regard
 to delivery;  for during labour, or even long before it, relaxa-
 tion34 takes place.  Sometimes the vagina is wanting or im-
 pervious, or  all the middle portion  of the canal  is filled up
 with  solid matter.  More frequently, however, there is only
 a firm septum stretched across, behind  the situation  of  the
 hymen, or higher up in the vagina; and this2* it  may be ne-
 cessary to divide.  In some cases, there is a great confusion
 of parts, and, indeed, it is  impossible to describe the varie-
 ties of  conformation;  for  the vagina may follow  a wrong
 course, or communicate  with the urethra, or the  rectum28
 may terminate in  the vagina, &c.  Malformation does  not
 always prevent pregnancy27.

   § 13.  INFLAMMATION AND GANGRENE OF THE VAGINA.

  In consequence  of very  severe labour,  inflammation, fol-
 lowed by gangrene of the vagina, may be produced.  If the
 sloughs be small, then partial contraction of the diameter of
the canal may take place, and  cause  much  inconvenience
from retention of the  menses,28 or during a subsequent la-
bour ; but in this last case,  the  parts gradually yield, and it
 is  seldom necessary to perform any operation : the  pain,
however, i« sometimes excruciating till the part yield.f
  In some instances the sloughs are so extensive, that the
whole vulva is destroyed, or part of  the urethra and vagina
• Vide Van Swieten Comment, in aph. 1290.
f Harvey, exercit. LXX1II. p. 492. 
60
come away, or general adhesion takes place, leaving only a
small opening, through which the urine and the menses How.
Should this, by any means be obstructed, the discharges can-
not take place; and  sharp pains, or even convulsions, may
be the consequence.  Sometimes  calculous  concretions form
beyond  the adhering part.*
  Whenever we have reason to expect a tender state of the
parts after delivery, we must be  exceedingly attentive; and
if the vagina, or any other organ, be inflamed or tender, we
must bathe the parts frequently, and inject some tepid water
gently,  to promote cleanliness.   Saturnine  fomentations and
injections are often of  service,  but they must not be thrown
high.  The urine must be regularly  evacuated ; and should
a slough take place, we must, by proper dressings, or the use
of a thick bougie, prevent coalescence of the vaginal canal29.

        § 14. INDURATION, ULCERATION AND POLYPI.

  The vagina may be contracted  by  scirrhous glands  in  its
course,  or induration of  its parietes,  which  become thick
and ulcerated, and communicate with the bladder or rectum.
This disease is generally preceded by, or accompanied with,
scirrhous uterus, and requires the same treatment.
  Foreign bodies in the vagina may produce ulceration, and
fungous excrescences.   The source  of irritation being  re-
moved, the parts  heal;  but  we  must, by dressing and injec-
tions, prevent coalescence.
  Polypous tumours may spring from the vagina, and are to
be distinguished from polypus of the uterus by examination.
The diagnosis betwixt  polypus and prolapsus,  or  invcrsio
uteri, will be afterwards pointed out.  The cure is effected by
the  application of the ligature, more solito.
        t
                    § 15. INVERSION.

  The vagina may be inverted or prolapsed, without any ina-

  * Vide Puzos Traite, p.^140.—Case by Mr. Purton, in Med. and Phvs.
Jour. Vol. VI. p. 2      ': 
61
terial change in the state of the womb, and without symptoms
of uterine irritation, farther than slight pain in the back, and
a little mucous discharge.  We find a fleshy substance pro-
truding at the back part of the vulva, having an opening be-
fore, leading into the vagina.   If the procidentia be consider-
able, the rectum is carried forward, and in every instance is
relaxed.  At first  the tumour is soft; but after sometime, if
the part has been irritated, it  may inflame, indurate, or ulce-
rate.  It is cured by strict attention to the state of the bowels,
thereby preventing accumulation in the rectum, by astringent
injections into the vagina, tonics, and, if these fail, by a globe
pessary, or by pregnancy ;*  but it sometimes returns after
delivery.30

                 § 16. WATERY TUMOUR.

  Water sometimes passes down from the abdominal cavity,
betwixt the vagina  and rectum, protruding the posterior sur-
face of the vagina in the form of a bag; and the  accumula-
tion of water in the  cavity of the pelvis is sometimes so  great
as to obstruct the flow of  the urine, or produce strangury.
When the person  lies down, the swelling disappears.   If
large, a candle held on the opposite side, sometimes shows it
to be transparent;  and in every case, fluctuation may be felt.
As this symptom  is connected with ascites, the usual treat-
ment of that disease must be  pursued, and, if necessary, the
water may be drawn off  by tapping the abdomen, or rather
by piercing31 the tumour, which is to be rendered  tense, by
pressing it with the finger.

                      § 17. HERNIA.

  Sometimes the intestine passes down betwixt the vagina
and rectum, forming perineal hernia,  or protrudes either  at
the lateral  or posterior part of the orifice of the vagina, like
the watery tumour; but is distinguished from it by its firmer
* Pechlin, lib. i. obs. 20. 
62
and more doughy feel, and by the manner in which it can be
returned.  By handling it, a gurgling noise may be heard,
and sometimes indurated feces may be felt.  As the os uteri
is pushed forward and the posterior part of the vagina occu-
pied by the herniary tumour, this complaint may put on some
appearance of retroverted uterus.  A case of this kind  is
mentionedby Dr. John Sims,in Mr. Cooper's work on hernia.
This complaint is frequently attended with  a bearing-down
pain; and on this account, as well as from its appearance, it
has also been mistaken  for prolapsus uteri.   Sometimes the
tumour does not protrude externally; but symptoms of stran-
gulated hernia may appear, the cause  of which cannot be
known,  unless the practitioner examine the vagina.   In a
case occurring to Dr. Maclaurin, and noticed by Dr.  Den-
man, the patient died on the third day, and the disease was
not discovered till the body  was opened.  Should a woman
have vaginal hernia during pregnancy, we must be careful to
return it before labour  begin, for the intestine may become
inflamed, and the feces  obstructed, by the head entering the
pelvis; or the labour itself, if the head cannot be raised and
the intestine returned, may be impeded so much as to require
the use of instruments.   Vaginal hernia requires the use of a
pessary.
  The rectum sometimes protrudes into the vagina, and al-
ways does so more or  less in an inversio vagine.   This is
remedied by the globe pessary, after all the indurated feces
have been removed.  The farther accumulation is prevented
by laxatives.

         § 18. ENCYSTED TUMOURS AND VARICES.

   Indolent abscess, or encysted tumours,  may form betwixt
the vagina and neighbouring parts. These are distinguished
from  hernia and  watery tumours, by being  incompressible,
and not disappearing by change of posture.  The history of
the disease assists the diagnosis, and examination discovers
the precise seat and connections of the tumour, though it
- annot with certainty  point out the nature of the contents. 
63
These tumours seldom afford obstinate resistance to delivery;
by degrees they yield to the pressure of the head, but some-
times they return after delivery.   The treatment is similar
to that required in other cases  of  tedious labour, and the
tumour must be opened if we cannot deliver the  woman
otherwise, with safety to the child.   Even in the unimpreg-
nated state, if it cause irritation, or if the bulk of the tumour
be so great as to impede the evacuation of the urine or feces,
an  opening must be made.   After delivery, in those cases
where no operation is  performed, the tumour sometimes  in-
flames and indurates even so low as the perineum.  Friction
on  the perineum, has in these circumstances done good.
   Varicose tumours of a knotted form, disappearing or be-
coming slack by pressure, and aneurismal tumours, distin-
 guishable by their pulsation, may  form about the vagina,
 and ought  not  to  be interfered with, except by supporting
 them w ith a globe pessary in the vagina.

                  § 19. SPONGOID TUMOUR.

   A very dreadful disease, which I have called spongoid tu-
 mour, may form either within the pelvis,  or about the hip
 joint, or tuberosity of the ischium, and spread inwards, pres-
 sing on the bladder and rectum, sometimes so much as to re-
 quite the use of the catheter.  We recognise the disease, by
 its assuming very early the appearance of a firm elastic tu-
 mour, as if a sponge were tied up tightly in a piece of bladder.
 Presently it becomes irregular, and the most prominent parts
 burst, discharging a red fluid, w hich is succeeded by fungous
 ulceration.  But I have never known it proceed to this  last
 stage within the pelvis.   I know of  no remedy, and  would
 dissuade from puncturing, except in the very last extremity.
 I have never met with a case where it was necessary.

            §20. ERYSIPELATOUS INFLAMMATION.

    The orifice  of the vagina, together  with the  labia, and
  indeed  the whole vulva,  may be affected  by erysipelatous 
64
inflammation.  This  appears  under two conditions:  1st, it
may originate in the vulva, and spread inwards, even to the
uterus; or, 2dly it  may begin in the womb, and extend out-
wards.  The parts are tumid, painful, and of  a dark red
colour.  The second affection is most frequent after parturi-
tion ; but the first may occur at any age, and under a variety
of circumstances.   It may be confined  to the external  parts
alone, or it may quickly spread within the pelvis, and destroy
the patient; for this  disease  generally terminates in gan-
grene.  Vigarous,* says, this state may  be distinguished
from abscess of  the  labium,  by both labia being equally
affected.  The general history of the case, and proper exami-
nation, will point out  the difference.    When the disease is
confined to the external parts, we may hope for a cure, and
even for the preservation of the parts,  by giving early, bark
and opium  internally, and applying to the surface, pledgits
dippedin a w eak solution of sulphate of zinc, with the addition
of a tenth part of camphorated spirit  of wine.  When this
application gives  continued pain, fomentations with milk and
water, or with decoction of chamomile flowers may be sub-
stituted.
  A highly sensible or inflamed state of the parts may occur
in nymphomania, or libidinous madness, either as a primary
or secondary affection;  and should the patient die under the
disease, the parts are generally found black.  The tepid bath
and fomentations give relief, but sometimes spirituous applica-
tions are beneficial.  If the patient be feverish she ought to be
blooded,  and have  cathartics administered,  and  be put on
spare diet.   Nauseating doses of tartar emetic, or full  doses
of the medicine, given so as to operate briskly, are of service,
especially if followed by sleep.  Strict  and prudent attention
must be paid to the  mind.   A constant  heat and tenderness of
the parts, if not occasioned by uterine disease, may  be relieved
by bathing with solution of sulphate of  zinc.
* Maladies des Femmes, Tome II. p. 169. 
65
                   § 21. FLUOR ALBUS.

  The vagina is always moistened with a fluid, secreted by
the lacune on  its surface.  To this is added the secretion
from the glands of the cervix uteri and the serous exhalation
from  the membrane  of the  uterine cavity.  Naturally the
balance between secretion and absorption is such, that except
on particular occasions, no fluid is discharged from the va-
gina.  But in a diseased state, the quantity of the secretion
is greatly increased,  and the discharge, whether proceeding
solely from the vagina, or partly also  from the womb, re-
ceives the name of fluor albus, or leucorrhoea.   Some confine
the term strictly to a discharge from the inner surface of
the womb ; and in order to determine whether the secretion
proceeds from the uterus  or not, it has been proposed to stuff
the vagina completely for some time, and then  inspect the
plug, to ascertain whether that part corresponding to  the os
 uteri be moistened.*  But this test is not satisfactory,  and
 will seldom be submitted to.
   When the discharge proceeds  from the  womb, it  some-
times injures the  function of that  organ  so much, or  is de-
 pendent on  a cause  influencing the uterus so strongly, as
 to interfere with menstruation, either stopping it altogether,
 or rendering it too abundant or irregular in  its appearance,
 and in such cases the woman seldom  conceives.  Very fre-
 quently, however, the menses  do continue pretty regularly ;
 and  in  those cases,  the  other discharge disappears  during
 the flow of  the menses,  but is increased for a  little  before
 and  after menstruation.   When the menses are  obstructed,
 it is not uncommon for the fluor albus to become more abun-
 dant, and to be attended with more pain in the hack about
 the menstrual period.  If a  woman, who has uterine  leucor-
 rhoea conceives,  the discharge stops, but a vaginal secretion
 is,  on the contrary, not unfrequently increased.  This it
 has  been  thought  dangerous to check  suddenly,  but it
 ought not to be  allowed to continue profuse, as it causes
 abortion.
               * Chambon Malad. des  Filles, p. 104.
    VOL. I.                        K 
66
   Fluor albus may occur  in two very different states of the
constitution, either as an effect of these, or produced in them
by accidental causes.   These are a state of plethora, or dis-
position to vascular activity, and  a state of debility.  The
one  is  marked by a  full habit, a good complexion and a
clear healthy skin. The other by a pale countenance, a sal-
low  surface, a  feeble  pulse, and  generally a spare  habit.
The one is attended with vertigo, or disease produced by ful-
ness.  The other by dyspepsia, palpitation, and  those com-
plaints which are connected with debility.
   The discharge is produced either by the lacune of the va-
gina, or the glandular and cxhalent apparatus of the uterus.
The most ample and the most frequent  source is from the
vagina.   The  discharge  itself may  consist simply  of  the
natural mucus  of the  part increased in quantity, in which
case it is glairy and transparent; or it may be so far changed
as to become opaque, and white like  milk,  which  is par-
ticularly the case when the organs of secretion of the upper
part of  the vagina and cervix  uteri are affected;  or it may
be purulent.  These may all  occasionally be mixed with a
little blood from the uterine vessels, if there be a tendency to
menorrhagia,  but  not otherwise,  unless there be  organic
disease.   In those cases where the  discharge is  yielded  by
diseased structure, it is modified by the nature of that struc-
ture, and by  the existence   of  ulceration   and  erosion.
When it proceeds from the morbid part itself and not from
the irritating effects of that part on  the vagina, by sym-
pathy, it is generally  foetid, and purulent,  often  of a dark
colour mixed with blood, and alternated  by uterine hemorr-
hage.  There is often  heat about the parts, and other symp-
toms of disease.  In all ambiguous, and in every chronic case,
it is necessary to examine carefully the  state of the uterus
and  vagina.
   We must bear in mind that  fluor albus may be caused by
local irritation, including the effect of diseased structure, or
misplaced uterus;  by  a state  of increased vascular action;
and  by debility, either preceded by increased action, or di-
rectly produced by weakening  causes. 
67
   Fluor albus is usually accompanied with pain, and sense of
weakness in the back.   The functions of the digestive organs
are always ultimately injured, and in those women who  are
of a weak habit, they are impaired from the first.  In them
the discharge adds greatly to the debility, and all the diseases
arising from that state increase, such as indigestion, derange-
ment of the hepatic secretion, torpor of the bowels, palpita-
tion, swelling of the feet, &c.  In the more plethoric patients
the debilitating effects are longer of appearing, but they are
not exempted from affection of the stomach.
   Fluor albus may be excited by the presence of a polypus
in utero, or in  consequence of prolapsus uteri, or of disease
of the womb; but in such cases it is symptomatic, and is not
at present to be considered.   The idiopathic fluor albus may
be produced by various exciting causes, such  as abortion,
menorrhagia, frequent parturition, excessive venery, cold or
fatigue after a  miscarriage or a delivery at the full time,  and
whatever can weaken the action  of the uterus.*  It was at
one time supposed, that it  might  also be produced by  a bad
state of the fluids of the body, a bilious cacochymy, a leuco-
phlegmatic habit, passions  of the mind, &c.  The applica-
tion Of  cold or other circumstances exciting irritation  of the
vaginal membrane may produce it in the same  way as they
produce catarrh.  Worms may cause it.
   In  treating fluor albus we must consider whether  it be
symptomatic of polypus, prolapsus, or cancer, &c.   If  it be
not, we have then to attend to the general state of the con-
stitution.  Should the patient be plethoric, or robust, it is
necessary, In the first instance, to  diminish the fulness  and
activity of the  vessel, by mild, and perhaps, spare diet, by
moderate  doses of laxative medicine, and even,  if requisite,
by the lancet.   Regular exercise, is in this view, of benefit,
but in all  cases fatigue  increases  the  discharge.  Then we
give bitters with alkali  to improve the state of the stomach
and bowels, and employ an injection of solution of acetite of
lead, which is to be thrown three or  four  times a day into

               * Chambon Malad. des Filles, p. 104. 
68
the vagina, and this may afterwards be exchanged for one of
a more astringent quality.
  If the disease occur in a weak habit, or if the plethoric
state, though  it existed at one time, has now been removed,
the internal remedies must be more directly tonic, and injec-
tions of various astringents must be employed; of those the
two best are solution  of sulphate of alumin and decoction of
oak bark.  The action of cold  and damp are to be avoided,
as these are hurtful in every affection  of mucous membranes,
whether chronic or acute.  Of the internal  remedies  some
are intended to act by sympathy on the secreting parts, as
emetics, others as general tonics.  Emetics are of very con-
siderable advantage,  on account of their operation  on the
stomach and alimentary canal, and are accordingly advised
by most writers.*  Purges have also  been used,f in order to
cany off noxious matter; but  they are only  to be given, so
as to keep the bowels regular,:): for brisk and  repeated purg-
ing  is hurtful.^   Tonic medicines and those  which improve
the action  of  the chylopoetic  viscera, such  as  lime water,
myrrh, bark,  steel, rhubarb, uva ursi, &c. are also of much
utility, and along with them we may, with great advantage,
employ the cold bath. The diet is to be light and nourishing,
and the patient ought not to indulge in too much sleep.
   Various medicines have been proposed  with a view of act-
ing specifically on the secreting parts, such as cicuta, balm
of gilead, diuretic salts, calomel, resins, cantharides, electri-
city, arnica, &c.  have been proposed;  but  they have very
little good effect,  and sometimes do harm.   Of all these the
tincture of cantharides(^) and oil of  turpentine, by exciting

  • Smellie, Vol. I. p. 67.—Vigarous, Tome I. p. 261.—Mead Med. precepts,
chap. XIX. sect. 3d.—Denman, Vol. II. page 104.—See  also  Ettmuller, Ri-
verius, &c. &&
  f Chambon Malad. des Filles, p. 107.—Mead, Med. precepts,  chap, xix,
section 3d.
  * Stoll. Prxlectiones, Tomus II. p. 385.
  § Vigarous, Malad, des Femmes, Tome I. p. 261.
  (q) Mr. Roberton  a surgeon of Edinburgh in a paper published in the
London Medical and Physical Journal, vol. XV. and also in a distinct work
on the Eflects of Cantharides, when taken internally, strongly recommends 
69
the uterine vessels in chronic secretions seem to be the best,
but no internal medicine  can be  much depended on in this
view.   By suckling a child, the discharge has in some in-
stances been  removed.  Plasters and liniments  have been
applied to the back, and sometimes  relieve the aching pains.
Opiates are occasionally required, on account of uneasy sen-
sations.
   When the  discharge  is  very opaque, and  attended with
considerable  pain in the back and loins, there is reason  to
think that the cervix uteri is in a state of irritation, and by
examination  it may be found tender to the touch,  and the
mouth soft and enlarged a little. This  state  does  not con-
stitute disease of structure though it may lead to it, but it con-
sists merely in an affection of the glands.  It is to  be man-
aged in the first stage, by the warm sea water hip-bath, mild
mercurial preparations, laxatives, and avoiding all irritation.
After the tender  state is  nearly subdued, and the discharge
has become  more  chronic, the cold bath, tonics, and mild
vegetable astringent injections  are proper.
   Purulent discharge implies previous inflammation, and the
present existence either of abscess, ulceration, or a  morbid
change of a secreting surface. The two first states are ascer-
tained by examination.   The last chiefly by the  smarting in
making water, and other symptoms excited by the action of
a virus.  To this species belongs the gonorrhoea, which is to
be cured by mild laxatives, and injections, first of acetite of
lead, and then of sulphate of zinc, dissolved in water.   The
two first states are to be managed according to the causes
which give rise to them.

this powerful article of the materia medica, in obstinate  cases of Leucor-
rhoea; and recites a number of instances, in  which it appears to have pro-
duced the best effects. In his exhibition of this medicine, he generally begun
with about Jij or Jijss of the tincture, in ^vj of water; a table-spoonful of
which was given thrice a day.   He continued gradually increasing the dose,
until his  patient  had taken Jiv of the tincture in 24  hours, 3jj of the
tincture being added to gvj of water.   It was generally given,  until con-
siderable pain, and a puriform discharge from the vagina  was produced.
I  cannot say, that in the few trials I have  made of  it  in this complaint,
the beneficial effects have been so conspicuous. 
70
    On the whole then, our practice  in  fluor albus,  unaccom-
 panied with organic affection, consists in rectifying the con-
 stitution, bringing it as far as possible  to a state of perfect
 health, employing topical applications in  the form of  injec-
 tions,  and avoiding the farther operation  of exciting causes.


              § 22. AFFECTIONS OF THE BLADDER.

    The bladder is  subject to several diseases.   The first  I
 shall mention is stone.   This excites very considerable pain
 in the region of the  bladder, remarkably  increased  after
 making  water.  There  is also irritation about the urethra,
 with a frequent desire  to  void  the urine; but  it does  not
 always flow freely,  sometimes stopping  very  unexpectedly.
 The urine deposits a  sandy sediment,  and is  often mixed
 with mucus.   These symptoms lead to a  suspicion that there
 is  a stone in the bladder, but we can be certain only  by pas-
 sing a sound.    By  means of soda,(r) the warm  bath, and
  (r) Our author has omitted to mention the efficacy of magnesia in calcu-
lous complaints, as recommended by Messrs. Brande and Hatchet. The result
of the inquiries of these ingenious gentlemen, on this very interesting sub-
ject, has been communicated to the scientific world in a paper printed in the
Philosophical Transactions for the year 1810, entitled " Observations on the
Effects of Magnesia, in preventing an increased formation of the Uric Acid,
by William T. Brande."  This gentleman (in a communication to Sir John
Sinclair) says, that the best method of giving the magnesia, is in plain water,
or milk, to be taken in the morning early, and at mid-day.  If the stomach is
weak, and  this produces flatulency or uneasy sensations, some common bit-
ters, such as gentian, may be taken with it: if it purges, a little opium may be
added.  He supposes its beneficial operation depends, on preventing the for-
mation of acid in the stomach.
  The dose of magnesia, he observes, must always depend upon the  circum-
stances of the case ;—generally, five grains twice or thrice a day to children
ten years of age ; fifteen or twenty grains to adults.
  Mr. Brande has always given the common magnesia, although he remarks,
that, the calcined may be occasionally used with advantage.  For fuller infor-
mation on this subject, the reader is referred to Brande's paper, above quoted,
in the Phil. Trans, and to a letter from Sir John Sinclair, vide Eclectic. Reper-
tory, vol. III. p. 120. ■
  Dr. Gilbert Blane, so well known in the medical world, has  also written an
interesting paper on the effects of large doses of mild vegetable alkali, or
potassa carbouata in gravel, and the beneficial effects of opium combined
with it. 
n
   opiates, much relief may be obtained,  and very  often the
   stone may be passed, for the urethra is short and lax.   But
   when these  means  fail, an operation  must  be performed.
   This has been done during  pregnancy,* but is only allow-
   able in cases of great necessity.  Sometimes the stone makes
   way, by ulceration, into the vagina.f  It has even  been
.   known to ulcerate through the abdominal integuments.:}:
     In many cases the symptoms of stone arc met with, although
   none can be found in the bladder.   This is most frequently
   the case with young  girls,  previous to the establishment of
   the catamenia, or with women of an irritable habit.  There
   is no organic disease, nor have I ever known it, in such peo-
   ple, end in  a diseased  structure of  the bladder or  kidneys;
   indeed, they rarely complain of uneasiness  about  the kid-
   neys.   I have tried many remedies, such as  soda, uva ursi,
   narcotics, antispasmodics, tonics, and  the warm and  cold
   bath, but cannot promise  certain  relief from  any  one of
   these.33  In process of  time, the disease subsides and disap-
   pears.   The use of a bougie may be of service.
     Induration, or scirrhus of the bladder, produces symptoms
   somewhat similar to calculus, but there is a greater quantity
   of morbid mucus mixed with the urine ;  and blood  with pu-
   rulent matter is discharged, when ulceration has  taken place.
   No stone can be found, but the bladder is felt to be hard and
   thick.    Sometimes  it  is much enlarged with such appear-
   ances, as give rise to an opinion, that the uterus is the part
  principally affected.34  The  scirrhus and ulceration may ex-
  tend to the uterus and vagina. In this disease we must avoid
  all stimidants, and put the patient on mild diet; avoid every
  thing which can increase the quantity ofsaltsin the urine; keep
  the  bowels open, with an emulsion containing oleum ricini;
  and allay irritation by means of the tepid bath and opiates.
  Mercury, cicuta, uva ursi, &c. with applications to the blad-
  der  itself, have seldom any good effect,  and sometimes do
  harm.

   * Deschamps Traite de l'Oper. de la Taille, Tome IV. p.9
   f Hildanus, cent. I. obs. 68 and 69.
   , Vide Case by M. Caumond in Recueil Period. 
72
   Chronic inflammation of the mucous membrane of the blad-
 der, produces frequent desire to void urine, and the discharge
 of viscid mucus which sometimes has a puriform appearance.
 Cicuta and balsam of copaiba seem to be the best remedies.
   Polypous tumours8* may form within the bladder, produc-
 ing the usual symptoms of irritation of that organ. Most dread-
 ful sufferings have been caused by worms in the bladder.
   In consequence of severe labour, or the pressure of instru-
 ments, the neck of the bladder may become gangrenous, and
 a perforation take  place by sloughing.  The woman com-
 plains of soreness about  the parts, and does not void the urine
 freely.  In five or six days the slough comes off, and then the
urine dribbles away by  the vagina.  In all cases of severe
 labour, and indeed  in every case wrhen the  urine does not
pass freely and at proper intervals, and especially if there be
tenderness of the parts,  we must evacuate the water, in order
to prevent distension and farther irritation of the bladder;
 and the parts must,  if there be a tendency to slough or to ul-
cerate, be kept very clean, and be regularly dressed, in order
to prevent improper adhesions.   If the bladder should give
way, we must try, by keeping in attentively an elastic cathe-
ter,*  to make the urine flow by the urethra, and then perhaps
the part  may heal.   If this have been neglected, it  will be
proper to make the edges of the opening raw by paring, if it
be large, or by caustic if it be small, and afterwards use the
catheter.  When an incurable opening is  left, we must, by
introducing asponge, or some soft, but pretty large substance,
like a pessary, into the vagina, close it up, at least so far as
to make  the woman more comfortable.  In a curious case I
met with, there  was  an attempt by nature,  to plug up the
 opening.36  Puzos justly remarks, that it is always the blad-
 der, and not the urethra, that suffers.
   Sometimes, after a severe labour, the woman is troubled
with incontinence of urine,  although the bladder  be entire.
 This state is often produced directly by pressure on the neck

  * This succeeded in a  very  bad case related by SedUliot, Recueil Period.
Tome I. p. 187. 
                          73

of the bladder; sometimes it is preceded by symptoms of in-
flammation about the pelvis, and, in such cases, the os uteri
is often found afterwards to be turned a little out of its proper
direction, and the patient complains much of irregular pains,
about the hypogastrium and back.  When the woman is in bed
some of the urine collects in the vagina,  and comes from  it
when she rises; after she is up, it comes from the urethra alone,
which distinguishes this  from the complaint last described.
Time sometimes cures this disease.   The cold bath is useful,
unless it increase the pain; and, in that case, the warm bath
should be employed.  It may be proper to use the bougie
daily, and also try the effect of tincture of cantharides.
  The bladder may descend, in labour, before the uterus, pro-
ducing much pain;  or it may prolapse for some time previous
to labour, attended with pains resembling those of parturition,
and sometimes with convulsive or  spasmodic affections.37
When the prolapsus vesice takes place as a temporary oc-
currence during labour, or antecedent to parturition, we must
be careful not to mistake the bladder for the membranes, for
thus irreparable mischief has been done to  the woman.  The
bladder when protruded, is felt to be connected with the pubis.
It retires when the pain goes off.   If the patient be not in la-
bour, the uneasiness is to be mitigated by keeping the bladder
 empty, and allaying irritation with opiates, and taking a little
blood if feverish or restless.  If labour be going on, the blad-
der must likewise be kept empty, and may, during a pain, be
gently supported, by pressing on it  with  two fingers in the
vagina, by which the bladder is  preserved from injury.   In
the  unimpregnated state, it sometimes  descends betwixt the
 vagina and pelvis,  so as to form a tumour within the vagina,
or at the vulva.  It produces a procidentia of the vagina, but
the  tumour is formed at the anterior part of the vulva, instead
 of the back part, as in the ordinary procidentia.  There is
 some degree of bearing-tlown pain in walking, particularly
 when the bladder is full.  Some patients complain of pain in
 the groin, others at the navel, and some suffer little or no in-
 convenience,  except pain about  the  bladder when it is  dis-
 tended.  If the disease has continued long, or if the prociden-
    vol. i.                          L 
74
 tia of the anterior part of the vagina be considerable, the os
 uteri is directed backward, and when the finger is introduced
 into the vagina, the anterior part of that canal can be pushed
 up farther than usual  over the fore part of the cervix uteri,
 which then appears to  be elongated, and perhaps in some
 cases the anterior lip is actually lengthened.  In a case dis-
 sected by my brother, the bladder was found to form a hernia
 on both sides of the pelvis, hanging like a fork over the ure-
 thra.  This procidentia is called a hernia* vesicalis, and is
 often attended with suppression of urine.   If this be inatten-
 tively examined, it may be taken for prolapsus uteri; but it
 will be found to diminish, or even disappear, when the urine
 is voided, and by pressure, the urine may  be forced through
 the  urethra.  The hernia vesicalis is to be remedied by the
 use of a globe pessary.  Sometimes it is combined with cal-
 culus in the bladder.   In this case, it has been proposed to
 open the bladder, extract the stone, and keep up a free dis-
 charge of urine through the urethra,  in order to allow the
 communication with the vagina to heal.  Deschamps advises,
 that the  opening should be made near the pubis, and not at
 the posterior part of the tumour, lest that part of the bladder
 be cut, which, when the tumour is reduced, would communi-
 cate with the abdominal cavity.  I can see no necessity for
 making  any change in the mode of extracting the stone on
 account of the procidentia.

          § 23. EXCRESCENCES IN THE  URETHRA.

   Excrescences may,  notwithstanding the opinion of Mor-
 gagni, form in the course, or about the orifice of  the ure-
 thra,38 and generally produce great pain, especially in mak-
 ing  water; on which account, the disease has  sometimes
 been mistaken  for a calculous affection.   The agony is at
 times so great, as to  excite convulsions,  and it is not un-
 common for the patient to have an  increase of her sufferings

  * Vide the Memoirs and Essays of Verdier and Sabbatier, and Hoin.  Sandi-
fort, Diss. Anat. Path. lib. I. cap. iii. and Cooper on Hernia, part 11. p. 66. 
75
about the menstrual period.   The tumour is vascular, florid,
moveable,  and exceedingly  tender.   When  excrescences
grow about the orifice of the urethra,  they are readily dis-
covered ; but when they are  high up, it is much more diffi-
cult to ascertain their existence.  Dr.  Baillie*  says, they
cannot be known, but by the sensation given by the catheter
passing over a  soft body.  They, however, in one case, were
discovered, by  turning the instrument to  one  side, so as to
open the urethra a little.39  When  their situation  will per-
mit, it is best  to extirpate them with the knife or  scissars ;
or if near  the  orifice, as they generally are, a ligature may
be applied.   Sometimes they have yielded to  the bougie,
though they had returned after excision.f  The removal  of
large excrescences, has occasionally been attended  with very
severe  symptoms.40  The daily use of the bougie, for some
time after extirpation, is of service.41
    Sometimes the urethra is partially, or totally inverted,48
forming a tumour at the vulva,  attended with difliculty and
pain in voiding urine.   A  slight inversion  may be relieved
by a bougie;  when  there is a considerable prolapsus,  the
part must be cut off.  The urethra is sometimes contracted
by a varicose  state of its vessels, or  by a  stricture:  but
 these are not common occurrences.   In continued irritation
 of the urethra, with difliculty of voiding water, the bougie is
 often of great  service,  even although there should be no con-
 traction of the canal itself.   Sometimes the urethra is prefer-
 naturally dilated,43 but this does not necessarily cause incon-
 tinence of urine.
    The mucous coat of the  urethra is sometimes  thickened,
 and its vessels become varicose.   This produces general
 swelling of the urethra felt by the finger in the course of it,
 pain or pressure, and in coitu, with a discharge of  mucus,
 and tormenting desire to  make  water.  When the  patient
 bears down,  the urethra is partially inverted, and appeals
 swelled and vascular.   These vessels should be scarified, the
• Morbid Anatomy, p. 321.
t Broomfield's Surgery, Vol. II. p. 296. 
7&
 part bathed with  an astringent  lotion,  and gentle pressure
 made with a thick bougie.

   § 24. DEFICrENCY AND MAL-FORMATION OF THE UTERUS.

   The  uterus  may be larger than usual, or  uncommonly
 small44,  or it  may be altogether  wanting45.  Unless these
 circumstances  be combined with some deficiency, or unusual
 conformation of the external parts or vagina, the peculiar
 organization is not known till after death.   It is, however,
 not uncommon for the external parts to be very small, when
 the uterus is of a diminutive size;  and when  it is altogether
 wanting, the  vagina is either very short, or  no traces of  it
 can be found.  In either of these cases,  no attempts should
 be made to discover a uterus by incisions, unless, from symp-
 toms of  accumulation of  the menses, we are certain that a
 uterus really exists.*
  The uterus may be double48:  in  this case there  is some-
 times a double  vagina, but generally only one ovarium and
 tube to  each uterus.  This conformation does  not prevent
 impregnation.
  The uterus  is sometimes divided into two, by a septum
 stretching across at the upper part of the cervix ;f or the os
 uteri is  almost, or altogether shut up,47 by a continuation of
 the lining of the womb or vagina, or by adhesion, consequent
 to ulceration, or by original conformation;  and in this last
 case, the substance of the  os uteri is sometimes almost car-
 tilaginous. The menses either come away more or less slow-
 ly, according to the size of the aperture, or are entirely re-
 tained when there is no perforation. As long as the menses
 are discharged, nothing ought to be done; but if they are
 completely retained, and violent  and unavailing efforts  made
 for their expulsion, an opening must, as  a matter of  neces-
 sity, be made from the vagina.   In such  cases, the  uterus

  * Nabothus mentions a rash operator, who undertook, by incision, to find
the uterus; but after cutting a little, he came to some vessels which obliged
him to stop.
  ~ Baill'.e-? Morbid Anatomy, chap, xix, 
77
has been tapped with success ;* but it has also happened, that
fatal inflammation has succeeded the operation.
  The vessels are sometimes enlarged; and I have seen the
spermatic veins extremely varicose, in an old woman who had
been subject to piles; but I do not know that any particular
inconvenience results from the veinous enlargement.

                     § 25. HYSTERITIS.

   The uterus is subject to inflammation; but in the  unim-
pregnated state, it is not common for  the  womb to  be the
original seat of acute inflammation.   After parturition, it  is
very frequently inflamed, and this will hereafter be consider-
ed.  Inflammation is discovered by pain in the  hypogastric
region, accompanied with tension, and the part  is tender  to
the touch; there  is acute pain  stretching  to the back and
groins; the  bladder is  rendered irritable; and acute fever
accompanies these symptoms.  Blood letting, purges, fomen-
tations, and blisters are to be used, as in other cases of peri-
toneal inflammation.   Wounds of the uterus are dangerous,
in proportion to the inflammation they excite.f
   Chronic inflammation of the cervix uteri is not uncommon.
The os uteri is open, soft, and tender to the touch.  The
cervix is not materially affected in size or hardness.  There
is a considerable discharge of white mucus which sometimes
becomes  puriform,  and  this is often mixed with blood;  or
there may be  very considerable uterine  hemorrhage.  The
patient feels pain in the uterine region, but generally com-
plains more of pain in some distant part of the abdomen, not
unfrequently near the liver.  There is no fever, but the pa-
tient becomes weak from  discharge,  irritation, and those
hysterical affections which may accompany the complaint.
   The warm sea-water  hip-bath, gentle saline purgatives,

  * The menses being retained, and great pain excited, they were let out
with a trocar by Schutzer.  Vide Sandifort, p. 69.
  -j- In one instance the woman was murdered, by thrusting a piece of glass
up the vagina; and Haller notices a fatal case, in which a piece of lead  was
thrust into the uterus. 
78
injection of decoction of hemlock, mild diet, and the use of
cicuta as an anodyne are useful at first;  and afterwards
when the symptoms are so far subdued, the use of the cold
sea-bath, bark combined with bitters, and mild injections of
vegetable astringents are  proper.   In  obstinate cases mer-
cury ought to be  tried, with a view of  altering the action of
the parts,

            «j 26. ULCERATION OF THE  UTERUS.

  The uterus may, from irritation, become  ulcerated like
any other part;  purulent  matter is discharged, the  woman
feels pain in coitu, or when the uterus  is pressed, and some-
times the finger can discover  the ulcer.  Simple ulceration
is very rare,  and, I apprehend, will always heal, by keeping
the parts clean with mild injections. Ulceration from mor-
bid poison is  more frequent.   Of this kind is the phagedena,
a most obstinate and  dreadful disease  of the womb, which
begins about its  mouth, and goes on,  gradually destroying
its substance, until  almost the whole of it be removed; and
sometimes it spreads to the neighbouring parts.   This dis-
ease is marked  by excruciating pain of the burning kind, in
the region of the uterus, copious foetid, purulent, or  sanious
discharge, alternating with some hemorrhage, small but fre-
quent pulse, wasting of the flesh, and  occasionally swelling
of the inguinal glands:  no tumour is felt externally,  but
the belly is flat.   Examination, per vaginam, discovers  the
destruction which  has taken place,  and how far it has pro-
ceeded.   It also ascertains, that the part which remains is
not enlarged.
  On inspecting the  body after death, the pelvis is gene-
rally  found filled with intestines, matted, and adhering to
the pelvis, and to one another.  In the  midst of the mass,
there are sometimes one or two simple  abscesses, containing
healthy pus.  On tearing out the mass, the uterus is discover-
ed to  be ate away all to the fundus, or a small  part of the
body.  The substance is very little thickened, but resembles
soft cartilage, with here and there small cysts, not larger 
79
than pin heads.   The  ulcerated surface is dark,  flocculent,
and has a dissolved appearance, whilst the substance in  its
immediate  vicinity is  vascular and livid.  The rapidity of
the destruction is various in different cases.  It is very diffi-
cult to cure this ulcer, or even to check its progress.  Some-
times mercury has effected a cure, either by itself, or com-
bined with cicuta; or hyocyamus, or other narcotics,  have
been  given alone.  Nitrous  acid  occasionally  gives relief,
and,  when greatly diluted, forms  a  very proper injection.
A very weak solution  of nitrate of silver, is also a good topi-
cal application.  Should  the pain be great,  tepid decoction
of poppies, or water with the addition of tincture of opium,
will be  of service as an injection.  Fomentations to  the
lower belly,  and friction with camphorated spirits on  the
back, also  give relief; but very frequently opium, taken in-
ternally, affords the only mitigation of suffering, and  the
quantity required is often great
   There is another kind of ulcer,  which attacks the cervix
and os uteri.  It is hollow,  glossy, and  smooth, with hard
margins;  and the cervix, a little beyond it, is indurated,  and
somewhat  enlarged, but the rest of the uterus  is healthy.
The discharge is serous, or  sometimes purulent.   The pain
is  pretty  constant,  but not acute; and  the progress is
generally slow,  though  it ultimately proves fatal, by hectici
In this, and all other diseases of the uterus, the morbid irri-
tation generally excites  leucorrhoea,  in  a greater or less de-
gree ; but  examination  ascertains the  morbid  condition of
the part.   Although this disease be very different in its  na-
ture from the former, yet the mode of treatment is very much
the same.   Material benefit may  he  derived from the warm
salt-water bath, and  the regular  use of a solution of some
saline purgativ e, or a laxative mineral water, such as that of
Harrowgate  or of Cheltenham.   This is especially  the
case, when  the ulcer is small,  or  when the part is only
indurated, ulceration  not having yet taken place.  In  this
stage,  the cervix is  felt hard and  sensible to  the touch,
and there is leucorrhoea, and  pain in  the uterine region.
A gentle mercurial course is occasionally of service.  Some 
80
 may consider  this disease as  a species of cancer, but the
 ulcer is never fungous.
   Excrescences of a firm structure, and broader at the ex-
 tremity than at the attachment, may spring from theos uteri,
 and generally, I apprehend, originate  from a lobulated or fis-
 sured state of the parts.  It bleeds readily and profusely, but
 when it is not irritated, the discharge is serous and so great,
 that thick folds of cloth are soon wet as if the liquor amnii had
 been coming away.  It is evident that astringents cannot ef-
 fect a cure, as they  do not alter  the nature of the substance
 which secretes.  If a ligature could be passed so as to destroy
 the circulation in the excrescence, a cure might be expected.
 When this cannot be done we can only palliate symptoms.
   Venereal ulceration may, although the external  parts be
 sound, attack the uterus, producing a sense of heat with pain.
 There is at first,  very little discharge, and this  consists of
 mucus; but if the disease be allowed to continue, foetid puru-
 lent matter comes away. The ulcer is at first small, and there
 is no hardness about the os uteri, nor is it perceived to be di-
lated; but it is painful to the touch, and sometimes bleeds after
coition.   The purulent discharge appears earlier than in can-
cer, but the health for a time is  not affected.  Then the ulcer
spreads, and mayjdestroy a great part of the womb and blad-
der, and occasion  fatal hectic.  The history of the patient
may assist the diagnosis.  The  cure consists in a course of
mercury,  which I have always found produce a good effect
soon after the commencement.*

                   § 27. SC1RRO-CANCER.

   Scirro-cancer generally, if not  always, begins in the cervix
 uteri.  It may take place in the prime of life, but is most fre-
 quent about the time of the cessation of  the menses.   It be-
gins with a feeling of heaviness  or heat, and darting pains
 about the hypogastrium, aching in the back, dull pain  about
 the upper and inner part of the thighs, with a sense of bearing-

   * Vide Med. Comment. Vol. XIX. p. 257.—Pearson on Cancer, p. 119. 
81
down, together with dysuria and mucous discharge with the
urine; glowing heat, or sometimes stinging pain betwixt the
pubis and sacrum, with itchiness of the vulva.   There is from
the first, a leucorrhoeal discharge.  The patient  is troubled
with flatulence, heartburn, and sometimes with vomiting, and
cutaneous eruptions from sympathy with the stomach.   The
general health suffers, the countenance becomes  sallow, the
pulse quickens, the strength declines, and the body wastes. If
the menses have  not entirely ceased, they become irregular
and profuse.  Presently a foetid, purulent, or bloody matter is
discharged, which  indicates that a cyst has  burst, and the
disease  has proceeded to ulceration.   Repeated hemorrhages
are now apt to take place, and hectic is established.   The
pain is constant, but subject to frequent aggravations, and
the  weakness  rapidly increases.  At length the pain, fever,
want of rest, discharge, and loss of blood, completely exhaust
the patient; and  death terminates at once both her hopes and
sufferings.
   At fii ;t, by examination per vaginam, the uterus is felt as
if it  were enlarged; the cervix is thickened, and the os uteri
hard, open, irregular, and more sensible to the touch, a cir-
cumstance which causes pain in coitu.  The cervix is either
totally indurated, or has imbcdcd in it a hard tumour, which
may acquire considerable size.  A little blood is often observed
on the finger after an examination.  In some time after this,
the os uteri is turgid, as if it contained a small cyst, and pre-
sently it is felt to be ulcerated  and fungous;   but sometimes
the fungi are less perceptible, deep excavations being formed,
the sides of which, however, after death, are found to be fun-
gous.
   The cervix uteri is sometimes considerably enlarged before
ulceration takes place; but, in  other cases, the augmentation
is much greater after ulceration, than before it.48   If the dis-
ease originally formed a distinct tumour in the cervix, that
 tumour may become as large as the first, adhering to the pel-
 vis so that it cannot be moved, and  pressing  so much on the
rectum or bladder, according to its situation, as  to give rise
   VOL.  I.                          M 
83
to much obstruction in the evacuations from either of these
parts.   The uterus itself is seldom much enlarged in genuine
cancer, but it is possible whilst the cervix is affected with this
disease, that the body  of the uterus may have undergone a
different morbid change.  The tubes and ovaria have  been
said to participate in the disease.*
  In some patients the disease proves fatal very early if there
be profuse hemorrhage;  in  others, great devastation takes
place, and  the bladder49  or rectumf  are opened.   In  most
cases, the vagina becomes hard and thickened, or irregularly
contracted with swelled glands, in its course.
   On examining the diseased part after death, it is found to
be thickened and indurated, and  sometimes its cavity is en-
larged. The substance is of a whitish or brownish colour, in-
tersected with firm membranous divisions ; and betwixt these
are numerous small cysts, the coats of which are thick and
white.   They contain a vascular substance, which,  when
wiped clean, is of a light olive colour.  In proportion as the
disease advances, some of the cysts enlarge, and thicken still
more;  and,  when opened, are  found  to contain a bloody
lymph, and to have the inner surface covered with  a spongy
vascular substance, similar to that which  fills the small cysts,
but rather more resembling fungus. Presently some of these
cysts augment so much as to resemble abscesses, though they
are not properly  speaking abscesses, and soon afterwards
they burst.
   It is extremely rare for a cyst to burst, or fungi to  shoot
out on the exterior surface of the uterus, which is covered
with the peritoneum.   The position of the uterus is often na-
tural, but sometimes it is inclined to one or other side, or
approaches to a state of retroversion.
   As this disease is apt to  be mistaken  for  fluor albus, me-
norrhagia, nephritis, or dyspepsia, it is  of great importance
that the practitioner should be  on his  guard, and examine

  * Vide Prochaska Annot. Acad. fasc. 2d.
  | M. Tenon found, in a case of cancerous uterus, all the posterior part of the
womb ulcerated, the rectum diseased, and a communication formed betwixt
♦hem. 
88
 early and carefully per vaginam. Much harm is done by the
 use of astringent injections meant to cure the supposed fluor
 albus.
   This is .a very hopeless disease, but still much may be done
 to check  its progress,  or mitigate its symptoms.  When un-
 easy sensations, about the cessation  af the menses,  indicate
 a tendency  to  uterine  disease, we  find advantage from the
 insertion of an issue in the arm or leg, the use of laxative
 waters,* and spare diet,50 and flannel dress.  If by examina-
 tion we  discover any alteration  in the shape, size, or sen-
 sibility of the  womb, the most  effectual treatment  we can
 have recourse to, is  the daily  use of from  two to  three
 drachms of  sulphas potasse cum sulphure;  and if this lose its
 laxative effect, one or  more aloetic pills may be added.  The
 warm sea-water bath  every night is likewise of great service.
 When there is much sense of throbbing, heat, or pain about
 the pelvis, cupping glasses applied to the back are of service,
 and the patient should keep in a horizontal posture as much
 as possible. When the disease has ev idently taken place, we
 must still persevere in the same plan,  and  avoid such causes
 as excite action in general, for the longer we can keep a scirr-
 hus from going into a state of activity  and  inflammation, the
 longer do we keep the disease at  bay. It is  therefore scarcely
 necessary to add, that if the patient be married she must not
 sleep with her  husband. We keep the parts clean,  by inject-
 ing tepid  water, or decoction of  camomile with hemlock or
 opium; allay pain by  anodynes; attend to the  state of the
 bowels; and  coriect   stomachic affections by bitters, and
 other suitable remedies.  Mercury, iron, arsenic, sarsaparilla,
 aconitum, cicuta, &c.  have been given internally, but have
 seldom  a good  effect.   It has  been proposed to produce, with
 an extracting instrument, a prolapsus uteri, and then cut off
 the protruded womb;  hut this operation is not  likely to be
 resorted to.

  * Rocderer relates a case where scirrhous swelling was cured by keeping
the bowels open, and giving every third evening, from ten to twenty grains
of calomel.—Haller Disp. Med. Tomus IV. p. 670. 
84
                     § 28. TUBERCLES.

  Tubercles  are common  in  the  uterus, insomuch that M.
Bayle says, that in seven months he met with fourteen cases.
They consist at first of fleshy matter, but in  process of time
become more like cartilage, or even bony, especially on their
surface.*   On examining the tumour, it is  sometimes found
to be intersected with membranous divisions;  and a section
always exhibits a pretty compact granulated surface without
vessels.  A tubercle may take place in one  spot, and all the
rest of the  uterus may be healthy, and  nearly of the natural
size.  The magnitude of the tubercle is very variable, and it
may either project on the outer surface, or within the cavity
of the womb; and in this last case, the adhesion to  the sur-
face of the cavity is generally slightf after the tubercle has
fully projected.   In this it differs, even in its most detached
state, from polypus,  which is attached not by cellular sub-
stance, but by a pedicle. Sometimes there are a great  many
tubercles, which are  found in various stages of projection,
and the uterus may become greatly enlarged, and very irre-
gular externally.:}: I have never seen the tubercle end in ulcer-
ation, nor the substance of the  uterus, although  thickened,
have abscess formed in it.  The  effects of this disease are
chiefly mechanical and often altogether trifling; at other times,
we have a pain in the hack, and sometimes in the hypogas-
trium, which is swelled, hard, and irregular, if there be much
enlargement of the womb,  dyspeptic symptoms, leucorrhoea,
and at length feverishness and gradual  loss  of strength. The
progress is generally slow, unless the cervix uteri, which is
always  sound  with regard to this disease, be affected  with
phagedena or cancer,  or unless simple  inflammation be ex-
cited by pressure on  some  neighbouring part.   Sometimes
one or more tubercles are thrown off, with pains like those of
labour.
  * Sandifort Obs. Anat. Path. lib. I, cap.viii.—Bayle in Jour, de Med. Tome
V.—Murray de Osteosteamate, p. 14. et seq.
  | Baillie's Morbid Anatomy, chap. xix.
  $ I have found the uterus as large as a  child's head of a year old, with manv
projections and tubercles.—Peyer has a similar case, P?rerg. Anat. p. 131. 
85
  Menstruation may be  rendered irregular, but sometimes
continues unaffected.  In the very last case I saw, the size of
the womb was large, and two thick hard ridges could be felt
in the abdomen, extending obliquely  up by the  sides of the
umbilicus.   The lower and anterior  part of the  womb  was
large, and filled the brim of the pelvis like a child's head;
whilst near the promontory of the sacrum,  the os uteri was
felt  healthy though compressed.  This woman had no com-
plaint except what proceeded from bulk; the bladder contrary
to expectation, was not in any degree affected;  the stools
easy, and menstruation regular.
   This disease can only be confounded with diseased ovarium,
but it is harder when felt through the belly, not so moveable
at first, and a difference may generally be felt per vaginam.
 It maybe  combined with tumour of the ovarium.
   No remedy has  any power  in removing the diseased sub-
 stance,  and therefore our treatment consists in  palliating
 symptoms, especially in  attending to  the bladder and bowels.
 We also  upon general  principles keep down  activity, and
 guard against inflammatory action.   The antiphlogistic regi-
 men should  be pursued in moderation.   The bowels espe-
 cially should be kept  open, and every source of irritation
 removed.  The tepid bath  is  useful.  Women  may live  a
 long time, even although these tumours acquire considerable
 magnitude.
   Sometimes the whole uterus is a little enlarged, and changed
 into a white cartilaginous substance, with a hard irregular
 surface; or it may be enlarged and ossified,31 and these ossi-
 fications may take place even during pregnancy.*   Steato-
 matous  or atheromatous tumours of  various sizes, j- or sarco-
 matous^: or scirrhus-like§ bodies, may  be  attached to the
 uterus.  All these diseases sometimes at first give little trouble.

   • Vide Observ. on Abortion, 2d. edition, p. 37.
   f Vide Rhodius, cent. HI. ob. 46.—Bcehtner Obs. Anat. fasc. 2d.—Stoll Ra-
 tio Med. part. II. p. 379.
   jVide Friedus, in Sandifort's Observ. lib. I. c. viii. and a case by Sandifori
 himself, where the tumour adhered by a cord, lib. IV. p.  113.
   § Beader Obs. Med. ob. 29. p. 170. 
86
 Even their advanced stage  has no  pathognomonic mark, by
 which they can be discovered, as they produce the usual effects
 of uterine  irritation.   I must also add, that they are very
 little under the power  of medicine.   The most we can do, is
 to palliate symptoms; by which, however, we greatly melio-
 rate the condition of the patient.

                 § 29. SPONGOID TUMOUR.

   The uterus is  more frequently affected with spongoid tu-
 mour than is  supposed; many cases of that disease  passing
 for cancer.  This is a firm, but soft and elastic tumour, the
 substance  of  which bears some resemblance to brain, and
 contains cysts of different  sizes,  filled with  red  serum  or
 blood, or bloody  fungus according to circumstances.   There
 is no certain way of distinguishing or discovering this dis-
 ease in its  early  stage, for it  often  gives very little  trouble,
 and any symptoms which  do occur, are common to other
 diseases  of the womb.   The tumour, however, enlarges, and
 can at length be felt through the  abdominal parietes.  It is
 soft and elastic, and on the first application of the hand,
 feels very like a  tense ventral  hernia.  There may  be two
 or more  tumours of unequal sizes  in  different parts of the
 belly, which can be felt to have a conncctioij with each other
 and may frequently be traced to  the pubis.   Per vaginam,
 the state varies in different cases; but  by pressing on the
 external  tumour at  the same time,  we discover its  connec-
 tion with the womb below.   We may find ulceration, or  the
 os uteri soft, and  tumified,  and opened, or the posterior lip
 may be lost in  a  soft elastic tumour, and quite obliterated,
 whilst the anterior one, after  a pretty careful  examination,
is felt high up,  and apparently sound.  Pressure  seldom
gives pain, till  ulceration is  about to take  place,  and no
blood is  usually observed  on  the finger  after examination,
unless a fungus has protruded. So  far as I have seen, fluor
albus is a rare attendant on this disease in the early stage,
and little inconvenience is at  that period produced,  except
what results from pressure on the bladder, causing strangury 
87
or suppression  of urine, attended with  fits  of considerable
pain, like those excited  by a stone.   The complexion is sal-
low, but the health is tolerably  good,  till ulceration or  in-
flammation take place.  Ulceration may happen in  different
parts ; lFmay be directed to the vagina, and  then we  have
foetid  bloody discharge, or sometimes considerable  hemorr-
hage, and ultimately the bladder or rectum are involved in
the destruction : or bloody fungus may protrude from  the
exterior surface of the uterus into the general cavity of the
abdomen, and at  length the  bowels become inflamed and
glued together: or the tumour  may adhere  to the parietes
of the abdomen, and the  skin after becoming livid  gives
way, and a fungus shoots out from the belly.   As the disease
advances towards  ulceration,  the health is  more impaired,
hectic  fever  takes place, and the  patient  is  ultimately
cut off.
   The whole treatment, I  am sorry to  say, consists in pal-
liating such sympathetic or local symptoms as may arise in
the course of the disease.

   [§ 30. CAULIFLOWER EXCRESCENCE FROM THE OS UTERI.

   Dr. John Clarke of London, considers himself as the first
writer who has taken notice of this disease.
   The cauliflower excrescence, according to him, arises al-
ways  from some part of the os uteri.  As several of the early
symptoms are not very distressing to the patient, the tumour
in the  beginning is rarely the subject  of medical  attention.
The first changes of structure have  therefore not  been  ob-
served.  In general the tumour is not less than the size of a
blackbird's egg.  At  this period it makes an  irregular pro-
jection, and  has a base as broad  as  any other part  of it,
attached to some part  of the os uteri.  The surface has a
granulated feel, considerable  pressure on  handling it, does
not occasion  any sense of pain.  The remainder of the os
uteri, will at this period, be found to have  no sensible altera-
tion of structure.  By degrees more and more of the circle ot
the os uteri, and the external part of the cervix uteri, become 
88
 affected with the same morbid alteration of slruct.iiv, till at
 length the whole is involved in the disease.
   The growth is in some cases slow, but in others rapid, so
 that in the course of nine months, it will sometime^cntirely
 fill up the cavity of the pelvis, and block up the entrance of
 the vagina.
   As the bulk of the tumour increases, the granulated struc-
 ture becomes more evident, and is found to resemble very
 much the structure of the cauliflower, when it begins to run
 to seed.  In most cases it is of a brittle consistence, so  that
 small parts of it will come away, if it be touched too rudely;
 and such pieces appear to be very white.  Sometimes, though
 no violence  has been used, small portions  of a white sub-
 stance  come away with the urine of the patient, and in the
 discharge from the vagina.
   When the tumour has arrived at a size greater than that
 of the  os uteri, it spreads very much, and  as the  base is
 the smallest part of the tumour, persons, not conversant with
 the disease, have often mistaken it for polypus.  A little at-
tention however, to the feel of the tumour, and  the breadth of
its base, will be sufficient to distinguish them.
   In the very early  state of the cauliflower excrescence, a
 discharge from the vagina  takes place like fluor  albus ; it
 very soon becomes thin and watery, and is sometimes tinged
 with blood. In most cases upon coming away, it is apparently
 as thin and transparent as  pure water;  but  the  linen on
 which it is received, when dry becomes stiff, as if it had been
 starched.  The quantity of the discharge  when the excres-
 cence is large, will sometimes be sufficient to wet thoroughly,
 ten or twelve napkins in a day.  Now and then a discharge
 of pure blood occurs.   When this ceases the discharge of thin
 transparent  fluid re-appears.   An offensive odour generally
 accompanies the discharge,  which  is greatest when there
 has lately been an evacuation of pure blood, or of the cata-
 menia.  Mucus has  sometimes been found in  the  fluid dis-
 charged, but pus never.
   Patients  labouring under this disorder, are variously af-
 fected  with regard to pain.  In the commencement none is 
89
felt; but during its  progress pain is in some cases experi-
enced.  Generally in  the advanced stage, the patient feels
pain in the back, and in the direction of the round ligaments
of the uterus.   The  pain is not described  to be lancinating,
as in cancer,  and is  without  any sensible  aggravation by
paroxysms; but on the whole, it is most felt after the patient
has been in a perpendicular attitude.
  The disease  attacks  indiscriminately women of all  ages.
The patient is  destroyed by the debility  occasioned by the
profuse discharge ; and in the course of the disease, she al-
ways becomes  extremely  emaciated from the  above cause.
It always  terminates fatally.  Respecting the treatment of
this disease, nothing satisfactory can be offered.   All stimu-
lating substances either in diet or medicine, seem to aggra-
vate it, by increasing the discharge; and no astringents in-
ternally given  appear to lessen it.  The only means from
which any benefit has been derived, is  the injecting into the
vagina three times a day, a strong decoction of cortex gra-
nati, or of cortex quercus, in which alum is dissolved in the
proportion of eight or ten grains to every ounce of it.  This
has the double  effect of lessening the quantity of the dis-
charge, and rendering it less offensive.   The use of anodynes
must be resorted to for the mitigation of pain, and the occa-
sional symptoms of suppression of  urine, and  costiveness,
 are to be relieved by the use  of a  catheter and mild laxa-
tives.^)]

                     § 31. CALCULI.

   Earthy concretions are sometimes formed  in the cavity
of the uterus,  and  produce the usual  symptoms of uterine
irritation;  and Vigarous considers them as very apt to excite
 hysterical affections.   As in the  bladder of urine, the con-
 stant presence of a calculus tends to thicken its coats; so the

  (s) Vide a paper on the Cauliflower excrescence from the os uteri, &c. by
John Clarke, M. D. Transact, of a Society for the improvement of Medical
and Chirurgical knowledge, 1812.  And new Medical and Physical Journal,
July, 1812.
    VOL. I.                          * 
90
irritation of a stone in the uterus can excite a disease of the
substance of the womb, and produce ulceration, which  may
extend to the rectum.  The disease in  question is very rare,
and  can only be discovered by feeling the concretion  with
the finger, or a probe introduced within the os uteri, which
is sufficiently open to  permit of this examination.  Nature,
it would appear, tends to expel the substance,52 and we ought
to co-operate, if necessary, with  this tendency.  We  must
also  relieve suppression of urine,* or any other urgent symp-
tom which may be present.

                      § 32. POLYPI.

   Polypous tumours are not uncommon, and may take place
at any age; they are  not, however, often met with  in  very
young women.  They always affect the health, producing
want of appetite, dyspeptic  symptoms, uneasiness in  the ute-
rine  region, a variable swelling of the abdomen, aching pain
in the back, bearing-down pains, tenesmus, and a dragging
sensation at the groins.   When these  symptoms have  con-
tinued some time, the strength is impaired, and the pulse be-
comes more frequent.  At first, there is generally a mucous
discharge; but at length blood is discharged, owing to the
rupture of some of the veins  of  the tumour} or sometimes
from the uterine vessels  themselves and the permanent dis-
charge not  unfrequently becomes foetid.  Mr. Clark, in his
late work, very properly notices, that the blood often coagu-
lates over the  polypus, and comes off like a ring.   These
symptoms,  however,  cannot point out,  to  a certainty, the
existence of a polypus: we must have  recourse to examina-
tion, by which we discover that the uterus is enlarged, its
mouth open, and a firm, but generally, moveable body within
it.  If the  os uteri have not  yet opened so as to admit the
finger, the diagnosis must be incomplete.
   By degrees the polypus descends from the uterus, or pain-
ful efforts are made more quickly to expel the tumour, the
• This proved fatal in a child of five years old 
91
body of which passes  into  the vagina53,  and  sometimes
occasions retention of urine.54  The pedicle remains in utero,
and the bad consequences  formerly produced still continue,
except in a few cases, where the tumour has dropped off,*
and the patient got well.   In such cases, it has been sup-
posed that the os uteri acted as a ligature;  and to the same
cause is attributed the bursting of the veins, which produce,
in  many instances, copious  hemorrhage.   But although
hemorrhage be most frequent after the polypus has descend-
ed, yet it  may take place whilst it remains entirely in utero.
   It sometimes happens that the uterus becomes partially
inverted,!  before  or after the polypus is  expelled into the
vagina; and this circumstance does not seem to depend al-
together on the size of the polypus, or its weight.  Polypus
may also be accompanied  with prolapsus uteri.:}:
   Polypi may  be  attached to any part of  the womb, to its
fundus, cervix, or  mouth ; and  it has  been observed,  that
there is less tendency to hemorrhage, when they are attach-
ed to the cervix, than either higher up, or to the os uteri it-
self.  If there be an union betwixt the os uteri and the tu-
mour,§ or if they be in intimate contact, polypus, may pass
for inversio uteri; but the history of the case, and attentive
examination, will  point out the difference, which will be no-
ticed when I come to consider inversion and prolapsus of the
uterus.  Here  I may only remark, that the womb is sensi-
ble, but the polypus is insensible to the touch, or to irrita-
tion ;  but  it should be  recollected, that if the polypus be
moved, sensation can be produced by the effect on the womb.
  Polypi are of different kinds.   The most frequent kind is
of a firm semicartilaginous structure, covered with a produc-
tion of the inner membrane of the womb; and indeed it
seems to proceed chiefly  from a morbid change of that mem-

  * Mem. de l'Acad. de Chir. Tom. m. p. 552
  f Vide case by Goulard, in Hist, de l'Acad. de Sciences, 1732. p. 42.—-Dr.
Denman, in his engravings, gives two plates of inversion, one from Dr. Hun-
ter's Museum, the other from Mr. Hamilton.
  % Med. Comment. Vol. IV. p. 228.
  «j Mem. of Med. Society in London, VoL V. p. 12. 
92
brane, and a slow subsequent enlargement ol  the diseased
portion; for the substance of the uterus itself  is not nece>
sarily affected.  The enlargement  is  generally greatest at
the farthest  extremity of the tumour, and  least  near the
womb; so that there is a kind of pedicle formed, which some-
times contains pretty large blood vessels,  and the tumour is
pyriform.  But if the membrane of the uterus be affected to
a considerable extent, and especially if the substance of the
uterus be diseased,  then the base,  or  the attachment of the
polypus, is broad.
  The vessels  are  considerable, especially the veins, which
sometimes burst.   In every instance, I believe, if the patient
live long, the tumour is disposed to ulcerate.  The ulcer is
either superficial  and watery, or it is hollowed out, glossy,
and has hard margins, or it is fungous.  The two last varie-
ties are most frequent.
  Some polypi are soft and lymphatic, but these are rare in
the uterus.   Some are firm  without, but contain gelatinous
fluid, or substance like axunge within.  Some are solid, others
cellular, with considerable  cavities.
  Polypi are hurtful at  first, by the irritation they give the
uterus,  and  by sympathetic derangement of the abdominal
viscera.   In a more advanced stage, they are attended with
debilitating and  fatal hemorrhage, and often with febrile
symptoms, especially if the discharge be offensive, or the
surface ulcerated. Notwithstanding the existence of polypus,
however,  it is possible for a woman to  conceive.*
  Various means have  been proposed for the removal of
polypi, such  as excision, caustic, or tearing them away; but
all of these are dangerous and uncertain ; and  therefore the
only method now practised, is  to pass a ligature round the
base or footstalk of the  polypus, and tighten it so  firmly as
to kill the part.   The ligature consists of a firm silk cord, or
a well twisted hemp string, properly rubbed with wax, or
covered with a varnish of elastic gum.  This  is better than

  * In M. Guiot's case, the polypus was expelled.—M. Levret adds other
cases, Mem. de l'Acad. de Chir. Tom. HI. p.  543. 
93
a silver wire, which is apt to twist or form little spiral turns,
which  impede the operation, and may cut the tumour.  It is
difficult to pass the ligature properly, if the polypus be alto-
gether in utero ; and it ought not even to be attempted, if the
os uteri be not fully dilated.   On this account, if the symp-
toms be not extremely urgent, it is proper to delay until the
polypus have wholly,  or in part, descended into the vagina;
and when thte has  taken place, no good, but much evil  may
result from procrastination.   It  has even been proposed to
accelerate the descent of the polypus,  and produce an inver-
sion of the uterus.*
   A double canula has  been long employed for  the  purpose
of passinrr the ligature, one end of which was brought through
each tube;  and the middle portion forming  a loop, was car-
ried over the tumour, either with the  fingers, or the assist-
 ance  of a  silver  probe with  a small fork at the extremity.
 By practice and dexterity, this instrument may doubtless be
 adequate to the object in view; but without these requisites,
the operator will be foiled, the ligature twisting or going past
the tumour, every attempt giving much  uneasiness to the
patient, and not unfrequently, after many trials and much
 irritation, the patient is left exhausted with fatigue, vexation,
 and loss of blood.  This is very apt to happen, if the polypus
 be so large as to fill the vagina.   The process may be facili-
 tated by employing a  double  canula, but the tubes made  to
 separate and  unite at  pleasure,! by means of a connecting
 base, or third piece,  which can  be adapted to them like a
 sheath. The ligature is passed through the tubes, which are to
 be placed close together, and  no loop is to be left at  the mid-
 dle.  They are then to be carried up along the tumour, gene-

   * M. Baudelocque observes, " Nous regardions ce  renversement neces-
 saire  pour obtenir la guerison de  la  malade."  Recueil Period. Tome
 IV. p. 137.
   f An instrument of this kind is proposed by M. Cullerier, and is described ■
 by M. Lefaucheux in his Dissert, sur lesTumeurs circonscrites et indolentsdu
 tissu cellulaire de lamatrice et du vagin.(*)
   (0 For a plate and description of this instrument, the reader is referred to
 Cooper's Surgery, Philadelphia edition. 
94
 ually betwixt it and the pubis.   Being slid up along the finger
 to the neck of the polypus, one of them is to be firmly retained
 in its situation by an assistant,  and the other carried com-
 pletely round the tumour, and brought again to meet  its fel-
 low.   The two tubes are then to be united by means of the
 common base.   The ligature is thus made to encircle the
 polypus, and, if necessary, it may afterwards be raised higher
 up with the finger alone, or with the assistance of a forked
 probe.
  When the ligature is placed in its proper situation, it is to
 be gradually and  cautiously tightened,  lest any part of the
 uterus which may be inverted be included.  If so, the patient
 complains of pain, and sometimes vomits; and if these symp-
toms were  neglected, and the ligature kept tight, pain and
 tension of the hypogastrium,  fever  and convulsions would
take place, and in all probability the woman would die.*5  In
some instances, however, the womb has been included with-
 out a fatal effect.56
  Even when the  uterus is  not  included, fever may succeed
the operation, and be accompanied with  slight pain in the
belly;  but the symptoms are mild, and no pain is felt when
 the ligature is first applied.
  If the first tightening of the ligature, by way of trial, give
 no pain, it is to be drawn firmly, so as to compress the neck
 of the  tumour sufficiently to stop the circulation.  It is then
to be secured at the extremity of the canula; and  as the part
 will become less  in  some time, or may  not have been very
 tightly acted on at first, the  ligature is to  be daily drawn
 tighter, and in a few days will make its way through.   After
 the polypus is tied, it is  felt to be more turgid, and harder;
 and if visible, it is found of a livid colour, and presently exhales
 a foetid smell.   These are  favourable signs.  The diet is to
 be light, and all irritation avoided during the cure. The bowels
 and bladder must be  attended to, and if there be sympathetic
 irritation of the  stomach, soda water is  useful, with  small
 doses of laudanum.{w)
  (k) The reader is referred to the following interesting paper on the subject
of the preceding article, viz, " Memoir sur l'organization des Polypes Uterins 
95
                § 33. MALIGNANT POLYPE.

  There are other tumours still more dangerous,* as they end
in incurable ulceration, and are so connected with the womb,
that the whole of the diseased substance cannot be removed.
These always adhere by a very broad base,57 and cannot be
moved freely, or turned round like the mild polypus.  They
are sometimes pretty firm, but generally they are  soft and
fungous,  or may resemble cords  of clotted blood.  When
dissected, they are  found  to  be very spongy, with cells or
cavities of various sizes; sometimes they are laminated. These,
which have been called vivaces by M. Levret, are always the
consequenee of a diseased state of the womb; but they are not
always, as that author supposes, vegetations from an ulcerated
■ surface.  They do, however, very frequently spring from that
source, being generally of the spongoid nature.  Occasionally
they have been mistaken for a piece of a retained placenta, and
portions of foetid fungi have been torn away, in attempts to
extract the  supposed placenta, or ovum.
   The hypogastric region  is tumid, and painful to the touch,
even more so than the tumour itself, which, felt per vaginam,
is less sensible than the womb.   Sometimes little pain is felt
in this disease,  except when the womb is pressed.  The tu-
mour often bleeds, discharges a sanious matter, and may shoot
into the vagina: but in this it differs  from polypus, that it
comes into  the vagina generally by  growth, and  not by ex-
pulsion  from the womb, which does not decrease or become
empty as the vagina fills.  The treatment must be palliative,
for extirpation does not  succeed, the growth  being rapidly
renewed.  Opiates and cleanliness are most useful.

et ^application de cette connoisance a la pratique chirurgicale, par P. J. Roux
in tome 3ieme des OZuvres chirurgicales de P. J. Desault par Xav. Bichat. p.
370.
  * Vide Mem. de l'Acad. de Chir. Tome III. p. 588—Herbiniaux Observa-
tions, Tome Lob. 39.—Baillie's Morbii Anatomy, eaap. xix—Vigarous dc
Malad, des Femmes, Tome I. p, 42 5. 
96
                         § 34. MOLES..

    Moles* are fleshy or bloody substances contained within
  the cavity of the uterus.  They acquire different degrees of
  magnitude, and are found of various density and structure."
  They may  form in women who have not borne children,! or
  they may succeed  a natural delivery,^ or follow an abortion,
  or take place in a diseased state of  the  uterus.§  It is the
  opinion of many, that these substances are never formed in the
  virgin state, and no case that I have yet met with contradicts
  the supposition.  The  symptoms produced by  moles are at
  first very much  the  same  with those of pregnancy, such as
  nausea, fastidious  appetite, enlargement of the breasts, &c.;
  buf the belly enlarges much faster, is softer, and more variable
  in size than in pregnancy, being sometimes as large in the se-
  cond month of the supposed, as it is in the fifth  of the true
  pregnancy.   Pressure  occasionally gives pain.   Petit  ob-
  serves, that the tumour seems to fall down when the woman
  stands erect, but this is not always the case.  It must be con-
  fessed, that the symptoms  are at first, in most cases, ambigu-
  ous,  nor can we for some time arrive at  certainty.  In ge-
  neral, the mass  is expelled  within three  months, or before
.  the usual time of quickening in  pregnancy; and  more or
  less hemorrhage accompanies the process, which  is very si-
  milar to that of  abortion, and  requires the same manage-
  ment. ||  Sometimes the expulsion may be  advantageously
  hastened, by extracting the  substance  with the finger;  but
  we must be careful not to lacerate it, and leave  part behind.
  If the mole be retained beyond the usual time of quickening,

    * Sandifort Obs. Path. Anat. lib. II. p. 78.—Schmid. de Concrement. Uteri,
  in Haller's Disp. Med. Tomus IV. p. 746.
    f La Motte, chap. vii.  Tliis chapter contains several useful cases, one of
  which proved fatal from hemorrhage.
    * Hoffman. Opera, Tomus, III. p. 182.—Stahl. Coleg. Casuale, cap. Ixxvi. p.
  797.
    «s With scirrhus of the uterus, Haller's Disp. Med. IV. p. 751 et 753.
#  || Puzos advises blood letting, Traite, p. 211.—Vigarous recommends eme-
  tics and purgatives, to  favour the expulsion, Tome I. p. 115. 
97
we find that the belly does not increase in the same propor-
tion as formerly, and the womb does not acquire the magni-
tude it possesses in  a pregnancy of so many months stand-
ing. There is also no motion perceived. Many of the symp-
toms of mole may proceed from polypus; but in that case,
the breasts are flaccid and the symptoms indicating preg-
nancy are much more obscure.   The os uteri is not neces-
sarily closed in a case of polypus; whereas in that of a mole,
if there have been no expulsive pains, it is generally shut.
   When a woman  is subject to the repeated formation of
moles, I know of no other preventive, than such means as im-
prove and invigorate the constitution in general, and the ute-
rus in consequence thereof.  This is of no small importance,
as a weak state of the uterine system predisposes to more for-
midable  diseases, and may be followed  by scirrhus of the
womb or of the breast.

                      § 35. HYDATIDS.

   Hydatids may also enlarge the womb, and these frequently
are formed in consequence of the destruction of the ovum at
an early period,59 or of the retention of some part of the pla-
centa, after delivery or abortion.  We possess no certain di-
agnostic :  when they are formed in consequence of coagula,
or part  of the placenta remaining in  utero,  the symptoms
must be  such as proceed from the bulk of the womb, or  from
its irritation, as if by a  polypus or mole.   The remarks in
the preceding section are therefore applicable here;  but in a
great majority of cases, hydatids are formed in  consequence
of the destruction of an ovum;  and accordingly, the symp-
toms  at first  are  exactly the same with  those of pregnancy.
These cease when the  ovum  is blighted, and the time when
this happens is marked by the breasts becoming flaccid, and
the sickness and the sympathetic effects of pregnancy going
off.   The conception remains, and the belly either continues
nearly of the same size, or, if it increase, it is  very slowly.
Menstruation does  not take place;  but there may occasion-
ally  be  discharges  of blood in different degrees, and there
   vol.  I.                         o 
98
always is at one period or other, a very troublesome discharge
of water,  so that cloths are  required, and even with these,
the patient is uncomfortable.  No motion is perceived by the
woman, and the size of  the belly and state of the womb  do
not correspond to the supposed period of pregnancy. In some
instances, the health does not suffer; in others, feverishness
and irritation are produced. After an uncertain lapse of time,
pains  come on, and the mass is discharged, often with very
considerable hemorrhage.  This expelling process may some-
times be advantageously assisted by introducing the hand to
remove the hydatids, or to excite the contraction of the womb;
but this must be done cautiously, and only when hemorrhage
or some other urgent symptoms occur. These must be treat-
ed on general principles.
  In some cases, milk is secreted after  the hydatids  are ex-
pelled.   In others, a smart fever, with pain in the hypogas-
trium, follows. It requires laxatives and fomentations.  When
hydatids form in  a blighted ovum, their number varies greatly
in different cases. In some, I have seen only a little bit con-
taining vesicles, often only the under part which had been for
some time detached in a threatened abortion.   In others, al-
most the  whole is changed,  and the mass much enlarged.
This,  I  presume,  is connected with jthe womb, by  the un-
changed portions alone; and therefore, in examining the in-
ner surface of such a uterus after the mass was expelled, we
should expect to find it more or less similar to the gravid state,
according to the greater or less change in the ovum. The re-
lative magnitude of the vessels  in the two states has not been
ascertained, few  opportunities being afforded of dissection in
this disease, (a;)

  (x)Ruysch in the first volume of his valuable works, has given two very
curious  and  accurate plates of  these  hydatids of the placenta or uterus.
There is also a representation of these vesicles in Baillie's plates of Morbid
Anatomy, executed with great truth and elegance. It is now generally con-
sidered by naturaUsts, that the hydatids found in the human body, are a sort
of imperfect animals; and as Dr. Bailhe has  observed, although there may
be some difference between them in simplicity of organization, this need be
no considerable objection to the  opinion, as life may be conceived to be at-
tached to the most simple form of organization. 
99
Sometimes there is only one  large hydatid,  or, at most, a
very few in the womb,  and the preceding remarks will also
be applicable, hi a great measure, to this case.  In the ad-
vanced stage, we find the belly swelled, as in pregnancy; but
the breasts are flaccid, and no child can be discovered in utero,
nor does the woman  perceive  any motion.   There may be
pain  in the abdomen, and obscure fluctuation is discernible.
The neck of the womb  is small, and the case much resembles
ovarian dropsy, except that the tumour occupies the region
of the uterus.  The duration  of this complaint  is uncertain;
but the water is at last discharged suddenly, and after making
some exertion.  The bag  afterwards comes away, and the
process is not attended with much pain.*  It is most prudent
to be patient; but if the symptoms be  troublesome, the fluid
can be drawn off by  the os uteri.   This disease,  a solitary
hydatid, is oftener combined with pregnancy, or with a mole,
than  met with alone.   The first combination60 is not uncom-
mon, and I have seen the hydatid expelled some  weeks before
labour.  Hildanus  gives an  instance  of the second, where
the ovum was converted into  a mole intimately connected to
the uterus, and complicated with a collection of fluid  to the
extent of  six pounds.   In this case, so much irritation was
given, as to exhaust the strength, and produce local inflam-
mation.

                 § 36. AQUEOUS SECRETION.

  A different disease from that described in the last section,
is an increased Secretion from the uterus itself,  accompanied
generally with symptoms of uterine irritation; and if the wo-
man menstruate, the menses are pale and watery. There may

  For further information on the subject of hydatids, particularly those of
the uterus, the student is referred to a paper by the editor, inserted m the
Eclectic Repertory, Vol. I. p. 499, and seq. Also to Monro's Morbid Anato-
my of the human gullet, stomach and intestines.  Edin. 1811. p. 255.
  * Hildanus, I think, relates the history of a woman who was supposed to be
pregnant, but, dwn nactu (urn maritt rem haberet, a sudden inundation swept
away her hopes. 
100
 be a constant stillicidium of water,* or from some obstructing
 cause  the fluid may be for a time retained,6* and repeatedly
 discharged in gushes; I do not know to a certainty, that this
 can take place without some organic affection of the womb, or
 some substance within its cavity.   At the same time, I have
 met with this where no hydatids were discharged, where the
 womb felt sound, and a cure was at last accomplished.  We
 must always examine carefully, for it may proceed from hyda-
 tids, or from disease, or excrescences about the os uteri.   If
 nothing can be discovered, we must proceed upon the general
 principle of improving the health, and injecting mild astrin-
 gents.   I  need scarcely caution the practitioner not  to con-
 found  a discharge of urine from an injury of the bladder, with
 this complaint.,f    ,


                        § 37. WORMS.

   Worms:}: have been found  in  the uterus, producing consi-
 derable irritation; and generally, in this case, there is a foe-
 tid discharge.   We can know this disease only by seeing the
 worms come away.  It is cured by injecting strong bitter in-
 fusions.         ■  .


                     § 38. TYMPANITES.

   Sometimes^ air is  secreted  by the uterine  vessels, and
 comes  away involuntarily, but not always quietly.  Tonics,
 and astringent injections, occasionally do good; and  as this

  * Hoffman mentions a woman who had a constant stillicidium, a pint being
discharged daily.  It at last proved fatal.   Opera, Tom. III. p. 326, and Tom.
I. p. 330.
  ■j- Vesalius, Tom. I. p. 438, says, that he found an  uterus containing 180
pints of fluid, and its sides in many places scirrhous.  I wish he may not have
mistaken the ovarium for the womb.
  * Vigarous Malad.  Tome I. p. 412.—Mr. Cockson mentions a case, where
maggots were discharged before the menstrual fluid. The woman was cured,
by injecting oil, and infusion of camomile flowers.  Med. Comment. Vol
III. p. 86.
  § Vide Vigarous' Maladies, Tome I. p. 401. 
101
disease rarely causes sterility, it is sometimes cured perma-
nently by pregnancy.  It is said, that the air is, in certain
cases, retained, and the uterus distended with it, producing a
tympanites of the uterus.

                   § 39. PROLAPSUS UTERI.

  The prolapsus, or descent of the uterus, takes place in va-
rious degrees.*  The slighest degree, or first stage has been
called a relaxation ; a greater degree, a prolapsus;  and the
protrusion from the external parts, a procidentia.  It is ne-
cessary to attend carefully to this disease,  to ascertain its
existence, as it may,  if neglected,  occasion  bad health, and
many uneasy sensations.   The symptoms at first, if it do not
succeed parturition are  ambiguous, as  some  of them may
proceed from other causes.  They are principally pain in the
back, groins, and about the pubis, increased  by walking, and
accompanied with a sensation of bearing-down.  There is a
leucorrhseal discharge, and sometimes the menses are increas-
ed in quantity.  In a more  advanced state, there is stran-
gury, or the urine is  obstructed,  and  the patient feels a
tumour or fulness toward the orifice  of  the  vagina,  with a
sensation as if her bowels were falling out, which obliges her
instantly to sit down, or to cross her legs as if to prevent the
protrusion. This is accompanied with a feeling of weakness.
There are also, during the  whole course of the complaint,
but especially after it has continued  for some time, added
many symptoms, proceeding from deranged  action  of the
stomach and bowels, together with a variety of  those called
nervous.   On this  account,  an inattentive practitioner may
obstinately consider the case as altogether hysterical, until
emaciation and great debility are induced.
   But  if the woman have been recently delivered, there is
less likelihood of the practitioner being  misled.  She feels a
 weight and uneasiness about the pubis and hypogastric re-
 gion, with an  irritation about the urethra and bladder ; and
  * Vide Memoir by Sabaticr, in 3d. Vol. of the Memoirs of the Academy of
Surgery. 
iOS
sometimes a tenderness in the course of the urethra, or about
the vulva.  A dull dragging pain is felt at  the  groins, and
when she stands or walks, she says she feels exactly as she did
before the child was born, or as if there were something full
and pressing.   Pains are felt in  the thighs, and the back is
generally either hot, or aches.   These  symptoms go off in a
great measure, when she lies down, though, in  some  cases,
they are at first so troublesome, as to prevent rest.   In some
instances, no pain is felt in the back; but whenever the pa-
tient stands, she complains of a painful bearing-down  sensa-
tion, or sometimes of pressure  about the urethra, or orifice of
the vagina.
  By examination, the  uterus is felt to be  lower down than
usual, and  the vagina always relaxed.  In certain circum-
stances, it prolapses, forming  a circular protrusion  at the
vulva.  Next, the 03 uteri descends so low as to project out
of the vagina.  In the greatest degree, or procidentia, the
uterus is forced  altogether out, inverting completely the
vagina, and forming a large tumour betwixt the thighs. The
intestines descend62 lower into the pelvis, and even may form
part of the tumour, being lodged in  the inverted vagina, giv-
ing it an elastic feel.   In  some instances,  this unnatural
situation of the bowels gives rise to inflammation.  The  uterus
is partially retroverted, for the fundus projects immediately
under the perinseum, and the  os uteri is directed to the an-
terior part of the tumour.  The orifice of  the urethra is
sometimes hid by the tumour,  and  the  direction  of the canal
is changed; for the bladder,  if it be not scirrhous, or distend-
ed with a calculus of large size, is carried down into  the pro-
truded parts*3; and a catheter  passed into it, must be direct-
ed downwards and backwards.  The procidentia is attended
with the usual symptoms of prolapsus  uteri,  and also with
difliculty in voiding the urine,  tenesmus,  and  pain  in the
tumour.  If it have been long or frequently down,  the skin
of the vagina becomes hard, like the common integuments,
and it very rapidly ceases to secrete.  Sometimes the tumour
inflames, indurates, and then  ulceration or sloughing takes
place. This  procidentia may occur in consequence  of ne- 
103
 glecting the first stage, and  the  uterus  is propelled with
 bearing-down pains;  or it may take place all at once, in
 consequence of  exertion, or of getting up too soon after de-
 livery.   It may also occur during pregnancy, and even dur-
 ing parturition.  Sometimes it is complicated with stone in
 the bladder,64 or with polypus  in the uterus.*
   Some have, from theory, denied, the existence of prolap-
 sus,6* and others have disputed wiiether the  ligaments were
 torn or relaxed. There can be little doubt, that when it oc-
 curs speedily after delivery, it  is owing to the weight of the
 womb,  aud the  relaxed  state  of the ligaments and vagina.
 From these causes, getting up  too soon into an erect posture,
 or walking, may occasion prolapsus, particularly in those who
 are weak or phthisical.  When it occurs gradually in the un-
 impregnated state, it is rather owing to a  nclaxation of the va-
 gina, and parts in the  pelvis, than elongation of the round
 ligaments.  By experiments made on the dead subject, we
 find,  that more resistance is afforded to the protrusion, by
 the connection of the uterus and vagina  to the neighbouring
 parts, than by the agency of the ligaments; for although the
 ligaments  be cut, we cannot, without much force, make the
 uterus protrude. Frequent parturition,  fluor albus, dancing
 during  menstruation, and whatever tends to weaken or relax
 the parts, may occasion prolapsus.   Sometimes a fall brings
 it on.   No age  is exempt from it.66-  When symptoms indi-
 cating prolapsus uteri manifest themselves, we ought to ex-
 amine the state  of the  womb, the patient having lately been,
 or rather being, in an erect posture.  The symptoms some-
 times at first turn the attention rather to the bladder or pubis,
 than the womb; but a practitioner  of experience will think
 it incumbent on him to ascertain the real situation of that
 viscus.   If we find that there is  a slight degree of uterine
 descent, we must immediately use means  to remove the relax-
 ation.   These consist in the frequent injection of solution of
 sulphate of alumin, either in water,  or decoction of oak bark,
 repeated ablution with cold water, tonics, and the use  of the
  • Vide the case of a girl  aged twenty-one years, related by Mr. Pynney.
The polypous excrescence  was extirpated from the os uteri, and then a pes-
sary was employed^  Med. Comment. Vol. IV. p. 228. 
104
cold bath, at the same time that the bowels are kept regular,
all exertion avoided, and a recumbent posture much observed.
If these things fail, or if the disease exist to a considerable de-
gree, then, besides persisting in them, we must have recourse
to the assistance of mechanical means. These consist of sup-
porting substances called pessaries, which are placed in  the
vagina, and resting on  the  perinseum, keep up the womb.
They always give immediate relief, but where the relaxation
is considerable, they only mitigate, but  do  not entirely re-
move the sensation,  which must continue more or  less, as
long as the relaxation remains.  In recent cases, or where
the relaxation is not great, a perseverance in the use of  the
pessary, topical astringents and general tonics may accom-
plish a cure.  Fatigue or exertion must always be avoided.
  Pessaries are made of wood, and are of different shapes,
some oval, some flat and circular, some like  spindles, or the
figure of eight, others  globular.  Of all these, the globular(t/)
pessary is the  best, and it ought  to be of such size as to re-
quire a little force to introduce it into the vagina; that is to
say, it must be so large as  not to fall through  the orifice,
when  the woman moves or walks.  Whatever be employed,
it ought to be taken  out frequently, and  cleaned.67   By di-
minishing gradually the  size of the pessary, and using astrin-
gents, we may often be able at last to dispense with it. In all
the stages, a firm broad  bandage applied round the abdomen,
frequently relieves  the  uneasy sensations about  the bowels,
hack, and pubis.  The cold bath is also useful. It is farther
necessary to mention, that  the symptoms and treatment of
prolapsus  may be modified by circumstances which  precede
it, but with which,  it  is not essentially connected.   For in-
stance, a tender or  inflamed state of the uterus, and  the. ap-
pendages, may take place after delivery, and when convales-
cent, the patient may rise too soon, or sit up, striving to make
the child suck, and thus bring on a degree of prolapsus.   In
this case, it is evident that the symptoms may be more acute
or painful, and they will not be removed by a pessary, until

  (#) The oval form is nevertheless preferred by many, and apparently not
without reason. 
105
by continued rest,  laxatives, and occasional fomentations,
the morbid sensibility  of  the parts within the pelvis be got
rid of.
  When the relaxation is great, it has been proposed to use
a hollow elliptical  pessary, so  large, as  that by pressing
against  the sides of the vagina, it may support both  itself
and  the  womb, but  it generally gives pain, and the  relaxed
vagina,  turns up within it,  and becomes irritated.   I  am
therefore, clearly of opinion, that the oval pessary  should,
though hollow, have no large aperture.  The long diameter
 must vary from 2* to  3*  inches, according to the degree of
 relaxation.  In such cases of relaxation, if the oval pessary
 do not succeed in removing  the distressing sensation of the
 abdominal viscera being  about to fall out, then, in addition
 to it or the globe pessary, benefit  may be derived from sup-
 porting the perineum itself, with a soft pad, with a spring
 on  a similar principle with that used for  prolapsus  ani.   A
 contrivance of this kind, or a  firm T-bandage must be em-
 ployed  with a globe pessary, where the perineum is greatly
 lacerated. (»)
   If a procidentia be  large, and have been of long duration,
 the reduction of the uterus may disorder the contents of the
 abdomen, producing  both pain and  sickness.  In this case,
 we must enjoin  strict  rest in a  horizontal  posture.   The
 belly  should be fomented, and  an anodyne  administered.
 Sometimes it is necessary to take away a little  blood;  and
 we must always attend to the state of the bladder, preventing
 an accumulation of urine.   When the symptoms are abated,

   (z) In my own practice, I  have generally preferred the oval pessary at
 elastic gum, by being apphed transversely;  as regards the vagina, there is
 less danger of impeding the evacuation of the faeces and urine, by pressure
 on the rectum and neck of the bladder, or urethra. Where this cannot be
 procured pessaries maybe made of silver, of the oval form and hollow, and
 with care  may be found  to answer.  But it is probable, that the sponge
 pessary, under proper management, will be found to answer every intention.
 This kind of pessary, appears first to have been publicly recommended by
  Dr Haighton, of London, and has since been approved and  adopted by
  several  practitioners of respectability.   See  a paper on tins subject, by
  Mr. Dawson, in the 13th Vol.  of Lend. Med  Physl. Journal
     VOL.  T.                          r 
106
  a pessary must be introduced,* and the woman may rise for
  a little, to ascertain how it fits ; but,  as in other cases, she
  ought for some time to keep much in a horizontal posture,
  and avoid for a still longer period every exertion.  If there
  have existed  inflammation of the displaced bowels, during
  the continuance of the procidentia, serious consequences may
 result  from the  reduction, owing to  the adhesions which
 have formed.   Should there be much  difliculty and pain  at-
 tending the attempt to reduce, it ought not to be persisted in.
   If the tumour, from having  been much  irritated, or long
 protruded, be large, hard, inflamed, and perhaps ulcerated,
 it will be impossible to reduce it until  the swelling and  in-
 flammation are abated,  by a  recumbent  posture,  fomenta-
 tions, saturnine applications,  laxatives, and  perhaps even
 blood-letting.f After some days we may  attempt the  re-
 duction, and will find it useful previously to empty the blad-
 der.  The reduction, in  general, causes for a time, abdomi-
 nal  uneasiness.  If  the  uterus  cannot  be reduced, and  is
 much diseased*, it has been  proposed to extirpate the tumour.
 This has been done,  it is true, with success,68 but it  is ex-
 tremely dangerous ;  for the bladder is apt to be tied:): by the
 ligature, which is put round the part;  and as  the intestines
 fall down above the uterus into the sac, formed by the invert-
 ed vagina, they also are apt to be cut§ or constricted.
   A prolapsus uteri does not prevent the woman from becom-
 ing pregnant ;69 and it is even of  advantage that  she should
 become  so, as we thus, at least for a  time, generally cure
 the prolapsus.  But we must take care, lest premature la-
 bour|| be excited; for the uterus may  not  rise properly, or
 may again prolapse, if exertion be used.

  * Dr. Denman very properly advises, that a pessary should not be intro-
duced immediately after the uterus is reduced.  Lond. Med. Journal, Vol.
VII. p. 56.
  f M. Hoin succeeded in reducing a very large, hard and even ulcerated
procidentia, by fomentations, rest, and low diet.  Mem. de l'Acad. de Chir.
Tome m. p. 365.
  $ This happened in Ruysch's case.  Obs. Anat. vii.
  «j This occurred in a case related by Henry, ab Heers. Obs. Med. p. 192
  i Vide Mr. Hill's case, in Med. Qomment. Vol. IV. p. S3. 
107
  Sometimes, especially if the person receive a fall,70 or have
a wide  pelvis,  the uterus may prolapse during pregnancy,
although  the woman  have not  formerly had this disease.
Our first  care ought to be directed to the bladder/1 lest fa-
tal suppression of urine72 take place.   Our next object is to
replace the uterus,  and retain it by rest, and a pessary.  If
it cannot be reduced,* the uterus must be supported by $ ban-
dage,! until, by delivery, it be  emptied of its  contents.  It
is then to be reduced.  The management of prolapsus during
labour, will be  afterwards considered.
  If prolapsus be threatened, or have taken place  after deli-
very, in consequence, for  instance, of getting  up  too soon,
we  must  confine  the woman to  a horizontal posture, till  it
have regained its proper size and weight; and this diminu-
tion is to be assisted by gentle laxatives, particularly the daily
use of the sulphas potassse  cum  sulphure, in doses of from
two to three drachms.  The bandage formerly noticed, is  also
useful and comfortable.
  In  some  cases, the  cervix  uteri lengthens and descends
lower in the vagina, though the body of the womb  remains
in situ.  This is not to be confounded with prolapsus, for  it
is  really a preternatural  growth  of part of the uterus;
and this portion, or elongation, has  been removed  by liga-
ture.

                      §  40. HERNIA.

  Inguinal hernia of the  uterus have been long ago described
by Sennert, Hildanus, and  Ruysch, and very lately by Lal-
lement.   This species of displacement  may occur in the
unimpregnated state, and the woman afterwards conceive; or
it may  take place  when  pregnancy  is somewhat advanced.
If it be possible to reduce the uterus, this must be  done;  and

  *  See a remarkable  case in prolapsus in  the gravid state,  where the
whole uterus protruded, and reduction was not accomplished till after deli-
very.  By P. C. Fabricius, in Haller. Disp. Chir. Tomu» HI. p. 434.
  f Vide Memoirs by M. Sabatier, in Mem. de l'Acad. de Chir. Tome DX
p. 370. 
108
in one stage,  an  artificial enlargement  of  the foramen,
through which the uterus has protruded, may assist the re-
duction.   If however, gestation be far advanced, then the in-
cision must be made into the uterus whenever pains come on,,
and the child must be thus extracted.

              § 41. DROPSY OF THE OVARIUM.

  The ovarium  is subject to several diseases, of which the
most  frequent is  that called dropsy.  The appellation, how-
ever,  is not proper, for the affection is not dependent on an
increased effusion of a natural serous secretion or exhalation,
but is more akin to encysted tumours, and consists in a pe-
culiar change of structure,* and the formation of many cysts,
containing sometimes watery, but generally viscid fluid, and
having cellular,  fleshy,f or indurated  substance interposed
between  them,  frequently in  considerable masses.   They
vary  in number and in magnitude.  There is rarely only one
large cyst containing serous fluid;  most frequently we have
a great many in a state of progressive enlargement; the small
ones  are perhaps not larger than peas, others are as large
as a  child's head, whilst the one which has made most pro-
gress may surpass in size the gravid uterus at the full time.
The inner surface of the cysts may either be smooth, or co-
vered  with eminences like the papillse  of a cow's  uterus4
Their thickness is various, for sometimes they are as thin as
bladders,  sometimes fleshy, and  an inch thick.   The fluid
they contain is generally thick and coloured, and frequently
foetid, and in some instances, mixed with flakes of  fleshy
matter, or tufts of hair;  occasionally, it  is altogether gela-
tinous, and cannot be brought through a small opening. The

  * Le Dran says, this dropsy always begins with a scirrhus, and is only a
symptom of it.—Dr. Hunter says he never found any part of a dropsical ova-
rium in a truly scirrhous state.
  f Dr. Johnson's patient had the right ovarium converted into a fleshy mass,
weighing nine pounds, and full of cysts.  Med. Comment. Vol.  VII. p. 265.
  + I have seen the inner surface of the ovarium studded over with nearly two
dozen  of large tumours.  M. Morand noti'.es two cases, in which a similar
structure obtained. 
109
tumour has been seen made up  entirely, or  in part,  of
hydatids.73
  The effects  or symptoms of  this disease of the ovarium,
may all be referred to three sources, pressure, sympathetic ir-
ritation, and action carried on in the ovarium itself. It some-
times, though not often, begins with pretty acute pain about
the groins, thighs, and side of the lower belly, with disturbance
of the stomach and intestines, and occasionally^byncope.  A
few patients feel pain very early in the mammae; and M. Ro-
bert affirms, that it  is felt most frequently in the same side
with the affected ovarium.  In some cases  milk is  secreted.74
But generally the symptoms are at first slight, or  chiefly de-
pendent on the pressure of the parts within the pelvis.  The
patient is costive, and  subject to piles, has a degree of stran-
gury, which in a few instances, may end in  a complete re-
tention of urine; and  sometimes one of the feet swells.  By
examining per vaginam, a tumour may often be felt betwixt
the vagina and rectum, and the  os  uteri is thrown forward
near the pubis; so that, without some attention, the disease
may be taken for retroversion of the womb.*   In  some time
after this, the tumour, in general, rises out of the pelvis,"
and these symptoms go off.  A moveable mass can be felt in
the hypogastric,  or one of the iliac  regions.  This gradually
enlarges,  and can be ascertained to have an obscure fluctua-
tion.   The tumour is  moveable, until  it  acquire  a size so
great, as to fill and render tense the abdominal cavity.  It
then resembles ascites, with which  it in general comes  to be
ultimately combined76.   Little  inconvenience is  produced,
except from the weight of the tumour, and the patient may
enjoy tolerable health for years.  But it is  not always so, for
the tumour sometimes  presses on the fundus vesicae, produc-
ing incontinence  of urine, or on the kidney, making part of
it to be absorbed; and it often irritates the bowels, causing
uneasy sensations, and sometimes hysterical affections.f  It

  * Mr. Home's case related by Dr. Denman, Vol. I. p. 130, had very much
the appearance of retroversion.
  f Case by Sh- Hans Sloane, in Phil. Trans. No. 252.—Dr. Pidtcny's patient, 
110
 augments in size, and carries up the uterus with it ;* so that
 the vagina is elongated: and this is  especially the case, if
 both ovaria be  enlarged,7'  The urine is not in the  com-
 mencement much diminished in  quantity, unless this disease
 be conjoined with ascites;  and the thirst  at  first, is not
 greatly increased." But when the tumour has acquired a
 great size,  tho urine is  generally much diminished  or ob-
 structed.* If, however, the bulk be lessened artificially, it is
 often, for a time, increased in quantity,  and the health im-
 proved.  This is well illustrated by the case  of Madame de
 Rosney,f who in the space of four years, was tapped twenty-
 eight times: for several days after each puncture, she  made
 water freely, and in  sufficient quantity; the  appetite was
 good, and all the functions well performed : but in proportion
 as the  tumour  increased,  the  urine,  in spite  of diuretics,
 diminished, and at last came only in drops. The woman ge-
 nerally continues to be regular for a considerable time, and
 may even become pregnant.
   In the course of the disease,  the patient may have attacks
 of pain in the belly, with fever, indicating inflammation  of
 part of the tumour, which may terminate in suppuration, and
 produce hectic fever; but in many cases, these symptoms are
 absent, and little distress is  felt, until the tumour acquire a
 size so  great as to obstruct respiration, and cause a painful
 sense of distention.  By this time, the  constitution becomes
 broken and dropsical effusions are produced.  Then the ab-
 dominal coverings  are often so tender, that they cannot bear
 pressure; and the emaciated patient, worn out with  restless
 nights,  feverishness, want of appetite,  pain,  and dyspnoea,
 expires.
   The symptoms of this disease all arising, either from  pres-
 sure or irritatftm, must vary according to the nature of the

whose ovarium weighed fifty-six pounds, had excruciating  pain in the lefi»
side, spasms, and hysterical fits. Mem. of Medical Society, Vol. II. p. 265.
  * This point is well considered by M. Voisin, in the Recueil Period. Tome
XVII. p. 371, et seq.—The bladder may also be displaced, as in the  case of
Mademoiselle Argant, related by Portal. Cours d'Anat. Tome V. p. 549.
  t Portal. Cours d'Anat Tome V. p. 549. 
Ill
parts most acted on, and the peculiar sympathies which exist
in the individual.   When  we  consider that,  in  many in-
stances, the whole  constitution, as  well as different organs,
may bear without injury, a great, hut very gradual irritation,
it is  not surprising that this disease, which, for a long time,
operates only mechanically, .should often exist for years with-
out affecting the health materially,  whilst'in more irritable
habits, or under a different modification of pressure,  much
distress, too often referred to hysteria, may be produced.
  This disease has sometimes  appeared to be occasioned by
injury done to the uterus in parturition, as, for instance, by
hasty extraction of the placenta; or by blows,  falls, violent
passions, frights, or the application of cold; but very  often,
no evident exciting cause can be assigned.
  In the first stage of  this complaint, we must attend to the
effects produced by pressure.  The bladder is to be emptied
by the catheter, when this is necessary; and stools are to be
procured.   It may be considered, how far, at this period, it is
proper to tap the tumour from the vagina, and  by injections
or other means, endeavour to promote a radical cure. When
the woman is pregnant, and the tumour opposes delivery, there
can be no doubt of the propriety of making a puncture,78
which is  preferable to the use of the  crotchet(a)   But this
has only been resorted  to, in order to obviate particular in-
conveniences, and  affords no rule of conduct in other cases,
where no such urgent reason exists.  I am inclined to dissuade
strongly from any operation at this  period, because in a short
time the tumour rises out of the pelvis; and then the patient
may remain tolerably easy for many years. Besides the ova-
rium in this disease contains, in general, numerous cysts; and
as these, in the first stage,  are small, we  can  only hope to
empty the largest.   Perhaps we may not open even that; and
although it could be opened and healed, still there are others
coming forward, which will soon require the same  treat-

  (a) Where the tumour in the vagina occupies a large space, Dr. Merriman
thinks it  a warrantable practice to remove it by excision if it consisted of a
soBd substance, and certainly to puncture it if it contained a fluid.  Vide Me-
dico>Chirurgical Transactions, Vol. HI. p. 47. 
112
 ment.  Puncturing, then, can only retard the growth of the
 tumour, and keep it longer in the pelvis, where its presence
 is dangerous.
   When the tumour has risen out of the pelvis, we must, in
 our treatment, be  much regulated by the  symptoms.   The
 bowels should be kept open,  but not loose, by rhubarb and
 magnesia,  aloetic pills, cream of tartar, or  Cheltenham salt.
 Dyspeptic  symptoms may sometimes be reliev ed by prepara-
 tions of steel, combined with supercarbonatc of soda, or other
 appropriate medicines, though their complete removal cannot
 be expected as long as the exciting cause remains.  General
 uneasiness or restlessness, occasionally produced by abdomi-
 nal irritation,  may  be lessened by the warm bath, saline ju-
 lap, and laxatives;  whilst spasmodic affections are to be re-
 lieved by fcetids;  and if these fail, by  opiates.  If, at any
 time, much pain be felt, we may apply leeches, and use fomen-
 tations, or put a blister over the part.   Upon the supposition
 of this disease  being a dropsy, diuretics have been prescribed,
 but not with much success,79 and often with detriment.  Some
 have supposed, that diuretics  do no good whilst the disease is
 on the increase;  but that, when it arrives at its acme, they
 are of service.   But this disease is never at a stand; it goes
 on increasing,  till the patient  is destroyed.  When they pro-
 duce any effect, it is chiefly that of removing dropsical  affec-
 tions combined  with  this disease; and in this respect,  they
 are most  powerful immediately after  paracentesis.   With
regard to the power of diminishing the size of the ovarium,
my opinion is, that they have no  more influence on it, than
they have over a mellicerous tumour on the shoulder. In one
case, fomentations and poultices appear to  have discussed a
tumefied ovarium.*
  Having  palliated symptoms until  the distension becomes
troublesome, we must then tap the tumour, which  gives very
great relief; and, by being repeated according to circumstan-
ces, may contribute to prolong life for a length of time.80  As
the uterus may be carried up  by the tumour, it is proper to

  • Vide Dr. Monro's fourth case, in  Med. Essays, Vol. V. 
113
 ascertain, whether it be the right ovarium or the left which
 is enlarged; and we should  always tap the right ovarium.on
 the right side, and  vice versa: by  a contrary practice, the
 uterus has been wounded.*   When the  disease is combined
 with ascites, it is sometimes necessary to introduce the trocar
 twice, and the difference between the two fluids drawn off is
 often very great.  We must neither delay tapping so long as
 to injure by great irritation and distention; nor have recourse
 to it too early, or too frequently,  for the vessels of the cavity
 excrete  much faster and more copiously after each operation,
 and it is to be remembered, that this is a cause of increasing
 weakness, not only from the  expenditure of gelatinous fluid,
 but also from the increased action performed by the vessels,
 which must exhaust as much  as any other species of exer-
 tion.
   Finally, it has been proposed, to procure a radical cure, by
 laying open the tumour, evacuating the matter, and prevent-
 ing the wound  from healing, by which a fistulous sore is pro-
 duced ; or by introducing a tent, or throwing in a stimulating
 injection.   Some of these methods have, it is true, been suc-
 cessful,81 but occasionally they have been  fatal ;82 and in no
 case, which I have seen, have they been attended with benefit.
 There are two powerful objections to all these practices, be-
 sides the risk of exciting fatal inflammation: the first is, that
 ftie cyst  is often irregular on its interior surface, and therefore
 cannot be expected to adhere: the second is, that as the ova-
 rium,  when dropsical, seldom consists of one single  cavity,
 so, although one cyst  be destroyed, others will enlarge, and
 renew the swelling; and, indeed, the swelling is seldom or
 never  completely removed, nor the tumour emptied,  by one
 operation.  Hence even as a palliative, the trocar must some-
 times be  introduced into two or more places.
   It has happened, that a cyst has adhered to the intestine,8,3
 and burst into it, the patient discharging glary or feetid mat-
 ter by stool.84  Such instances as 1  have known, have only

  * In a case of this kind related by M. Voisin, the uterus was wounded, and
the patient felt great pain, and fainted.  She died on the third day after the
operation.  Recueil Period. Tome VII. p. 37*, &c.
   VOL. T.                          Q 
Ill
been palliated, but not cured, by this circumstance.   Some-
times the fluid has been evacuated per vaginam,85 or the ova-
rium has opened into the general cavity of the abdomen, and
the fluid been effused there.
  There is another disease, or a variety of the former dis-
ease, in which bones, hair,  and teeth, are found in the ova-
rium.86   The sac, in which these are contained, is sometimes
large, and generally is filled with watery or gelatinous fluid.
The bony substance, and teeth, usually adhere to the inner
surface of the cyst.   This disease produces no inconvenience,
except from pressure.  It has been deemed by  some, to he
merely an ovarian conception; hut it may undoubtedly take
place without impregnation, nay similar  tumours have been
found in the male sex.87   It is to be treated  as  the  former
disease.

         § 42. OTHER DISEASES OF THE OVARIUM.

  The  ovaria are sometimes affected with scrophula, and
the tumour may prove fatal by producing retention of urine.
When  it rises out of  the  pelvis, it is often  productive of
hypochondriasis, and very  much  resembles the ovarian dis-
ease, formerly mentioned, but is firmer, seldom gives a sen-
sation  of fluctuation, and  sometimes  is  very painful when
pressed.  It rarely terminates  in suppuration ;  but when it
does, the fluid, as Portal observes, is blanchatre, filamenteux.
grumeleux, mal digere.   The substance of the ovarium is soft,
and similar to that of other scrophulous  glands.  Occasion-
ally it contains  a cheesy substance, which is found,  at the
same time, in  the  mesenteric  and other glands.   Burnt
sponge,  cicuta,  mercury,  electricity, laxatives, &c.  have
been employed,  hut seldom with benefit.  The most we can
do, is to palliate symptoms,  such as retention of urine, cos-
tiveness, dyspepsia, or  pain.
  The ovarium  may also be  enlarged, and become hard and
stony,88 or converted into a fatty substance.89   Sometimes it
is affected  with  the spongoid disease,  and is changed into a
substance like brain, with cysts containing bloody  serum. 
115
 The tumour in this disease, feels tense and clastic.   It may
 burst through the abdominal parietes, and throw out large
 fungous  excrescences.   Frequently we find,  on cutting  an
 enlarged ovarium,  that  part of  it resembles  the spongoid
 structure,  havjrjg bloody fungous  cysts;  part is like firm
jelly, and pat&like cartilage, or dense fat..  Often the uterus
 participates in the disease.   I have seen a mass of this kind
 weigh thirteen pounds.   I  have never found the ovarium
 cancerous.

                     § 43. DEFICreNCY.

   The ovaria may be wanting on  one or  both sides,(6)  or
 may be unusually small.  In such  cases, it sometimes  hap-
 pens, that the growth  of the external parts stops early, and
 the marks of puberty are not exhibited.  The ovarium may
 form part of a herniary  tumour.

       § 44.  DISEASES OF THE TUBES AND LIGAMENTS.

   The tubes may be wanting, or impervious, and are sub-
 ject to many of the diseases of the ovaria.
   The round ligaments may partake of the diseases of the
 uterus, or may have similar diseases, originally appearing in
 them.  WThen  they are  affected, pain is  felt at  the ring of
 the oblique  muscle,  artd sometimes a swelling can  be per-
 ceived there.

  (b) See a case of deficiency of  the ovaria, by Charles Pears,  F. L. S. in
the Phil. Trans, for 1805. This woman died  at the age of twenty-nine. She
had never menstruated.  She ceased to grow at the age often years 
116
                      CHAP. XI.

                     Of Menstruation.

  The periodical discharge of sanguineous fluid which takes
place every month from the uterus, is termed the menses;
and whilst the discharge  continues, the woman is said to be
out of order, or unwell.
  In some instances, the discharge takes place at puberty,
without any previous or attendant indisposition; but in most
cases, it is preceded by uneasy feelings, very often by affec-
tions of the stomach and bowels, pain about the hack and pel-
vis,  and  various hysterical symptoms.   These affections,
which  are more or less urgent in different individuals, gra-
dually abate;  but at the end of a month, return with more
severity,  attended with  colic pains, quick pulse, sometimes
hot skin, and a desire to vomit.  There now takes place from
the vagina, a discharge of a serous fluid, slightly red, but it
does not in general become perfectly sanguineous for several
periods.   When the discharge flows, the symptoms abate;
but  frequently a  considerable degree of weakness remains,
and  a dark circle  surrounds the eye.  In a short time the
girl  menstruates, often without any other inconvenience than
a  slight  pain  in the  back, though  sometimes, during the
whole of her life, she suffers from many of the former symp-
toms every time she is unwell; and all women, at the men-
strual period,  are more subject  than at other times to spas-
modic and hysterical complaints.
   When  a girl begins to menstruate,  certain changes take
place, denoting the age  of puberty.   The uterus  becomes
more expanded, and receives its adult  form; the vagina en-
larges; the mons veneris swells up, and is covered with hair;
the pelvis is enlarged; the glandular substance of the breasts
is unfolded, and  the  cellular part increased; at the same
time the mental powers become stronger, and new passions
begin to operate on the female heart.
   The age at which menstruation begins, varies in indivi- 
117
duals, and also in different climates. It is a general law, that
the warmer the climate, the earlier does  the discharge take
place, and the sooner does  it cease.  In  Asia, for instance,
the menses begin about  nine years  of age;  whilst  in the
North, a woman does not arrive at puberty until she is eigh-
teen or twenty years old; nay, if  we may credit authors, in
very cold countries, women only menstruate in  the summer
seasons.*   In the temperate parts of Europe,  the most com-
mon age at which the menses appear, is thirteen or fourteen^
years.f
   The  quantity  of the discharge varies, also, according to
the climate and constitution of the woman.  In this country
from six  to eight ounces are lost at  each menstrual period;
but this does  not flow suddenly; it comes away slowly for the
space of three  or four days.  Some  women discharge less
than this, and are unwell for a shorter  space of time:  others,
especially those  who  live  luxuriously, and are confined in
warm apartments, menstruate  more copiously, and continue
to do so for a week.
   In this country, menstruation ceases about the forty-fourth
year, lasting  for a period of about thirty years.  In the East,
the menses begin soon, flow copiously, and end early; the
women in Asia, for example, being old, whilst the Europeans
are still in their prime.  In the north,  the menses begin late,
flow sparingly, and continue long.
   The menses are  obstructed  during pregnancy,:): and the
giving of suck;  but if lactation be very long  continued, the
menses return, and the milk disappears or becomes bad.
  * Linnaeus and others have said that the women of Lapland do not men-
struate more than once or twice in the year.  C.
  f Menstruation commences about the  same  age in the United States,
and continues to the fortieth or forty-fifth year.  C.
  % This is a point still debated.  The weight of authority is, however, de-
cidedly against menstruation continuing during pregnancy. By Baudelocque,
Denman, and almost all the modern writers,it is denied. Those who main-
tain the contrary opinion, have very probably mistaken a hemorrhage from
the vagina, which sometimes recurs with  considerable periodical regularity,
for the menstrual flux.  Several cases of this kind have come under my own
observation, where I had an opportunity  of examining the discharge accu-
rately.  In every instance, I found it pure coagnlable blood. 
118
    The discharge appears  to be yielded by the uterine arte*
 lies, but is not an  extravasation or hemorrhage, for when
 collected, it does not separate into the same parts with blood,
 neither does it coagulate.(c)  In many instances, a great quan-
 tity has been retained for some months  in the  uterus and
 vagina, but it has never been found  clotted when it was  eva-
 cuated.
    Menstruation has-been  attributed  to the influence of the
 moon, to  the operation of  a ferment  in  the blood, or in the
 uterus, to the agency  of a general or local plethora, or to the

  By adverting to the state of the pregnant uterus, this is exactly what we
should be led to expect.  Contemporary with conception, we know that the
uterine cavity is lined with the  membrana, decidua, and  that soon  after-
wards the os tinc<e is completely  sealed with  impacted mucus.   Were an
effusion therefore to take plaee, especially in the early months of gestation,
it would destroy the attachment of the membrane, and produce all the con-
sequences of uterine hemorrhage.
  It would seem, moreover, that the action which the vessels of the uterus
take on to fabricate and support this membrane, is totally incompatible with
the menstrual secretion.   The two actions cannot co-exist. This is proved
not only by the alleged cessation  of the menses during pregnancy, but still
more clearly by the fact  which has not been sufficiently attended to, that in
a large proportion of cases of obstinate amenorrhcea, the membrana decidua
exists, and that the first symptom of the return of the discharge  is the com-
ing away of  the membrane. Of  the identity of the  two membranes there
ran be no doubt.  It has been  ascertained by  Dr. Bailhe and  many other
competent judges.  C.
  (c) The celebrated John Hunter was, perhaps, the first physiologist who
look notice publicly of this fact, at least in Great Britain.  In his Lectures on
the Theory  and Practice of Surgery, (as quoted by Dr. R. W. Johnson, Sys-
tern of Midwifery, 2d edition, 4to, p. 34 and  35) he observes,  that  " the
blood discharged in menstruation, is neither similar to blood taken  from  a
vein of the same person, nor to that extravasated by an accident in any other
part of the body; but is a species of blood changed, separated, or thrown off
from the common mass, by an action of the vessels of the uterus, in a pro-
cess similar to secretion; by which action the blood having lost its living prin-
ciple, it does not afterwards coagulate."  In  his Treatise on the Blood, vol.
I. p. 24, Philadelphia edition, he says, "in healthy menstruation, the  blood
Which is discharged does  not coagidale,- in the irregular, or unhealthy it
does.  The healthy menses, therefore, (he continues) shew a peculiar  action
of the constitution •, and it is most probably in this actions that its salubrious
purposes consist." 
119
existence of a secretory action  in the  uterus.*  The last of
 these is the most probable opinion; but as this work is meant
to  be practical,  I think it wrong to devote more time to the

  * I am too, very much inclined to believe, that menstruation results from
a secretory action of the uterus.  Every other theory on  the subject is in-
deed totally irreconcileable with facts.  I will briefly enumerate the leading
arguments by which the doctrine may be defended.
  1. That the uterus in its villous and vascular structure resembles*in ^ome
degree a gland, and also, in its diseases, being equally liable to scirrhus,
cancer, &c. &c.
  2. That, like  other secretory organs,  blood is  very copiously  diffused
through it.
  3. That by the arrangement of its vessels, it is evidently designed that
the circulation should be retarded for the purpose  of  secretion.  The arte-
ries are not only exceedingly convoluted, but they are larger and with thin-
ner coats than their corresponding veins.  Thus, Haller says,  " the blood is
brought to the womb in greater quantity, and more quickly through its lax
 and ample arteries, and on  account of the rigidity and  narrowness of the
 veins, it returns -with difficulty."
   4. That, in common with other secretions, menstruation is often,  at ^irst,
imperfectly  done, and  is subject  afterwards to vitiation and derangement.
At is commencement the discharge is  commonly thin, colourless, and defi-
 cient, and recurs at protracted and irregular intervals with pain and difficulty.
   5. That, in many of the inferior animals, during the season of venereal in-
 calescence,  there is an uterine discharge which is undoubtedly a secretion.
 This answers seemingly the same end as menstruation, namely, giving to the
 uterus an aptitude to  conception.   Though this fluid generally differs from the
 menses in complexion, yet in some instances they  are precisely  similar.
 Whenever the venereal desire suffers a violent exacerbation from restraint,
 or other causes, the discharge in these animals becomes red.  This has been
 more especially remarked in bitches kept from the male.
   6. That the menses are a fluid sui generis, or at least, varying very essen-
 tially from the blood, having neither its  colour nor odour, nor coagulability,
 and on chemical analysis present different results.  These  last circumstances
 are enough alone to  establish the theory.
   7. To the  objection that  the uterus is not sufficiently glandular  for the
 function of secretion, it has been, I think, very satisfactorily replied, that
 there is hardly a viscus or surface of the body which is not competent to the
 secretion of a fluid.   It would really seem that no operation of the animal
 economy requires a less  complex apparatus.   Of what indeed does a gland
 consist, except a congeries of vessels ? Even the most perfect  of the secre-
 tions are affected by this simple contrivance.   If a few vessels, "creeping
 over the coats of the stomach,"  can secrete the gastric liquor, why may not
 the infinitely more glandular organization  of the uterus elaborate the men-
 strual fluid ?(J)  C.
   (d) Saunders has been presumed by somelvto have been the first who con- 
120
  discussion of theories and  speculations.  The use of men-
  struation, seems to be to preserve the womb in a fit state for
  impregnation; at least, we know, that the presence of men-
  struation is generally necessary to, and indicates a capability
  of, conception.
   The action of menstruation has an  effect on the vascular
 and  nervous system, and on the stomach and bowels.   All
 tender or diseased parts are worse, and if visible, their vessels
 are more turgid previous to menstruation.   The nervous sys-
 tem is more irritable, and convulsive affections of the body, or
 aberrations of mind, are  more frequent at this period than at
 other times.  The stomach may be affected with severe sick-
 ness and violent retching, or by sympathy with the skin, may
 produce urticaria, whilst the  bowels, for a day or two before
 menstruation, sometimes are much inflated and costive, or at
 the period itself are affected with spasm.
   As the female system is more  irritable  during menstrua-
 tion than at other times, "and as changes effected in the sys-
 tem,  or in particular organs, at that time,  may  come  to in-
 terfere with the due performance of the uterine  action, it is
 a general  and proper custom with physicians, and a prac-
 tice consonant to the prejudice of women themselves, not to
 administer  active medicines during the flow of  the menses.
 It is also proper, that indigestible food, dancing in  warm
 rooms,  sudden exposure to cold and mental agitation,  espe-
 cially in hysterical habits, be avoided as much  as possible.
 By  neglecting these precautions, the action  may either be
 suddenly stopped,  or spasmodic  and troublesome affections
 may be excited.

sidered the catamenia as a secretion; but Bordeu, a French physiologist of
great merit and of earlier date, treats of the uterus as a gland; and of course,
it is to be presumed, must have viewed the menses as a secreted fluid. Haller
also, in his Notes on the Prelectiones Academics of Boerhaave, [Amste-
lodami, A. D. 1744,] speaks of the menses as a secretion. His words are,
"Sed facile ipsa fabrica partium  demonstrat uterum naturale organum esse
hujus srcreiionis."  Vol. VI. p. 72. Dr. Chapman says, that Dr.  Craven sup-
ported this opinion, m a Thesis published at Edinburgh in the year 1778. 
121
                      CHAP. XII.

        Of Diseased States of the Menstrual Actioii.

                    § 1. AMENORRHEA.

  Amenorrhoia, or absence of the menses, has been divided
into the retention, or emansio mensium, and the suppression of
the menses.   By the first  term, we are to understand, that
the menses have not yet appeared, the action being longer
than usual of being established.   By the second, is meant the
interruption of the action which has already been established,
and hitherto performed. This may be subdivided into checked
menstruation, and prevented menstruation, commonly called
obstruction.
  The retention of the  menses is very  generally attended
with chlorosis, or a feeling of weariness and  debility, with
dislike to active employment;  a pale  or  sallow complexion,
cathectic appearance, (edematous swelling of the legs and
feet;  costiveness, dyspeptic complaints, such as  flatulence,
acidity, loathing of food, but craving for  indigestible sub-
stances, as chalk, lime, or cinders; pains of the head, and dif-
ferent parts of the body; swelling of the belly, with hysteric
symptoms, such as palpitations, or dyspnoea; and if this state
be not soon removed, it is apt to end either in consumption or
dropsy.
  The menses, may, from  one person not arriving so early
as another at puberty, be longer of appearing in some women
than in others; and in such cases, no peculiar inconvenience
attends  the  retardation.  But when  the retention proceeds
from other causes, it is to be considered as a disease; and
generally, is to be attributed to a want of vigour in the system;
by  which, not only a new action  is prevented from being
formed, but also those-which were formerly performed become
impaired.  In some cases, indeed, the absence of the menses
depends upon a malformation of the organs of generation, a
   vol.  i»                         « 
132
deficiency of the ovaria,* an imperfect developement of, or
a special want of energy in the uterus; but in far the greatest
number of instances, the action is  postponed, merely from
general debility of the system; and accordingly, the most
successful mode of treatment consists in improving the health,
and increasing the  strength  of the patient.  This is to be
done by regular exercise, proportioned to the ability of the
person; the use of  the  hot salt-water bath every day, suc-
ceeded  by  frictions with dry flannel,  or a soft brush ; suffi-
cient clothing, and particularly a flannel dress; a nourishing
and digestible diet, with a proper portion of wine; avoiding
every thing which disagrees or ferments; the administration
of tonic medicines, particularly preparations of iron, such as
chalybeate waters, tincture of muriated iron, or the carbonas
ferri precipitatnm combined  with myrrh.  The  use of the
Bath waters, internally as well as externally, is of service in
the chlorotic state, but hurtful if the patient be of a full habit.
Strict attention must in every case be paid to the state of the
bowels.   This  is necessary  in  the chlorotic  condition to
stimulate the system; for the bowels are generally torpid,
and communicate a  similar debility to the rest of the system.
The aloetic or compound rhubarb pill should be freely em-
ployed.  The cold bath in chlorosis is  seldom proper, as it
is apt to be followed by dullness, headach, and languor.  It
is only  useful when  succeeded by a sense of heat  and com-
fort.  The warm salt-water bath is generally of greater ser-
vice.  Besides this general plan, it  has also been proposed,
to excite more directly the uterine action, by marriage, and
the use of emmenagogues; but with respect to the latter part
of the proposal, I must observe, that some of these, if rashly
employed,  may, from their stimulating qualities, do harm;

  * There is much reason to believe, that an influence somehow derived from
the ovaries, excites the uterus to the menstrual effort.—Certain it is, that in
several instances, a permanent suppression of the menses has followed the
loss of these organs. May not amenorrhoea, oftener than we suspect, be oc-
casioned by a diseased state of the ovaries ? This, at least, was the opinion of
the celebrated Cullen.  Cases have also occurred, where, from original defi-
ciency of the ovaries, menstruation never took place. G. 
i£3
and they do not generally succeed  without  the use  of such
means as  tend  to invigorate and improve the  system.
Should the tonic plan, however, fail, then  we may employ
some of those medicines,  which will he  presently mentioned.
  Chlorosis, whether produced in young girls, or succeeding
to abortion, laborious parturition, or fever,  is often attended
with  symptoms much resembling  phthisis  pulmonalis.   In
many instances the pulse continues long  frequent;  there is
nocturnal perspiration;  considerable emaciation, with cough
and pains about the chest; and yet the person is not phthisi-
cal, she suffers chiefly from debility; but if great attention
be not paid to improve the health,  the case may end in con-
sumption; and hence many consumptive  women  date  the
commencement of their complaints  from an abortion, or from
the birth  of  a  child, succeeded  by  an hemorrhage.   In
chlorosis, the symptoms are  induced, not by previous pul-
monic affections, but by some other evident cause of weak-
ness ; the pulse,  although frequent, is not liable to the same
regular exacerbation, as in hectic; a full inspiration gives no
pain,  and little excitement to cough; the person can lie with
equal ease on either side; the cough is not increased by mo-
tion, nor by going to bed, but it is  often worse in the morn-
ing,  and  is accompanied with a  trifling  expectoration of
phlegm.   It is not short, like that  excited by tubercles,  but
comes in fits, and  is sometimes convulsive; whilst  palpita-
tion, and  many hysterical affections, with  a timid and de-
sponding  mind, accompany these  symptoms.  The bowels
are generally costive, and the person does not digest well.
  In chlorosis, attended with symptoms resembling phthisis,
it is of considerable utility, to administer occasionally, a gen-
tle emetic, and at  the  same time  the  bowels must be kept
open.   Myrrh, combined with the  oxyde of zinc, is, I think,
of approved efficacy; and the ammonia, given in  the form of
an emulsion with oil, very often is effectual in relieving the
cough.  A removal to the country, and the  use of moderate
exercise  on horse-back,  will contribute  greatly to the re-
covery.  The  diet  ought to be light, but nourishing.   In 
                          124

many cases, milk agrees well with the patient, but it is not
necessary to restrict her from animal food.  Pain in the side
may be removed, by the application of a warm plaster ; and,
if the  cough be troublesome, the squill may be used as an
expectorant, and an opiate should be given  at  bed-time.  If
the skin  be permanently  hot, or  irregularly hot  and cold,
without weakening perspiration, the tepid bath is of service,
or small  doses of saline julap may be given.  Should the per-
son be of a phthisical  habit, and  the symptoms increase or
continue obstinate, it  will be proper to remove her to a mild
climate, or the southern part of the island.  Emmenagogues
are either useless or detrimental.
  If retention should be combined with a plethoric state, the
best plan is to use purgatives regularly, in a degree propor-
tioned to  their effect  on  the system, and make the patient
take  as  much  exercise  as she can  do without  producing
fatigue.
  Suppression of the  menses may take place under two cir-
cumstances.  The discharge may be suddenly checked during
its flow,  or it may be prevented from taking  place at  the
proper period, by the operation  of certain causes  previous
to its expected  return.  The first may be  called checked
menstruation, and it is produced  chiefly by such causes as
are capable of operating powerfully and speedily, on either
the  nervous  or  vascular systems.   The most frequent of
these causes are violent passions of the mind, and the appli-
cation of cold to the surface of the body.  The effect is  to
stop the  discharge, and produce great  pain in the uterine
region, with spasm of the stomach or intestines, violent hys-
terical affections,  and not  unfrequently smart fever.   After
these subside, the womb may still be so much injured, or the
general health  so impaired, that menstruation may not re-
turn for many months.  The most  effectual means of reliev-
ing these acute  symptoms, are  the  semicupium,  with full
doses of laudanum, combined with  ipecacuanha, or with the
saline julap, and warm diluents.  A clyster is to be given to
open the bowels, and this,  if necessary, is to be succeeded by 
125
a purgative.  If there be febrile symptoms, some blood should
be taken from the arm.   If laudanum cannot be retained in
the stomach, it must be given as a clyster, with some asafce-
tida, and  the belly fomented  and rubbed with tincture of
soap and opium.  Should the menses not return at the next
period, we must proceed, as shall presently be directed.
  The menses may be prevented from returning at the regu-
lar time, by the interference of causes  during the interval.
This, which has been called obstruction, is naturally produc-
ed by pregnancy, and,  very generally, by such diseases as
tend greatly to weaken the patient.   The first of these causes
is soon recognised,  by its peculiar  effects.  In the second,
the effect is  often mistaken  for the cause;  the bad health
being attributed to the absence of the menses, and much
harm  frequently done by the administration  of stimulating
medicines.   But in such cases it will be found, upon inquiry,
that before the menses were suppressed, the patients had be-
gun to complain.  In them, the irregularity of the menses is
symptomatic, and generally indicates considerable debility,
induced, perhaps, by great  fatigue,  bad  diet, loss of blood,
or long continued serous discharge,  hectic fever, or dyspep-
sia.  At the same time,  it is also certain, that in some in-
stances, the popular opinion, that had health is produced by
 obstruction of the menses, is correct.   For, if other organs,
 as for instance, the stomach or liver,  may become  impaired
in their  action,  and occasion disease, I see  no exemption
which  can be claimed for the uterus from  a similar state,
and this state unquestionably may influence the constitution.
 Repeated  abortion,  or  excessive.venery, may in this  way,
render the uterus incapable of  performing its  function, al-
though the general health,  may not for a length of time be
 injured.   The existence likewise, of a different action in the
 womb, may prevent menstruation; hence  the effect of one
 species of fluor albus, that proceeding from the cavity of the
 womb, in sometimes causing obstruction.
   The immediate, and remote effects of suppression, arc much
 modified by the previous state of the system, particularly with
 regard to irritability and plethora; and also by the condjr 
126
tion of individual organs,* which, if already disposed to
disease, may thus be excited more speedily into a morbid ac-
tion.   In many cases, nausea, tumour of the belly, and other
indications of pregnancy are produced.
  It also sometimes happens, that in consequence of suppres-
sion of the menses, hemorrhage takes place from the nose,
lungs, or stomach ; and these discharges do, occasionally, ob-
serve a monthly period, but oftener they appear at irregular
intervals.
  When suppression of the menses takes place in consequence
of some chronic  and  obstinate disease, such as consumption or
dropsy, it would he both useless and  hurtful to attempt, by
stimulating  drugs, to restore  menstruation.   But in those
cases, where the menses are suppressed inconsequence of some
removable cause, which we conclude, if there be no symptoms
of other incurable disease, it is proper to interfere,  both as
the suppression is a  source of anxiety to the patient,  a cause
of farther injury, and also as the  rational means  of restora-
tion tend to amend the health.
  It is proper, in our curative plan, to recollect, that the sup-
pression may take place in different circumstances  of the con-
stitution.  It may occur with a debilitated condition, in which
case we are to proceed much in the same way as in retention
of the menses, with regard to medicine and diet.  Moderate
exercise,  particularly  on horseback, and a residence in the
country, will be of much advantage, and where there is not
decided chlorosis, the cold sea-bath will be of advantage, pro-
vided it do not produce head-ach,  dullness, or languor.  In
that case, it must be tepid.   Great attention must be paid to
the bowels, and the digestive powers must, if possible, he in-
creased by steel and bitters, such as uva ursi, combined with
soda,  Along with  the  tonic  plan of treatment, it will be
proper to  have recourse to the use of emmenagogue medi-

  * Baillou  lias  observed, that both  in young  girls, and elderly women,
when the menses are obstructed or irregular, the spleen sometimes swells:
and subsides again, when the menses become regular.  De Virgin, et Mu«
her. Morbis. Tomus IV. p. 75. 
137
cines, such  as savin,* hellebore,!  madder, myrrh, mustard
nitrous  acid; and  of these, the three first are  the most ac-
tive.:^) About the time when the menses are expected to ap-

  * From 5 to 10 grains of the powdered leaves may be given three or four
times a day.
  f A dram of the tincture may be given twice or thrice daily.
  * In suppression of the menses, evidently connected with atony of the ute-
rus, I have had some success with the tinct. cantharid. I give it in the dose
of ten drops, morning, noon, and night, gradually increasing the quantity till
it amounts to two or three drachms in the day.  The most obvious effects of
this medicine, which I have observed, are an increase in the force  of the
pulse, and a very copious flow of urine.
  From the sp. terebinth. I have also, under similar circumstances  derived
Some advantage.
  In one case of this complaint, in which there was general torpor of the
system accompanied with a low degree  of temperature, I administered a
phosphorus, but its use was interrupted too soon, by the prejudices of the pa-
tient, to judge of its efficacy.  The phosphorus is a most powerful medicine,
and requires great care in its administration.  I gave of it,  a tenth of a grain
intimately blended with olive oil.  Even, in this small dose it produced a
universal glow and excitement.  When properly regulated, phosphorus is
both a safe,  and I beheve,  an eminently useful remedy.  In the armies of
France, it has recently been employed, I am told, with extraordinary success
in typhus fever, gangrene, &c.
   Does it not also promise to do good in many other diseases, such as para-
lysis, epilepsy, chronic mania, &c. &c.  C.
   (e) To the above fist of emmenagogue  medicines, may be added the poly-
gala senega, first used in this complaint, as far as I know, by Dr. Hartshorne
of this city, and introduced to the notice of practitioners generally, by Dr.
Chapman, in a paper on this subject inserted in the Eclectic Repertory for
October, 1811; in which some interesting cases and  remarks, in illustration
of the use of this powerful article of the materia medica are given.
   The mode in which it is prepared and used, is as follows.  In making the
decoction, a pint of boiling water is added to an ounce of the senega bruised,
in a close vessel;  and it is suffered to simmer over the fire, till the  quantity
is reduced one-third; to prevent naUsea,it is best to make the addition of an
aromatic, such as the orange peel or cassia. Four ounces  of this decoction at
a medium, is to be given during the day.   But at the time when the men-
strual effort is expected to be made, and till the discharge is actually induced,
the dose is to be pushed as far as the stomach will allow.  In the intervals of
the menstrual periods, the medicine is directed to be laid aside for a week or
two; as without these intermissions  it becomes  nauseous  and disgusting to
the patient. While under a course of the senega, it is recommended to keep
the general system properly regulated; and it is observed, that excessive ex-
citement or debility is to be equally obviated by the Use of the appropriate 
128
 pear, it is sometimes of advantage to exhibit a mustard emetic,
 and to make use of the  warm-bath or scmicupium or pedilu-
 vium.  Tourniquets have,  about this time, been  applied to
 the thighs, but not with much benefit.  Electricity, directed
 so as to act on the uterus, is occasionally of service.*
   When along with suppression of the menses, there is a ple-
 thoric condition, and more especially, if there be a febrile
 state, marked by heat of the skin, frequent pulse, flushing of
 the face, and irregular pains in the chest or abdomen, stimu-
 lating medicines are hurtful.   It is, in this  state, of  advan-
 tage, to keep the bowels open, by the daily use of some saline
 purgative,  dissolved in a considerable  quantity of water: and
 should there be dyspnoea, with pain about the chest, increased
 by inspiration, it will be proper  to take  away some blood.
 Should the skin still remain hot, the common saline julap will
 be of service.   The febrile symptoms being removed,  much
 advantage  may  be derived from a combination  of myrrh,
 oxyde  of iron, and the supercarbonate  of potash;  and if
 emmenagogues be thought  advisable, the black hellebore is
 the best.  The aloetic pill is the best purgative.f
   In the flabby relaxed  habit, in which there is  a disposition
 to  watery  effusions, laxatives, squills, and preparations of

remedies. For fuller information on this subject than can be compressed into
the limits of a note, the reader is  referred to  the interesting paper by Dr.
Chapman, above alluded to.
  * Blisters apphed to die region of the uterus, at this time, are exceedingly-
useful.  C.
  fin chlorosis, and indeed, in all the forms of amenorrhea, I have found
purges, I think, very beneficial. Calomel and aloes combined, I have prefev-
rod in these cases, To be useful it is necessary to continue this plan of treat-
ment for weeks.
  Professor Hamilton of Edinburgh, who is a most skilful practitioner in fe-
male complaints, advises very  strenuously, a mixture of digitalis and the sp.
scther. nitros.  in chlorosis.  The former, he directs mi large doses, as much as
len drops of the tincture every hour.  It would seem that digitalis is  only
applicable to those cases of the disease, which are attended with oedematous
swellings, but he does not thus restrict its administration.  I have never had
 occasion to try the medicine.  But certain it is, that among the best of the
emmenagogues, are the active diuretics,  C. 
129
 steel, with regular exercise, and frequent friction of the whole
 body, are the proper remedies of a general nature.(/)

       § 2.  FORMATION OF AN ORGANIZED SUBSTANCE.

   It sometimes happens, that the uterus, instead of discharg-
 ing a fluid every month, forms a membranous  or organized
 substance, which is expelled with pains and hemorrhage, like
 abortion.  Morgagni* describes this disease very accurately.
 The membrane, he says, is triangular, corresponding to the
 shape of the uterine cavity; the inner surface is smooth, and
 seems as if it contained a fluid; and that it does so, I have no
 doubt from  my own observation; the outer surface is rough
 and irregular.   According to Morgagni, the expulsion is fol-
 lowed by lochial discharge.^)
   Dr. Denman supposes, that no woman can conceive who is
 affected with this disease; but some cases, and amongst others,
 that related  by Morgagni, are against this opinion.  Mer-
 cury, bark, chalybeates, myrrh, and injections, have all  been
 tried, but  without much effect.  Time, in general, removes
 the disease better than medicine, which is only to be advised
 for the relief of pain, weakness, or any other symptom which
 may attend, or succeed to this state.   A knowledge of this
 disease may be of great importance to the character of indi-
 viduals.

                    § 3. DYSMENORRHEA.

   Some women menstruate  with great pain, and the dis-

  {/) In these cases blisters are strongly recommended. Vide a paper " On
♦he connexion that subsists in certain cases, between amenorrhcca and phthisis
pulmonalis, as Cause and Effect, by WiUiam Shearman, M. D."  Eclectic Re,-
pertory, Vol. I. p. 453.
  *  Vide Epist. XLVIII. Art. 12.
  (g) For the purpose of expelling  this membrane, the  volatile tincture of
gum guiaicum has been recommended, but in general it has failed in afford-
ing  relief, as fur as my experience goes. It is in cases of this description, that
Dr.  Chapman particularly recommends the poly gala senega; and thinks that
its use is theoretically supported, by the analogy- of its peculiar pow«r in de-
taching the membrane of the croup.
   VOL. I.                           g 
130
 charge generally takes place slowly, and is sparing^  This
 disease  is called dysmenorrhea.  It seems to be dependent
 on an imperfect menstrual action ; and this opinion is sup-
 ported by  observing,  that mild emmenagogues give  relief,
 but those of a stimulating quality arc not so proper. Saffron,
 madder, or rue, are often of service;  at the same time, the
 warm bath, or  semicupium,  is to  be employed for a day or
 two previous to menstruation, and should be repeated every
 night, during  its continuance.  The bowels are  to be kept
 in a regular state, by the careful exhibition of laxatives, and
 the general health is to be attended to on general principles.
 During  the attack, nothing  gives so much relief as opium,
 particularly if  combined with ipecacuanha, and given in a
 full dose so directed, by tepid diluents, as to produce perspi-
 ration.  It is to be given, if possible, just before the attack.
 If it cannot be  kept on the  stomach, it  must be given as a
 clyster.*
   This state of the womb sometimes produces, besides uterine
 pain, spasmodic affection  of the bowels, or violent bearing-
 down efforts of the abdominal muscles, as if it were intended
 to  expel the womb itself.  Such efforts arc also  sometimes
 made periodically, when the menses are altogether or nearly
 obstructed.  Under such  circumstances, we must  examine
 carefully into the state of the womb, and the  appearance of
 the discharge,  or whether  fibrous slreds  are not expelled.
 If no organic affection can be discovered, and the whole ap-
 pears to arise from spasm, we have only to  trust to opium in
 the meantime, with  such treatment in the  intervals,  as the
 state of the system may point out.   Some women though

  * Nothing I have found to afford more relief in painful menstruation than
 large doses of opium and camphor.  This medicine, however, will often fail.
 The extracts of hyoscyamus has been highly extolled.   But it is certainly in-
ferior to opium.  It would be well, I think, to try the datura stramonium, not
only inlhis, but in amenorrhcca generally.
  Blisters, in those cases, should not be omitted.  When applied to the sa-
crum, or the lowest of the lumbar vertebra, they will sometimes remove the
pain and bring on a free discharge of the menses.  There is, however, unfor-
tunately in private practice a great repugnance to the application of blisters
to these parts.  C. 
131
they menstruate abundantly, suffer much pain,  not only in
the uterine region, but also in  the belly, like  colic, accom-
panied with violent vomiting and head-ach.  This is relieved
by bitters, tincture of hellebore, and especially laxatives dur-
ing the interval, and by opiates during the attack of pain.

               § 4. COPIOUS MENSTRUATION.

   Some women menstruate more copiously, or more frequent-
ly than they  ought to do, by the general laws of the female
system. The discharge is menstruous, and does not coagulate,
which distinguishes this state from uterine hemorrhage.  Of
the two varieties, we oftener meet with those who menstruate
copiously, and for a  longer time than usual, than with those
who menstruate too  often, for the generality of these do not
menstruate, but  have  hemorrhage.   Copious or  prolonged
menstruation is only to be considered as a disease, when it is
not natural, that is, when it has not been habitual, and when
it produces weakness.  It may occur in those who are robust
and plethoric, or in  those who  are relaxed  and debilitated;
but women of the latter description are  oftener liable to he-
morrhage, than this state of menstruation.   If it is necessary
to interfere,  we must enforce  that  plan  which prevents the
vessels from being distended with blood, which lessens the
determination to the uterus, and which rectifies the state of
the constitution that predisposes to this  excessive  secretion.
1 need not be more particular,  as I shall  enter more into de-
tail in the next section.

                    § 5. MENORRHAGIA.

   Hemorrhage takes place from the uterine  vessels more fre-
quently than from any other organ in the female system.  It
may occur in  two very different states of the constitution;
in a full, robust, and active habit, or  in a weak and perhaps
emaciated frame.  In these opposite states, the v essels of the
womb may give way,  in the one case from over-action,  or
distention ; in the other from  debility.  In the  one, there is 
132
generally a forcible circulation, but always a turgescence of
the vessels; in the other, there is a languid motion, and not
unfrequently from the same cause, the hemorrhoidal vessels
swell, producing piles.
  Uterine hemorrhage is always accompanied with marks of
uterine  irritation, such as pain  in the back and about the
pelvis, and is besides attended by constitutional or general
syjnptoms, such  as a febrile  state in one case, and debility,
trith hysterical affections in another.   During  the intervals
pf repeated menorrhagia, the health suffers more or less, ac-
cording to the loss of blood, and  in addition to this general
effect,  there is usually, especially in those of a debilitated
frame, many dyspeptic affections, and very often leucorrhseal
discharge.  In process of time, visceral disease may be pro-
duced, or the patient becomes dropsical.
  The causes giving rise to menorrhagia, may be divided into
those which occasion the two predisposing states of plethora,
and weakness of  the vascular system, and those which act
more immediately on the vessels of the uterus.  Of the first
kind, may be mentioned those which, on the one hand, in-
crease the quantity of blood,  as rich diet, indolence, &c. and
on the other, debilitate the body, as fatigue, abstinence, pro-
fuse discharges, &c.  Amongst the exciting causes, or those
more particularly affecting the uterine vessels, may be men-
tioned, the excitement produced by excessive venery;  irrita-
tion of the neighbouring organs; torpor of the veins, pro-
duced by costiveness;  debility of the womb, occasioned by
abortion, qj* laborious  parturition.   Menorrhagia may  also
be caused by irritation  of the  vessels communicated by the
state of the uterus itself, and hence it very often attends
prolapsus, some change of structure,  or other organic dis-
ease, and therefore in  all cases  of  obstinate discharge, wc
onght carefully to examine the state of the womb, both as to
position and structure.
   Married women are  more liable to menorrhagia than vir-
gins, and it  is rare for these, if otherwise healthy, to have
uterine hemorrhage.
   The management during the  attack, must depend  on the 
133
state of the constitution, and the effect of the discharge.   In
full robust habits, when the pulse is firm, a febrile state exists,
and if the hemorrhage has not produced much debility, excel-
lent effects may result, as in other active hemorrhages, from
the early use of the lancet, by which the uterine discharge is
speedily checked,  and that  before  the vessels are so much
weakened  as to occasion a rapid return.  But if the pulse be
small or weak, and no febrile state exist, venesection is not
to be proposed, nor can I conceive, that it is in any case use-
ful, if delayed long.  Whether the lancet is, or  is not to be
used, the succeeding part of the treatment is much the same.
The patient, on a general principle, is to  be kept from the
very first  in bed, that she may he  in a  recumbent  posture.
This I consider as of the utmost importance.  Next,  we are
to moderate the action of the vascular system by cold, that
is, we are to have  the windows open, if  in summer, and no
fire if winter,  and  no more  bed-clothes than  are necessary
to prevent shivering.  The  drink  is to be  sparing and cold.
Sulphuric  acid is  to  be given  freely,  and along with this,
digitalis(A) may be prudently administered, so as to moderate
the circulation.  For the same purpose, nauseating doses of
emetic medicines have been  employed, and sometimes with
good effect.   The  diet is to be almost dry,  and of the least
nutritious quality.  Wine and all stimulants are to be avoid-
ed.   In order to restrain the  action of  the uterine vessels,
cloths wet with cold water are to be applied to the vulva, or
to the back and pubis.  If these do not check the discharge,
the vagina must be stuffed with a  soft cloth, to  retain  the
blood and promote coagulation.(i)

  (A) Digitalis must be used with great caution and discrimination in uterine
hemorrhages. Where it has been injudiciously exhibited, it has been knowu
to increase the flow; particularly  where the inordinate  discharge depends
upon a topical relaxation of the vessels, which this medicine must necessari-
ly tend to aggravate.
  (*) This by the French physicians is termed le tampon.  It is, perhaps, most
readily effected, by taking a pretty large piece  of soft cloth, dipping it in
oil, and then wringing it gently. It is to be introduced by the finger, portion
after portion, until the  lower part of the vagina is well filled.  The remain-
dtr is then to be pressed firmly on the  orifice, and held there for some time1." 
134
   In debilitated  habits, or  in plethoric patients, when the
 discharge has been profuse,  and produced much debility, the
 treatment must  be modified.  Immediate confinement to a
 horizontal posture, is,  as in the former case, to be strictly
 enforced.   Cold must be applied both generally and locally,
 but it cannot be carried so far as in active hemorrhage, nay,
 in extreme  cases, where the vital powers are much depressed
 and the extremities cold, it may be necessary to apply warm
 flannel  to the feet and legs,  or even  to  the body in general,
 to preserve the heat requisite for recovery.  This is a matter
 not of choice, but necessity, and to the judgment of the prac-
 titioner it must be left,  to avoid the evils arising  from the
 stimulating effects of heat, and the depressing effects of cold.
 In this, much attention  must be paid to  the sensations of the
 patient.  When the debilitating effects are not considerable,
 we are  satisfied with a  horizontal posture, avoiding the sti-
 mulating  effects of heat, stuffing the vagina to promote coagu-
 lation,  applying cloths wet with cold water to the external
 parts, and administering a dose of opium not  less  than two
 grains,  and this is to be repeated if the debility  be greater.
 The diet  is to  be sparing, the drink  acidulated, and  every
 exertion avoided.
  If the debility be great, or the face pale, the lips blanched,
 the extremities cold, the pulse small, and the patient attack-
 ed with vomiting or syncope, the danger is not small; it is
 great in proportion to the extent of the weakness, and the
 obstinacy of the discharge.   In such cases the patient must be
 carefully watched.  The  vagina is to be kept stuffed, or if the
 plug is removed, it is only for the purpose of injecting a strong
 solution of sulphate of alumin.   The  strength is to be sup-
 ported by liberal doses of opium; by jellies  and soups : by
 the moderate and well-timed use of wine, either cold or warm-
 ed with spices; by external heat so far as is necessary to pre-

This acts by giving the effused blood time to coagulate.  It gives no pain,
and produces no irritation.  It is strongly recommended by Osborne and
Burns. In obstinate cases, before introducing the tampon, it has been recom-
mended to insert a little powdered ice, tied up in a rag. Vide Burns's Obser-
vations on Abortion,  p. 102. 
13d
vent the body becoming cold; and by the use of aromatic cor-
dials, sudi as aromatic spirit of ammonia, mixed with cinna-
mon water.
  The immediate violence of the attack, in either of the cases
I have been considering, being over, the patient may remain
for some time free from  a return of the discharge, and then
may have another severe attack, or she may have every day
more or less hemorrhage.  I must therefore next direct the
attention to those means which are to be employed for the per-
manent cure of the patient.   These must depend on the state
of the constitution, and the nature of the exciting  causes.  In
the robust or plethoric habit; we must lessen the  quantity of
blood, and diminish the force  of the circulation, or the dis-
tension of uterine vessels, by  dry diet, of the least nourishing
and stimulating kind; a large proportion of vegetables ought
therefore to be taken at dinner, and both wine and malt li-
quor should be avoided.  Regular exercise must  be resorted
to, in such a degree as shall  prevent fulness,  and strengthen
the vessels, on the one hand,  without going the length, on the
other, of exciting the circulation, so much as  to produce rup-
ture.   Purgative medicines  are of much service, especially
those which act also on the kidneys, such as sulphate of mag-
nesia, or Cheltenham salts.   These not only lessen the quan-
tity of circulating fluids, but  divert the current from the ute-
rine vessels.  This  may be farther assisted by supertartrite
of potash, ethereal spirit of nitre,  and other  mild diuretics.
The application of cold to the  surface, especially if unequal,
and to the lower extremities is  hurtful, by determining to the
internal parts. Heat in a stimulant view is to  be avoided; but
on the other hand,  cold, by checking  the  perspiration, is
hurtful.   The sleep should be abridged, and taken on a hard
bed, with not too much covering.  The uterine vessels arc to
be strengthened by the daily use of the  bidet, and injecting
cold water into the vagina.   Astringent injections  are not
proper, until the active state of the vessels be removed. Every
exciting cause must be avoided.   After the plethoric condi-
tion is obviated, the cold bath is excellent. 
136
  In debilitated habits, whether the weakness have existed from
the first, or have succeeded to plethora, the practice must be
somewhat varied.   Moderate laxatives, especially mineral
waters, are proper to improve the tone  of the  bowels, and
prevent languid  circulation in the veins.  Tonic medicines
are to be given, such as different preparations of iron, chaly-
beate waters, such  as that of Tunbridge,  and bitters; of the
last, the uva  ursi in doses of half a dram,  three times a day,
is often of use; at the same time,  to either of those medicines,
may be added such doses of squills, as shall direct moderately
to the  kidneys.  Much liquid is to  be avoided, but the diet
should be more nutritious than in the former case, and so much
wine may be  given  as shall not stimulate the  circulation, or
produce heat or flushing.  Claret is the  most  useful  wine.
Opiates at bed time  are often of advantage, in preventing irri-
tation. The cold bath is of great benefit;  and by way of pro-
ducing contraction of the uterine vessels, astringent injections
should be frequently employed.  In obstinate cases, a similar
effect may be produced by ipecacuanha emetics. They rarely
do harm, and have been known to check the discharge in very
alarming  situations.  Friction on the surface of the body is
useful, by determining to the extreme vessels.   Every thing
which can excite the uterine vessels, must be avoided, such as
dancing, long walks, venery, &c. If in spite of these means,
the hemorrhage still continue or return, there is reason to
fear, that it is kept  up by something more than the general
condition, which I have been considering;  for instance, by
some organic affection of the uterus, not discoverable by the
finger, perhaps as yet in an incipient state; by a diseased  or
varicose state of the vessels; or if the patient be young, by a
scrophulous  constitution, which does  not readily yield  to
general remedies.
  In  constant stillicidium, unaccompanied with organic af-
fection, the best remedies are tonics and astringent injections.
This often stops spontaneously for two days before and after
menstruation.
  In weak habits, there is sometimes  a slight discharge of 
137
blood for a day, at the end of a fortnight after menstruation".
This is to be cured by strengthening means.*
                         CHAP. XIII.


                  Of the  Cessation of the Menses.

    About the period when the menses should cease, they be-
 come irregular, and sometimes are obstructed for two or three
 months, and then for a time return.   This obstruction,  like
 many other cases of retention and suppression of the menses,
 is accompanied with swelling of the belly, sickness, and loath-
 ing of food.   These effects are frequently mistaken for preg-

   * Hitherto, those uterine hemorrhagies -which observe a periodical regu-
 larity in their recurrence, have been, very commonly, confounded with an
 increased flow of the menses.   To this error we are, perhaps, to impute, in
 some degree, the uncertainty of our practice in .these  complaints.  My own
 experience  confirms the observation  of Mr. Burns, «* that all profuse dis-
 charges from the uterus are hemorrhagies." These are often to an extent to
 threaten immediate danger.  Menorrhagia, on the  contrary, even  when
 most copious, is never alarming, except in its remoter consequences.   The
 former complaints may be commonly checked, like other hemorrhagies, by
 the acetate of lead, by combinations of opium and ipecacuanha, by bleeding
 where the pulse is full and excited, &c. But the latter, as resulting from a
 natural secretory action of the uterus,  will run on to the usual period  of its
 termination, whatever may be done, unless the discharge be suppressed by
 some  rash and violent isterference.  In  menorrhagia proper, httle else is
 required during the flow than rest, a cool room, some acidulated  drink, as
 cremor tartar: to open the bowels, and occasionally, if there be pain or irri-
tation, an anodyne.  But, in the intervals of menstruation, we should endea-
vour by various  means to make such an  impression on the system as w ill
 restore to the uterus its healthy actions.  The remedies, in these cases, are
well known.   Before dismissing this subject, it may, however, be useful to
 mention, that professor Hamilton, of Edinburgh, urges the most intrepid em-
 ployment of opium in periodical hemorrhagies.  He says, that he has given,
 in a case, as much as twelve grains of it in twenty-four hours with singular
 advantage.  Though it is difficult with me to reconcile the efficacy of such
 doses of opium in hemorrhagy with the views I have adopted of the  mode
 of operation of the medicine, yet from my faith in the judgment of Dr.
Hamilton, I would, if necessary, not hesitate to make the experiment. C.
   VOL.  I.                             T 
138
nancy: for, as La Motte remarks, many women have such a
dislike to  age, that they would rather persuade themselves
they are with child, than suppose they are feeling any of the
consequences of growing old; and  this persuasion they in-
dulge like Harvey's widow, donee tandem spes omnis in Jlatum
et pinguedinem faeesseret.  In this situation, the belly is soft
and equally swelled, and enlarges more speedily after the ob-
struction, than it does in pregnancy.  No motion  is felt, or
if it be, It is from wind in the bowels, and shifts its place.  Ex-
ercise, chalybeates and laxatives, are the proper remedies in
this case.*
  The period at which the menses cease, or  «the time of
life," is considered as  critical, and, without doubt, it is an
important epoch.  If there be a tendency to any organic dis-
ease, it is greatly increased at this time, more  especially, if
it exist in the uterus or mammae: and, indeed,  the cessation
of the menses does  of itself seem, in  some cases, to excite
cancer of the breast.  Diseases of the liver, also,  make greater
progress  at this period, or first appear soon after it. Dys-
peptic affections are still more frequent.  When there is  no
tendency to local disease, it is very common for  women, after
the menses cease, to become corpulent, and sometimes they
enjoy  better health than formerly.
  From an idea of the cessation of menstruation being uni-
formly dangerous, some, by the use of emmenagogues, tried
to prolong the discharge, others, by issues, endeavoured to
prevent bad effects.   The first of these means is foolish and
hurtful, the last is not necessary.   When the health  is good,
no particular medicines are requisite; but if there be a ten-
dency to any peculiar disease, then the appropriate remedies
must be employed.   The bowels must be kept open.(/e)

  (fc) For some very interesting practical remarks on this subject, the stu-
dent is referred to a paper by the justly celebrated Dr. John Fothergill, on
" The Management proper at the Cessation of the  Menses," in Medical
Observations and Inquiries, vol. V. Also in the collection of his Works.
•V-"1 
139
                        CHAP.  XIV.

                        Of  Conception.

   Conception seems to  depend  upon the influence of the '
 semen exerted on the ovaria, through the medium of the rest
 of the genital system;  for  women  hare  conceived,  when
 semen has been applied merely to the vulva, the hymen  being
 entire.(£)  In consequence of this,  an ovum fs excited into ac-
 tion ; it enlarges; the peritoneal covering becomes more vas-
 cular, and is made to protude a little.  Then that part which
 covers the vesicle is absorbed, whilst the vesicle itself escapes
 into the fallopian tube, which had, at the time of  impregna-
 tion, embraced the  ovarium;  and thus it  is conveyed into
 the uterus.   When the ovum is received into the tube,  and
 either carried into the womb,  or brought a certain way along
 the canal,  the tube  loosens from  the  ovarium, and the ab-
 sorbed spot on  the  surface of the ovarium  is  perceptible.
 This afterwards forms a corpus luteum.*
   It  would  appear, that although  an ovum be impregnated,

   (/) A collection of cases of  this kind, will be found  in a work entitled
 Speculations on Impregnation  by R. Couper, M. D. &c. they are however of
 doubtful accuracy. In all the cases of this kind which have been investigated
 by the Editor, it would appear  that minute foramina have existed in the
 membrane called Hymen.
  * Amid the uncertainty which exists on the subject of generation, there
seem to be some points very accurately ascertained.  Thus, from the expe-
 riments of De Graaf on rabbits, we long since learned.
  1. That the ovaries are the  seat of conception.  2. That one or more of
their vesicles become changed.  3. That the alteration consists in an en-
largement of them, together with a loss of transparency in their contained
fluid, and a change of it to an opaque and reddish hue.  4. That the num-
 ber of vesicles thus  altered, corresponds  with the number of foetuses, and *»
 from the former are formed the true ova.  5. That these changed vesicle's,
 at a certain period after they  have received the stimulus o£-the male, dis-
 charge a substance, which, being laid hold of by the fimbriated extremity of
 the fallopian  tube, and conveyed into the uterus, soon assumes a visible
 vascular form, and is called an ovum.  6. That these rudiments of the new
 animal, which, for a  time, manifested  no arrangement of parts, afterwards
 begin to elaborate and evolve the different organs of which the new animal
 is composed.   To these facts ir#^ay add, that the calyx, or capsule, which 
140
 yet, by various causes, the process afterwards may be  inter-
 rupted ; the ovum  shrivels,  and is absorbed.   If there be an
 impervious state of the tubes, or any conformation or condi-
 tion, rendering it impossible for a child to be supported, the
 ovum decays, and  the woman is barren.   Or if such a state
 be induced after impregnation, and before the ovum descends,
 the process stops.*
          •
 formed the parietes of the vesicles, thickens, by which the cavity i9 dimin-
 ished.  This cavity together with the opening through which the foetal rudi-
 ments escaped,  becomes obliterated, and from the parietes of the vesicles
 having acquired  a yellowish hue, they are called corpora lutea.  Such was
 pretty nearly the extent of our information respecting this mysterious func-
 tion, when the celebrated Mr.  Haighton some few years ago, engaged in
 an experimental'investigation of the subject, and established, among others,
 the following additional points.
   1. That the existence of the corpora lutea,  as was previously alleged by
 De Graaf, is iflfcontestible" proor of impregnation having preceded.
   2. That contrary to «the opinions of most physiologists, neither the vesi-
 cle of the ovary is ruptured, nor the fallopian tube applied to the ovary dur-
 ing the act  of coition ;  but, that several days elapse before the vesicle ar-
 rives at sufficient maturity to discharge its contents, till which time, the fal-
 lopian tube does not change its ordinary position.
   3. That, in contradiction to the observation of De Graaf, Malpighi,  and
 Cruikshank, the  substance which  passes from the ovary is merely a gela-
 tinous fluid, which assumes nothing of the circumscribed vesicular character
 of the ovum till a considerable period after it is deposited in the uterus.
   4. That the semen masculinum is apphed to the ovary neither by the fallo-
 pian tubes, nor by absorption, nor in the form of aura seminalis.
  He concludes,  therefore, that  fecundation is performed  by  that " law of
 the animal system termed sympathy, or consent of parts."   The doctrine is
 thus stated:
  The  semen first stimulates the vagina, os uteri, cavity of the  uterus, or all
of them.
  By sympathy, the ovarian vesicles enlarge, project, and burst.
  By sympathy the tubes incline to the ovaries, and having embraced them,
convey the rudiments of the foetus to the uterus.
  By sympathy the uterus makes the necessary preparations for perfecting
the formation and growth of the  foetus: and finally,
  By sympathy the breasts furnish milk for its support after birth.  C.
   * Dr. Haighton found, that by dividing the tubes, after a rabbit was im-
pregnated, the ova were destroyed.  Or if only one tube was  cut, and the
female afterwards became impregnated, corpora lutea were found in both
ovaria, but no ova were found in the tube or horn ofthe uterus, on the injured
side.  Phil. Trans. Vol. LXXXVn. p. 175. &c, 
141
   In the human subject, only one ovum is generally impreg-.
 nated by one seminal application, but sometimes two or more
 may be carried down  into  the uterus; and even after one
 ovum has reached the uterus, and grown to a certain degree
 within it, we find, that it is possible for a second to  be ex-
 cited into action, and brought down into the womb, where it
 is nourished and supported.*
   From the experiments of Mr. Hunter,! it is probable, that
 each ovarium is capable  of producing only a certain number
 of ova; and that if one ovarium be removed or rendered use-
 less, the constitution cannot give to the other the  power of
 producing as many ova as could have been done by both.
   It has been attempted to ascertain what age, and what sea-
 son  was most prolific.   From an accurate register made by
 Dr.  Bland,  it would  appear, that more, women,  between the
 age  of twenty-six and  thirty years, bear children,, than  at
 any  other period.  Of 2102 women, who bore  children, 85
 were from fifteen to twenty years of age; 578 from twenty-
 one  to twenty-five ; 699 from twenty-six to thirty;  407 from
 thirty-oue to thirty-five; 291  from thirty-six  to forty; 36
 from forty-one to forty-five; and 6 from forty-six to forty-nine.
   At Marseilles,  M. Raymond says, women conceive most
 readily in Autumn, and chiefly in October; next in Summer;
 and  lastly in Winter and Spring; the month of March hav-
 ing fewest conceptions.  M. Morand again says,. that July,
 May, June, and August,  are the most frequent dates of con-
 ception ; and November, March,  April, and  October, the
least frequent in the  order in which they are  enumerated.
I have been  favoured with a register, for ten years,  of an ex-
tensive parish in this  place;  from which it appears, that the
greatest number, both of marriages and births  take place
m May, and the fewest births in  October.  From this we
would consider August  and September to be most favourable
to coioception ;  but it is evident, that these  conclusions are-
liable to great uncertainty.

  * Vide Med. and Phys. Journ. Vol. XVII. p. 489.
  f Vide Phil. Trans. VoL LXXVII. 
142
   Women are supposed to conceive most readily immediately
 after the menstrual evacuation, but it is doubtful how far this
 opinion  is correct; and therefore, in calculating  the time
 when labour should be expected,  it is usual to count from  a
 fortnight after the last appearance of  the menses, or to say
 that the woman  will be confined  at the end of the forty-
 second week from that period.
   The process of gestation usually requires forty-weeks, or
 nine calendar months for its  completion ; but many circum-
 stances may render  labour so'mewhat  premature,  and it  is
 even possible for the process to be completed, and  the child
 perfected to its usual size,  a week or two  sooner  than  the
 end of the ninth month.  On the other  hand, it is equally cer-
 tain that some causes, which we cannot explain nor discover,
 have the power of retarding the process, the woman carrying
 the child longer than nine months ;(m) and the child, when
 born, being not larger than the average size.  How  long it
 is possible for labour to be delayed beyond  the  usual time,
 cannot easily be ascertained; but it is very seldom protracted
 beyond a few days,  counting  the commencement  of preg-
 nancy, from the  day preceding  that  on which  the menses
 ought  to have appeared, had the woman not conceived.

  (m) The ancient laws of France allowed that a legitimate birth might take
place ten months after the connexion of the sexes : in Scotland, the law con-
siders a child born six months  after the marriage of the mother, or ten
months  after the death of the father,  as legitimate.  The English law,
\v hich has been adopted in the United States, considers all children as legiti-
mate, who are born in lawful matrimony, or within about forty  weeks after
the dissolution of the marriage by the death of the husband.  It endeavours
to avoid enquiring when, or by whom the child may have been begotten ;
 the general rifle being prestanitur pro legitimatione. 
143
                      CHAP. XV.

                  Of the Gravid Uterus.

                 § 1. SIZE AND POSITION.

  When we compare the unimpregnated with the gravid
uterus at the full time, we must be astonished at the change
which has taken place during gestation, in its magnitude alone.
  In  the ninth month, the size of the  womb is  so much
increased, that  it extends almost to the ensiform  cartilage
of the sternum; and this augmentation it receives gradually,
but not equally, in given times; for it is found to enlarge
much faster in the latter, than in the earlier months of preg-
nancy.  This is true, however, only with regard to  the abso-
lute increase, for  in the  first month, the  uterus perhaps
doubles its original size,  but  it does not go on in the same
ratio.  It is not twice as large in the ninth  as in the eighth
month.
  In the second month, the uterus is enlarged in every part
without much change of shape.  Towards the end of the
third month, it generally measures from the mouth to the
fundus above five inches, one of which belongs to the cervix.
In the fourth month, it reaches a little higher, and measures
five inches from the fundus to the beginning of the  neck.  In
the fifth, it has become so much larger, as to render the belly
tense, and may be felt, like a ball, extending to a middle point
between the pubis  and navel, and measures about six inches
from  the  cervix  to  the  fundus.  In other two months, it
reaches to the navel, and measures about eight  inches.   In
the eighth month, it ascends  still higher, reaching to about
half way between the navel and the sternum.  In the ninth
month, it reaches almost to the extremity  of  that bone,  at
least in a first pregnancy, when the tightness of the integu-
ments prevents it  from hanging so much forward as it after-
wards does. At this time, it generally measures, from top 
144
 to bottom, ten or twelve inches, and is oviform in its  shape.
 For th* first month, the shape of the uterus is not altered;
 it is enlarged  in every direction.  But after this it swells
 before and behind; and soon becomes globular, having the
 cylindrical undistended cervix  depending from it; after the
 fifth month it becomes more oblong, and  by the seventh it
 resembles a balloon.   These calculations are not invariably
 exact, suiting every case, but admit of modifications.
  In pregnancy, the mouth of the uterus is directed back-
 ward, whilst the fundus lies forward.  This obliquity, how-
 ever, does not take place until the uterus begins  to rise out of
 the pelvis, and it always exists in a greater degree in those
 who have born many children.
  From this position it appears, that the intestines can never
 be before the uterus, but must lie  behind it and  round its
 sides.
  Previous to the descent of the ovum, the uterus  begins to
 enlarge, especially at its upper part,  or fundus;  and  it is
 worthy  of notice, that the posterior face of the uterus  always
 distends more than the anterior one, as we ascertain by ex-
 amining the situation of the orifices of the fallopian tubes.
  When the fundus begins to increase, it not only grows
heavier, but also presents a greater surface for pressure to
the intestines  above:  it, therefore, will  naturally descend
lower down in  the pelvis, and thus project farther into the
vagina.   In this situation the uterus will remain, until it be-
 comes so large as to rise out of the pelvis. This ascent takes
 place towards the end of the second quarter of pregnancy, if
 the pelvis  be  well formed, and the uterus increase  in the
 usual ratio.

 § 2. DEVELOPEMENT OF THE  UTERUS AND STATE  OF  ITS
                         CERVIX.

  In the fifth month of pregnancy, the cervix begins to be de-
 veloped :  so that by the end of the  month, one  quarter of its
 length  has become distended, and contributed to  augment 
145
the uterine cavity; the other three-fourths, which remain pro-
jecting, become considerably softer, rather thicker, and more
spongy. In another month, one half of the cervix i$ distend-
ed, and the rest is still more thickened, or the circumference
of the projecting part greater : the uterus has also risen far-
ther up, and the vagina is more elongated. -  In the seventh,
we may, with the finger, distinguish  the head of the child
pressing on the lower part of  the uterus, which we can sel-
dom do before this.  In the eighth month, the neck is com-
pletely effaced, and its orifice is  as high as the brim  of the
pelvis.  The ninth month affects the mouth of the  uterus
chiefly.  The alterations of the cervix are discovered, by in-
troducing the finger into the vagina, and estimating the dis-
tance betwixt the os uteri and the body of the uterus, which
we feel expanding like a balloon.
   The mouth of the uterus is  merely the termination or ex-
tremity of the cervix, and consists of two lips of the same con-
sistence with the rest of the uterus.   When the womb* is  not
gravid, these are always open,  and will  admit the tip of the
finger.  But, soon after conception, the os uteri is  closed,
except at the very margins, at the same time that it gradually
becomes softer.  In proportion  as pregnancy advances, and
the cervix stretches, the lips shorten, until  they sometimes
totally disappear ; but more frequently they continue to pro-
ject a little, until labour commences.   All the inner surface
of the cervix uteri, in the whole course of gestation,  is  full
of  glandular follicles, which  secrete a thick viscid  mucus.
This extends from the one side to the other,  and  fills up  the
mouth of the uterus very perfectly, being thus interposed as
a guard betwixt the membranes and  any foreign body.   By
maceration, it may be extracted entire, when a mould of the
lacunae will be obtained by floating it in spirits, saturated with
fine sugar.

                  § 3. MUSCULAR FIBRES.

   Vesalius describes three strata of muscular fibres, trans-
verse, perpendicular, and oblique.  Malpighi describes them
   vol.  i.                         v 
146
as forming a kind of net work; whilst Ruysch maintains, that
they appear at the fundus, in concentric planes, forming an
orbicular muscle.  Dr. Hunter paints them as transverse in
the body of the uterus, but, at the fundus describing concen-
tric circles arqund each of the  fallopian tubes.  These con-
tradictions of anatomists serve to sho>v, what may readily be
seen by examining the uterus, that the fibres are not very re-
gular and distinct in their course, but exhibit confusion, rather
than any well marked figure.
   The increased sized of the uterus is by no means chiefly ow-
ing to the addition of muscular fibres.  These become indeed
larger, and better developed, but do not contribute so much
to the increase, as the enlargement of the blood vessels, and
perhaps the deposition of cellular substance.   This gives the
uterus a very spongy texture, and makes it so ductile, that a
small aperture may be greatly dilated, without tearing.(rc)
From examination, it appears, that although the whole uterus
does not grow thinner in proportion to its increase, it yet
does, at the full time, become thinner near the mouth ; whilst
the  fundus  continues the same, or perhaps grows a little
thicker, at least where the placenta is attached.

                      | 4. LIGAMENTS.

   No one, who understands the anatomy of the ligaments of
the unimpregnated uterus, will be  surprised to find a great
change produced in  their situation and  direction, by preg-
nancy.   The broad  ligament, which is only an extension of
the peritoneum from the sides  of the uterus, is, in the ninth
month, by the increase of the viscus, spread completely over
its surface; and consequently, were we to search for this liga-
ment, we would  be disappointed.  Its duplicatures are all
 separated, and laid smoothly over the uterus.   It will there-
 fore be evident, that we can no longer find the ovaria and
 fallopian tubes floating loose  in the pelvis,  nor the round

   (?i) See a paper already referred to on the Muscularity of the Uterus, by
Charles Bell, Esq. F. R. S. Eilin. pubhshed in the 5th vol. of the Eclectic
Repertory, p. 27. 
Off
 ligaments running out at an angle from the fundus uteri to
 the groin.  All these are contained within duplicatures of the
 peritoneum, or ligamentum latum; and therefore, when this
 is spread over the uterus, it follows, that the ovaria, tubes,
 and round ligaments, cannot now run out loosely from the
 uterus, hut must be laid flat upon its  surface, and  bound
 down by the stretched peritoneum.  This description applies
 only to the state of the uterus in the full time.  Earlier, we
 may readily observe the broad ligament flying  out, and al-
 lowing the ovaria free play. The loose extremity of the tube
 becomes more expanded, and very vascular, and  forms  a
 kind of cavity called the antrum.
   On the ovarium we observe a  corpus luteum.  This is &
 substance something like a gland,  divisable into cortical and
 medullary  matter, placed immediately under  the  membrane
 of the ovarium, and adhering to the ovarium by cellular sub-
 stance.  By separating this, it can be turned out.  It is of a
 yellowish colour, and is largest soon after conception. There
 is a corpus luteum for every foetus.

                      § 5. VESSELS.

  The  origin, and distribution of the blood vessels of the
 uterus have been already noticed;  I have only to add, that in
 pregnancy, they become prodigiously enlarged. Even before
 the ovum enters the  uterus, we  find the uterine artery as
large as the  barrel  of a  goose quill,  and  sending large
 branches round the  cervix  uteri,  and  up the  sides of the
 womb.  As pregnancy advances, the trunks, but especially
the branches, become still larger, particularly near the im-
plantation of the  placenta.  The  veins are enlarged in the
same proportion  with the arteries.  They are destitute of
 valves, and receive the name of sinuses.
  The lymphatics are very large and very numerous.   The
 lwrves have already been described. 
14H
                   § 6. OF THE F02TUS.

  Although many opportunities have occurred to anatomists,
of examining not  only abortions, but also the uterus  itself,
at an early period of gestation; yet it  has not been exactly
determined at what precise time  the ovum enters the womb,
or when the foetus first becomes visible.   This may depend,
partly on want of information respecting  the exact number
of days which have intervened betwixt impregnation and our
examination; and partly, perhaps, upon irregularities of the
process in  the human female, induced by various causes.
   We know that considerable changes take place in the cavity
of the uterus, before the  ovum descends, and these generally
are not accomplished in less than twenty or thirty days.  In
a very accurate dissection performed by the late Mr. Hun-
ter, and related by Mr. Ogle,* no ovum could be found either
in the  uterus  or the tubes, although there is reason to sup-
pose  that  nearly a month  had elapsed  from the time of im-
pregnation. I have examined very carefully three uteri about
the  same period,  and have not  been able to discover either
ovum or foetus.  If we  admit analogical  evidence  on this
subject, we shall be more confirmed in a belief that the ovum
does  not, in the human female, enter the uterus, until at least
three weeks  after  conception.!   In the  rabbit,  whose
period of gestation is only thirty days, the ovum is not to be
found in the uterus earlier than the fourth day, according to
Mr. Cruikshanks,!  or the sixth,  according to Dr. Haigh-
ton ; and the foetus is not  visible till the eighth day, when it
may  be seen by  dropping vinegar on the ovum.§   Haller
found,  that  in the  sheep, whose term of gestation  is five
months, the ovum does not  enter the uterus till the seven-
 teenth day,|| and  the foetus is not visible till the nineteenth.
  * Transactions of a Society, &c. Vol. II. Art vi.
  ■J- Dr. Comb possessed a preparation, where there was an appearance of a
very minute  fcetus. From pecuhar circumstances, two and twenty days were
supposed to  have elapsed from the time of conception.  Vide Dr. Hunter's
Anatom. Descrip. p. 87.
   * Phil. Trans. Vol. LXXXVII.
   § Phil. Trans. Vol. LXXXVII. p. 204.
   D Elementa, Tom. A in. p. 59.—Opera Minora, Tome II. p. 434. 
149
  The ovum, at first, contains no visible embryo ;  nothing
but vesicular involucra appear.   This  point  is  fully esta-
blished by examining the inferior animals, and is especially
confirmed by the incubation of the eggs of fowls.  I have ex-
amined carefully a most perfect ovum in the ninth week after
menstruation, consequently not less than the fifth after con-
ception.  In it no embryo could be  detected.   The chorion
was as large as a small chesnut, covered with shaggy vessels,
and filled with transparent jelly like the vitreous humour of
the eye.  Within, and adhering to one side, was the  amnion,
not much larger than a coriander seed.* It contained nothing
but transparent fluid.
  When the human foetus is first  distinctly visible  through
the membrane,  it is not above a line in length,  and of an
oblong figure.   In the sixth week, it is seen slightly curved,
resembling, as it floats in the water,  a split pea.  In the
seventh week,  it is equal in size to a small bee; and, by the
conclusion of the second month, it is bent  and as long as a
kidney bean.
  The embryo, at first, appears like two oval bodies of un-
equal size, united together by a neck.   The one of these is
the head, the  other the trunk.  The head is a membranous
bag, which is large in proportion to the body; but  after the
first  month of its growth, the relative size decreases: on
opening it,  nothing but a soft pulp is found within.   In a
little  time, the  face appears,  the most prominent features of
which are the eyes; these are proportionally larger in the
embryo than in the advanced foetus, and are placed low down.
The face itself is  small, compared to the cranium.  The nose
does not appear until the end of the second month ; but some-
what  sooner, we  may obsci've two apertures in the situation
of the nostrils.  The mouth, at first, is  a round hole, but by
degrees lips appear; and after the third month, they are closed,
but do not cohere.  The external ear is not formed at once,
but in parts, and  is not completed  before the fifth month;
even  then, it differs in its shape from the car after birth.  It
is at first like a gently depressed circle.
   The extremities early appear like the buds of a plant.  The 
150
 arms are directed obliquely forward, toward the face, and are
 larger than the inferior extremities.  The genitals, for a time,
 are scarcely to be observed; but in  a third month, they are
 large  in proportion to the body.
   The foetus does not grow in a uniform  ratio, but, as has
 been observed, by the learned anatomist, Dr. Soemmering,(o)
 the increment is quicker in the third than  in  the second
 month.  In the beginning of the fourth it becomes slower,
 and continues so  until the middle of that month, when  it is
 again  accelerated.  In the sixth month,  it is once  more re-
 tarded, and the progression remains slow during the rest of
 gestation.
   The proportion between the weight of the foetus and its
 involucra, is reversed at the beginning and the end of gesta-
 tion.  When the embryo does not weigh more than a scruple,
 the membranes are as large as a small egg.  Even  when the
 fcetus  is not larger than a fly, the membranes resemble,  in
 shape  and size, a  large chesnut.  On the other hand, at the
 full time, when the foetus weighs seven pounds, the placenta
 and membranes do not weigh a pound and a half, and the pro-
 portion of liquor amnii is greatly lessened.   In the twelfth
 week,  the foetus weighs nearly two  ounces, and measures,
 when stretched out, about three inches.   The membranes are
 larger than a goose's egg, and weigh, if we include the liquor
 amnii, several ounces.  In the fourth month, the  foetus  is
 about five inches long.  In the fifth month, it measures six or
 seven inches.   In the sixth month, the foetus is perfect  and
 well formed, measures eight or nine inches, and weighs about
 one pound troy; whilst the placenta and membranes weigh
 about half a pound, exclusive of the liquor amnii.  The foetus

  (o) The student is particularly requested, where that most valuable work
is within his reach, to compare this description of the foetus in its different
stages of progressive developement and growth, with the most accurate and
elegant plates of Soemmering, entitled, Icones Embryonum Humanorum. Dr.
Hunter's plates of the gravid uterus, are also highly  worthy of inspection.
These invaluable works may be almost said to supply the place of anatomical
preparations; so closely and minutely has nature been copied by the faithful
pencil and graver of the artist. 
151
 is now so vigorous in its action,  that there have  been in-
 stances, though most rare, of its continuing to live, if born at
 so premature a period.  In the seventh month, it has gained
 about three inches in length, and is now more able to live in-
 dependent of the uterus; though even at this time, the chance
 of its surviving six hours from birth is much against it.  In
 the eighth month, it measures about fifteen inches, and weigh
 four, or sometimes five pounds, whilst  the involucra weighs
 scarcely one.  These calculations vary according to the sex
 of the child, and also the conformation of the parents.   Male
 children generally weigh more than females.  Dr. RoedeBer*
 concludes, from his examinations, that the average length of
 a male, at the full time, is tvv enty  inches and a third, whilst
 that of a female is nineteen inches and seventeen eighteenths.
 Dr. Joseph  Clarke has given a table of the comparative
 weight of male and female children at the full time, from which
 it appears, that although the greatest proportion of both sexes
 weigh seven  pounds, yet there are more females than males
 found  below, and more males than females above that stand-
 ard.  Thus,  whilst  out of sixty  males,  and sixty females,
 thirty-two of the former,  and twenty-five  of the  latter,
 weighed seven pounds, there were  fourteen females, but only
 six males, who weighed six  pounds.   On the  other  hand,
 there were sixteen males, but only eight females, who weighed
 eight pounds. Taking the average weight of both sexes, it
 will be found, that twelve males are as heavy as thirteen fe-
 males.  The placenta of a male, weighs, at an average, one
 pound two ounces and a half, whilst that  of a female weighs
 half an ounce less.  Female children, who, at the full time,
 Weigh under  five pounds, rarely live;  and  few males, who
even weigh five pounds, thrive.  They are generally feeble
 in their actions, and die in a short time.
  When there are two children in utero, the weight of each
 individual is generally less than that of the foetus who has
 no companion; but their united weight is greater.  When a
 woman has twins, it either usually happens, that both chil-

                   * Comment. Gottin. 1753. 
152
 drcn are  small, or one is of a moderate size, and the other
 is diminutive; though I have known instances, where both
 the  children were rather above, than under  the usual stand-
 ard.  The average weight of twelve twins, examined by Dr.
 Clarke, was eleven pounds the pair, or five and a half each.
 Twins require more pabulum from the mother, and a greater
 degree of  action in the  uterus;  for two placenta; must have
 their functions supported. The uterus is also generally more
 distended, and produces greater irritation; it  has more
 blood circulating in it;  and the weight  of  its contents, to
 that with a single child, has been stated as twenty to fifteen.
 Twin gestation often produces a greater effect on the system,
 making the woman more disposed to disease,  and less  able to
bear it;  hence the chance of recovery has been supposed to
be four times less in them,  than in  those who  have single
 children.   The children, being generally  feebler than when
 only one is contained  in the uterus, are more disposed to
 disease; and,  as  the mother is  less able to suckle children
 after a twin labour, many perish, who might have been pre-
 served,  by providing a good and careful nurse, soon  after
birth, for the weakest child.
  When the number of children increases above two, the ag-
 gregate weight does not increase.  Thus Dr. Hull  of Man-
 chester  met with a delivery  of  five children, who did not
 weigh two pounds and a quarter; they measured from eight
 to nine inches in length, and two  of them were born alive.
  Calculations have  been made  of the proportion of single
 births, those where there were a  plurality of children.  In
 the Dublin hospital, one woman in fifty-eight had twins.  In
 the British lying-in hospital, one in ninety-one. In the West-
 minster hospital, one in  eighty.   In my own practice, about
 one  in ninety-five.(jf)   In the Dublin hospital, triplets have
  (p) In the lying-in hospital, called l'Hospice de la Maternite at Paris, about
one in eighty-nine had twins, as appears from Baudelocque's  Tableau des
Accouchemens.
  In the lying-in ward of the Philadelphia alms-house, as appears from a re-
gular record kept for 19 years, enchng 1815, one woman in about 52 had
twins. The proportion of males to females, born within the above period,
was about 10 males to 8 females. 
153
not occurred above once in five thousand and fifty- times.(«7)
More than three are not met with, once in twenty-thousand
times.
  The proportion of male  children, born in single births, is
greater than of females. In an extensive parish in this place,
the number  of  males, born in  a given time, was to  that  of
females,  as  3716 to 3177.   In  the Westminster hospital, it
was as 972 to 951;  but in the same hospital, it is worthy of
remark,  that the number of  male twins was only 16, whilst
that of females was 30.(r)

                  § 7. ITS  PECULIARITffiS.

  The foetus has many peculiarities which distinguish it from
the adult, and which are lost after birth, or gradually removed
during gestation.  In particular, the liver is of  great size,
by which the abdomen is rendered more prominent than the
thorax.   It  appears very  early, and increases rapidly till
the fourth month, after which its growth is  slower.   In the
child,  after  birth, the greatest  quantity of  blood  in  the
liver is venous, and  from  this  the bile seems to be secreted.
But in the foetus, the blood is more nearly approaching in its
nature to arterial;  and no bile, but a  fluid  different in its
properties,  is  secreted.  The  gall  bladder is filled with a
green  fluid, which,  before birth, becomes  darker,  with a
tinge of blue, but is said  not  to have a  bitter taste.  The
umbilical vein, which  contains blood, changed in the pla-
centa,  enters the liver, and sends  large branches to the left
side; the vena  porta  enters the  liver, and ramifies on the
right side;  whilst a branch, or canal of  communication, is
sent from the umbilical vein to the vena portae. By this con-
trivance, the left side is supplied altogether with pure blood
  A different average, particularly as it regards the proportion of twin cases,
was stated in the former edition  of this work, but that was taken from the
result of five years only, in which twin cases had very rarely occurred.
  (g) In l'Hospice de la Maternite at Paris, triplets occurred but twice in
12,605 women.
  (r) Of 12,751 infants born in the lying-in hospital at Paris, above alluded
to, 6,524 were males, and 6,227 females.
   VOL. I.                           X 
154
 from the placenta, and the right side is supplied with a mix-
 ture of pure and impure blood, which does not form perfect
 bile.   After birth, as the  circulation  from  the  placenta is
 stopped, the branches of the umbilical vein, which supplied
 the left side, would  be empty, did not the canal, which for-
 merly served to carry a portion of blood from this vein to
 the vena portse,  now permit  this latter vessel to fill  the
 branches in the left side, which henceforth form a part  of the
 vena porta.  The whole liver is thus supplied with blood en-
 tirely veinous.  Bile is formed, and sometimes  in very con-
 siderable quantity.
   The blood of the foetus differs from that of the adult.   It
 forms a less solid coagulum, for, in place of  fibrous matter,
 it yields a soft tissue, almost gelatinous.   It  is  not rendered
 florid by exposure to air,* and  it contains  no  phosphoric
 salts.  But soon after the foetus has respired, the colouring
 matter, exposed to oxygen, acquires the  vermilion tint; and
 salts are formed, particularly the phosphate of lime.
   The stomach is smaller in the foetus, than in the child after
 birth.   The intestines, which at  first,  are seen like threads
 arising from the stomach,  are  redder, and said to be longer
 in  proportion  to  the  body in  the foetus, than  in the  child.
 They are at first uncovered, but, after some time, the  abdo-
 minal muscles and integuments form a  complete inclosure.
 They contain a soft  substance like ointment, of  a dark  green
 colour, called meconium.
   The testicles of the male, and the ovaria of the female, lie
 on the psose muscles, but, before birth, the testicles pass into
 the scrotum.  The kidneys are large and lobulated, and  the
 ureters thick.  The  glandulse renales are large, and contain
 a reddish fluid.  The bladder is more conical and lengthened
 than in the adult.  The  lungs are dense  and  firm, and a
 large gland, called thymus, is contained in the thorax.  The
 heart is very different from its adult state.  In the chick, we
 find that there is in the situation of the heart, a  single cavity

  * Bichat made experiments to ascertain this upon Guinea pigs, and always
found the foetal blood black.  Anatomie Generale, Tome II.  p. 343. 
155
which afterwards corresponds to the left ventricle.   At the
forty-sixth hour, the ventricle and bulb of the aorta are visi-
ble. Then an auricle is formed by the vena cava: this auricle
does not adhere directly to the ventricle, until the sixth day,
but is connected with it till that time by a short duct, called
canalis auricularis.  In about ninety-six hours the  auricle
begins to exhibit marks of a division into two cavities, or a
right  and left side; and some time afterwards, the right ven-
tricle and lungs are evolved.  The  structure of the heart,
however, is still different from that which obtains after birth;
for though the  auricles  are divided into two  cavities, yet
these  are seen, in  the human foetus, to communicate freely by
a vacancy  in the septum ; and even after this is supplied, it is
only with a valve, which  allows the blood  to pass from the
right  to the left side.  This  is the  foramen ovale, which is
shut up after birth.   Another peculiarity of the foetal heart
is, that the pulmonary artery,  although it divide  into  two
branches  for the  lungs, yet sends  a  third, and still larger
branch, directly into the aorta, just at its curvature, and this
is the ductus arteriosus.   The blood is received in a purified
state from the placenta, by the umbilical vein, which,  after
giving off branches in the liver, sends  forward the continua-
tion of the trunk,  to terminate in the  vena cava, or largest
of the hepatic veins, and this continuation is named ductus
venosus.   The mixed blood which is thus found in the vena
cava, is carried to the right auricle,  and thence to the cor-
responding ventricle.  By the pulmonary artery it ought to
be conveyed to the lungs,  but  this  would be useless in the
foetus, and therefore the greatest part of it  passes on by the
ductus arteriosus to the aorta.   But it follows from this, that
as little blood is carried to the lungs, so little can be brought
from them by the  pulmonary veins to the left auricle. Now,
to obviate  this, and fill that auricle at the same time with the
right, the foramen ovale is formed ; and thus,  as the blood
can pass freely from the right to the left, the two auricles are
to be  considered as one cavity,  being  filled and emptied  at
the same time.
  The aorta is distributed to the different parts of the body; 
156
but this singularity prevails, that the hypogastric vessels run
up all the way to the navel, and pass out to form the umbili-
cal arteries.   After  birth, these  arteries are obliterated in
their course to the navel; and the  foramen ovale, and ductus
arteriosus become impervious.
  The head  of the foetus is, at first, membranous, and the
brain a pulp, soluble in aqua kali puri.  By degrees, distinct
cartilaginous plates are formed over  the  brain, which are
gradually converted  into  bones.  These, at birth, are only
united by intermediate membranes.
  The pupil of the  eye, till the  seventh month, is shut up
by a membrane; and the eyelids, for some months, adhere
together.
  The skin is covered with a white substance, which, though
unctuous to the feel,  does not melt, but dries and crackles by
heat.   It is miscible with spirits,  or with water, through the
medium of soap or of oil.
  The male foetus differs from the female, in having the head
larger, but less rounded, and flatter at the  back part.  The
thorax is longer, and more prominent, and formed of stronger
ribs than in  the female.  In her, it is wider from the upper
part to the fourth rib, and narrower below; the belly, also,
in the  female, is more prominent, and the  symphysis pubis
projects more.  The upper extremities are shorter than those
in the male; the thighs are thicker at the top, and  more
tapering to the knees.  Dr. Soemmering  says, that the spi-
nous processes of  the  lower dorsal, and upper lumbar ver-
tebra, make  in the male an eminence like a yoke, in the  fe-
male a sinuosity.   I may remark, that as the clitoris is large
in the young foetus, females sometimes pass in abortions for
males.
  When in utero, the foetus assumes that posture which occu-
pies least room.  The  trunk is bent a  little forward, the chin
is pushed down on the  breast, the knees are drawn up  close
to the belly, and the legs are laid along the back part of the
thighs, with the feet  crossing each  other.  The arms are
thrown into  the vacant space betwixt the head and knees.
This is the general position, and the child  thus forms an oval 
157
  figure, of which the head makes one end, and the breech the
  other.   One side  of it is formed by the spiuc and back  part
  of the head and neck, and the other by the face and contract-
  ed extremities. The long axis of this ellipse measures, at the
  full time, about ten inches, and the short one, five or six.  In
  the eighth month,  the long axis measures about eight inches.
  In the sixth, betwixt four and five.  In the fourth month, it
  measures nearly  three inches and a half:  and in the third,
  about an inch  less.  In the early months, however, there is
  no  regular  oval  formed, and these measurements are taken
  from the head to the breech, which afterwards form the ends
  of the distinct ellipse.  The extremities are at first small and
* slender, and bend loosely toward the trunk.

                     § 8. UMBHJCAL CORD.

     The umbilical  cord is an essential part of the  ovum, con-
  necting the  foetus to its involucra.  It is  found in oviparous
  and viviparous animals, and also in plants; but in these dif-
  ferent classes, it  appears with many modifications.  In the
  human subject, it consists of three vessels; of  which two are
  arteries, and one is a vein.  These are imbedded in gluten,
  and covered with a double membranous coat.   The two arte-
  ries are continuations of the arteria hypogastrica of the child,
  and passing out at the navel, run in distinct and unconnected
  trunks, until they reach the placenta, where they  ramify and
  dip down into its  substance.  When they reach the placenta,
  the one artery, in some cases, sends across a branch to com-
  municate with the other.   The vein commences  in the  sub-
  stance of the placenta,  forms numerous rays on its surface,
  corresponding to the branches of the arteries; and near the
  spot where the arteries begin to give off branches, these  rays
  unite into a single  trunk,  the  area of which is rather more
  than that of the two arteries.  None of these vessels are fur-
  nished with valves.
     The umbilical  vessels run in a spiral direction, within the
  covering of the cord, and the twist is generally from right to
  left.  Besides this twisting,  we also find, that the ve-sels, 
15S
 especially the arteries, form very frequently  coils,  loosely
 lodged in the gluten.
   The cord does not consist entirely of vessels, but partly of
 a tenacious transparent gluten, which is  contained in a cel-
 lular structure ; and these numerous cells, together with the
 vessels, are covered with a sheath, formed by the reflection
 of both chorion  and amnion from the placenta, and of neces-
 sity, the amnion forms the outer coat of the cord.   The cho-
 rion adheres firmly to the cord every where, but the  amnion
 does not adhere to the chorion; it is not even in contact with
 it at the placental extremity, but forms there a slight expan-
 sion, which, from its shape, has been called by Albinus, the
 processus infundibuliformis.
   The proportion of gluten is larger in the early than in the
 advanced stage of gestation; and the vessels, at  first,  run
 through it in straight lines.   In some instances, the cells dis-
 tend or augment  in number,  so as to  form tumours on the
 cord, which hang from it like a dog's ear.
   There is a small sac, or bladder, found on the placenta, at
 or near the extremity  of the cord, in  the early part of gesta-
 tion It is most distinct betwixt the third  and  fourth  month
 of pregnancy, and is placed exterior to the amnion.   It is
 filled, though not quite  distended, with  a whitish fluid, on
 which account, it is called the vesicula alba.*   From this, a
 very fine vessel  proceeds along the cord,  adhering firmly to
 the amnion ; but, without a glass, it cannot be traced all the
 way to the navel.  It  has been supposed to be subservient to
 the nourishment of the foetus in its early stage.  A small ar-
 tery and vein pass  along the cord  from the navel, to the  ve-
 sicle which is between the chorion and amnion.  These  are
 the omphalo-mesenteric vessels.
   Besides the blood vessels, there is in brutes another vessel,
 which is a continuation of the fundus vesica.  It passes out
 at the navel, and, running along the cord,  terminates in
 a bag, which is placed betwixt   the  chorion  and amnion.
. The bag, is called the allantoic, and the  duct  the uradius.

    * Vide Albinus, Annot. Acad. lib. I. cap. xix. p. 74. et tab. 1. fig. 12. 
159
  In the human subject, in place of the urachus, we find only
  a small white impervious cord.  There is of course no allan-
  tois.
    When the ovum is first visible in the uterus, there is no
  cord, the embryo adhering directly to the involucra, but it
  soon recedes ;  apd about the sixth week, a cord of communi-
  cation is perceptible.
    The cord  at the full  time  varies in length, from  six in-
  ches* to four feet ;f but its usual length is two feet.  When
  it is too long, it  is often  twisted round  the neck  or body of
  the child, or occasionally has  knots formed  on it4 most fre-
  quently, perhaps, by the cliild passing through a coil of it
  during labour.^
    The vessels of the cord sometimes become varicose, and
 form very considerable tumours.   These, occasionally, so far
 impede the circulation, as to interfere with the growth of the
 child, or even to  destroy  it altogether.  Sometimes the ves-
 sels burst, and  blood  is poured into the uterus, which  pro-
 duces a feeling of distension, and excites  pain.  There can
 however, be no certainty of this accident having taken place
 until the membranes burst, when clots of blood are discharg-
 ed.  If the foetal and maternal vessels should communicate,
 the mother is weakened,  and may even faint; and, in every
 instance, the child suffers, but  does  not always die.||   Deli-
 very must  be resorted to,  either on account of the effects
 produced on the mother, or to  prevent the destruction of the
 child.
   The cord may by a fall, or violent concussion of the body,
 be torn at a very early period of gestation.  In this case, the
 child dies, but is not always immediately expelled.   It may
be retained for several weeks; afterwards the ovum is thrown

  * Hildanus, cent. II.  obs. 50.
  f Mauriceau has seen it a Paris ell and a third, obs. 401.—Hebenstreit 40
inches—Haller Disp. Anat. Tom. V. p. 675.—Wrisberg 48 inches.—Vide
Com. Gotting. Tom. IV. p. 60.
  * Vide Mauriceau, obs. 133 and 156.
  4 Dr. Hunter thinks he has twice seen these formed previous to birth.
  H Vide Baudelocque l'Art, note to section 1084. 
160
off, like a Confused mass, inclosing a foetus, corresponding in
size to the period when the accident happened.*  The cord
may be filled with hydatids.
  The cord has been found unusually small and delicate, or,
on the contrary, very thick.  In the latter case, it is always
proper to apply two ligatures, instead of one, on the portion
which remains attached to the child.f It has happened, that,
by the shrinking of the cord under the ligature, the child has
died from hemorrhage.^:
  Two cords have been met with, connected  with one pla-
centa, or with two placenta belonging to one child. In other
instances, the vessels are supernumerary or deficient. Stories
have  been told of the cord being  altogether wanting, but
these are incompatible with the foetal economy.

                      § 9.  PLACENTA.

  A  placenta, or something equivalent to  it, is to be found
connected with the young of every living creature.
  We find it requisite that a pabulum  should be supplied to
every animal, and that certain changes should be  performed
on  the blood, qualifying it for supporting life.   In oviparous
animals, two different parts of the ovum perform these sepa-
rate functions.   The umbilical vessels of the chick ramify on
the membrane of the albumen, and thus come in contact with
the air,  which is absorbed through the pores of the shell;
and, by this contrivance, changes analogous to those effected
by  respiration, are produced on the blood.   From the inner
surface of the membrane of the vitellus, a nourishing fluid is
absorbed which is conveyed to the intestine by a proper duct;
and,  before the chick is hatched, the remainder of this fluid,
inclosed in the membrane  of the vitellus, is taken  within the
 abdomen, and covered with the abdominal integuments.1
   In many quadrupeds we find, that, after impregnation, cer-

  * Vide Case by M. Anel, in Mem. of Acad, of Sciences, 1714.
  f This was proposed by Mauriceau, in consequence of meeting with an in-
stance, where the child suffered  much from loss of blood, obs. 256.
  ^ Vide Case by M. Degland, in Recueil Period, Tome V. p. 345. 
101
tain portions of the inner surface of  the uterus enlarge, and
form protuberances, having many hollows or foramina, from
which a milky fluid can be squeezed.  From the chorion, cor-
responding  vascular  efflorescences  arise,  which shoot into
these apertures;  and thus an  union is effected betwixt the
mother and  foetus.
  In the  sow and the mare there is no projection from the
uterus, but  its surface is every where  smooth and vascular.
There is no  efflorescence from the chorion, but it has nu-
merous vessels disposed over it, which  are the extremities of
the umbilical arteries and veins.  In these animals, then, we
have no distinct placenta, the chorion  alone serving that
purpose.
  The cetacea have uteri like  quadrupeds, but I am  unac-
quainted with the precise  mode of  connection  betwixt the
mother and  the foetus.
  The monkey differs from other quadrupeds, in having no
permanent papilla ; but the maternal part of the placenta is
deciduous, like that of women.
  In the human subject,  the placenta  is a  flat circular sub-
stance  about a span  in diameter, and, when uninjected, an
inch in thickness.  It becomes  gradually  thinner from the
centre to the circumference, by  which it ends less abruptly
in the  membranes.  Its common shape is circular; but it is
Sometimes oblong, or divided into different portions.
  The umbilical cord may be fixed into any part of the pla-
centa, or sometimes into the membranes, at a distance from
the  placenta.  When this happens, the  vessels run in distinct
branches to  the placenta, without forming any spongy sub-
stance  on the membranes.  Most frequently, however, the
cord is inserted at a point about half way between the centre
and the circumference of the placenta.  From this the umbi-
lical vessels  spread out like a fan, ramifying over the surface,
and dipping their extremities into the  substance  of the pla-
centa itself.
  That surface of the placenta which  is attached to the
uterus, is divided into lobes, with slight sulci between them,
and is covered with a layer of the decidua like clotted blood.
  vol. i.                          v 
162
 On the surface which is next the child, we see the eminent
 branches of the umbilical vessels, over which we find  spread
 the chorion and amnion.
   If we inject, from the umbilical vessels of the human foetus,
 we find that the placenta is rendered turgid, and vessels arc
 to be found filled in every part of it; but always between their
 ramifications, there remains an uninjected substance; even
 the uterine surface of the placenta is not injected, for  the foe-
. tal vessels do not pass all the way to that surface.
   If we inject from the uterine arteries, we, in like manner,
 render the placenta turgid, but nothing passes into the umbi-
 lical vessels;  and, when we cut into the  placenta, we  find
 cells full of injection, and  covered with a  fibrous uninjected
 matter.   Hence we may infer, that the placenta consists uni-
 formly of two portions.  The one  is furnished by  the deci-
 duous coat of the uterus, the other by the  vessels of the cho-
 rion; and these two  portions may, during the first three
 months, be separated, by maceration from each other.
 .  The structure of the foetal portion, so far as we know, ap-
 pears to be similar to that of the pulmonary vessels, the arte-
 ry terminating  in the vein.  But the other portion is some-
 what different: there is not a direct  anastomosis, but the
 artery opens into a cell,  and the vein begins from  this cell;
 for, by throwing in wax  by the .uterine artery, we may  fre-
 quently inject the veins.  These cells communicate freely
 with  each other in every part of the placenta, and  may be
 compared to the corpora cavernosa penis.
   From the general principles of physiology, as well  as from
 experiments on the chick in ovo, and from the fatal effects
which instantly  follow compression of the cord whilst the
 child is in utero, it is allowable to infer,  that the placenta
 serves to produce a djange  on the  blood of the foetus, ana-
logous to  that which  the  blood of the  adult  undergoes in
the lungs; and from considering, that the foetus itself cannot
create materials for its own growth and  support, we may
farther infer* tha^t the placenta is the source of nutrition also.
  The placenta may be formed at any part of the uterus,  but,
 in general, it  is found attached near the fundus. 
163
  Its structure is sometimes changed, part of it being ossi-
fied or indurated, or on the contrary, unusually soft.  These
changes may produce either hemorrhage, or retention of the
placenta.  Hydatids may form in the placenta; or fleshy tu-
mours may grow in its substance.  In neither of these cases
does the child necessarily die.

           § 10.  MEMBRANES AND LIQUOR AMNII.

  The ovum, when  it descends into the uterus, consists of
two membranes, one within the other, having very transpa-
rent jelly interposed between them.   But in process of time,
the innermost, which is called the amnion, grows so much
faster than the outermost, which is called the chorion, that it
comes in contact with it, or at least has only a thin layer of
jelly interposed.
  The amnion is thin, pellucid,  and totally without  the ap-
pearance of either vessels or regular fibres; yet, in  the end
of pregnancy, it is stronger than the chorion and its vascular
covering:  it lines the chorion, covers  the  placenta, and
mounts up on the navel string, affording a coat  to it all the
way to the umbilicus, where it terminates.
  The sac, formed by the amnion, is filled with a fluid, which
appears to be  composed chiefly  of water, with a very little
earth, mucus, and saline matter.  As this water is contained
within the amnion, it has  received the name of liquor amnii.
In this sac the foetus lies.
  The quantity  of water, upon an average, which is contain-
ed within the amnion, at the full time,  is about two English
pints; but  sometimes it is much more, and at  other times
scarcely six ounces.  In the early periods, the quantity is
larger, in proportion to  the size of the  uterus, than after-
wards.
   The chorion, like the amnion, is thin and transparent, ad-
heres firmly to the placenta, and covers all the vessels which
run on its surface ; but it does not dip down  with them into
the substance of the placenta.  When the ovum  first de- 
164
scends, the chorion is every where  covered  with vessels,
which sprout out from it.  These form a covering to it, which,
from its appearance, has been called the shaggy, or spongy
chorion.

                      § 11. DECIDUA.

  The last coat to be described, is one yielded entirely by the
uterus, and serves to connect the uterus with the foetal vessels
of the chorion.  This, as Harvey observes, is not a covering
of the foetus, but a lining of the uterus, which falls off after
delivery; and therefore it is called the caducous coat, or the
membrana decidua.
  The illustrious Haller supposed, that this was formed by
naked vessels shooting out from the uterus. Dr. Hunter ima-
gined, that the arteries of  the  uterus poured out coagulable
lymph, which was afterwards changed into  decidua.  His
brother, Mr. John Hunter,  attributed its origin to coagulated
blood, which formed a pulpy substance on the inner surface
of the uterus.
  Having been so fortunate as to meet with three or four op-
portunities  of investigating the state of the uterus, within a
month after conception, I shall describe what  appears to me
to be the structure of the decidua.  Very speedily after im-
pregnation, and always before the embryo enters into the
womb, its size is  increased, its fibres  are softer and more
separated from each other, and its vessels very much en-
larged.  On cutting it up, its cavity is found to be consider-
ably broader and longer, and somewhat wider than in the un-
impregnated  state; and all the fundus  and body have their
surface covered with a dense  coat,  which adheres firmly to
the  uterus.   If the  vessels have been injected, this evidently
is seen to consist of two different substances, namely vessels,
and a firm  tough gelatine.  It seldom happens that all the
vessels can he equally filled, and  therefore some spots arc
redder than "others. *The vessels do not pass on to the  sur-
face of this coatf bu| arc seen shining through it.   They  pro- 
                          165

ceed directly from the surface of the wombj and project at
right angles to the plane which yields them; they are inter-
mixed  with a little gelatine, and consist of both arteries and
veins.  Over their extremities is spread a layer of gelatinous
matter, which very early is observed to contain fibres, form-
ing a kind of net-work.  Thus the decidua consists of two
layers, one highly vascular, proceeding  directly from the
uterus ; the other, which  is  most probably formed by these
vessels, is more fibrous and gelatinous; and when this  is re-
moved, the primary vessels, or outer layer, may he seen like
a fine  efflorescence, covering the surface  of the  uterus: in
some cases  the decidua extends  a  little  into the fallopian
tubes; in other instances  it does not.  In  no case does the
cervix form decidua.   It is only produced by the fundus and
body of the womb ; and  immediately above the cervix, the
decidua stretches across, so  as to form a  circumscribed bag
within the uterus.  In  some instances, however, I have ob-
served this continuation to  be wanting,  although the parts
were opened with care.  In all  otiier circumstances,  these
uteri resembled those  where  the  decidua was  continued
across; but, perhaps, notwithstanding this, there  may'have
been a difference of two or  three days in the period of im-
pregnation, occasioning this variation.   In every case, the
decidua, consisting thus of two layers, is  completely formedC
before the ovum descends.
  When the embryo passes down through  the tube, it is stop-
ped, when it reaches the uterus, by the  inner layer which
goes across the aperture of the tube, and thus would be pre-
vented from falling into the cavity of the uterus, even were it
quite loose and unattached.  By the growth of the embryo,
and the enlargement of the membranes, this layer is'distend-
ed,  and made to encroach upon the cavity of the  uterus, or
more correctly speaking, it grows with the ovum.  This dis-
tention or growth gradually increases, until at last the whole
of the cavity of the uterus  is filled up, and  the protruded por
tion of the inner layer of  the decidua comes in contact with
that portion of itself which  remains 'a&ached to  the outer
layer.  We find then, that the  inner layer is'turned  down 
166
and covei's the chorion; from which circumstances* it has
been called the reflected deciduals)
  Thus we see, that whenever the ovum descends, it is encir-
cled by a vascular covering from the uterus, which unites, in
every point, with those shaggy vessels which sprouted  from
the chorion, and which made what was called the spongy
chorion.  One part of these vessels forms placenta, and the
rest gradually disappear, leaving the chorion covered by the
decidua reflexa.  This obliteration begins first at the under
part of the chorion.
                       CHAP. XVI.

                        Of Sterility.

   Sterility  depends either on malformation, or imperfect
action of the organs of  generation.   In some instances the
ovaria are wanting, or too small; or the tubes are imperfo-
rated; or the uterus very small.   In these cases the menses
generally  do not  appear, the breasts are flat, the external
organs small, or they partake of the male structure, and the
sexual desire is inconsiderable.
   In a great majority of instances, however,  the organs of
generation seem to be well formed, but their action is imper-
fect or disordered.  The menses  are either  obstructed or
sparing, or they are profuse  or  too frequent, and the causes
of these morbid conditions have been already noticed.
   It is extremely rare for a woman to conceive, who does not

  (s) By others it is thus explained, viz. That after the cavity of the uterus
is  completely lined with the secreted decidua, the ovum passes into it from
the fallopian tube, and in passing along its parietes, involves and covers it-
self completely over every point of its surface with a coat of the decidua,
which at that period may be  compared to a coat of white paint;  as the
ovum increases in size, the decidua  immediately covering it, (called decidua
reflexa)  ultimately comes in!b Intimate contact with that  portion  of the
decidua, which continues to line the cavity of the uterus, and forms ap-
parently but one membrane. 
167
menstruate regularly;  and on the contrary, correct menstru-
ation generally indicates a capability of impregnation on the
part of the woman.
  A state of weakness and exhaustion of the uterine system
occasioned by frequent and promiscuous  intercourse with the
other  sex, is another very common cause  of barrenness  in
women, and hence few prostitutes conceive.
  A morbid state of the uterus and ovaria, often accompanied
with fluor albus, may likewise be ranked  amongst the causes
of sterility, and this is known by its proper characters.
  Women who are very corpulent, are often barren, for their
corpulence either depends upon want of activity of the ovaria,
spayed, or castrated animals  generally becoming fat, or it
exists as a mark  of weakness of the system.
  When sterility depends upon organic disease, we have it
seldom in  our power to remove  it;  but  when there is no
mark of the existence of such a state, and we have ground to
suppose that it is occasioned by debility, or imperfect action
of the uterine system,  we are to employ such means  as arc
supposed capable of removing this, either by operating on it
along with the general system  of the body, or more directly
on the uterus itself.  Our first  attention  must be directed to
menstruation, as the state of that function  is our principal
directory in the choice of the class of medicines to be em-
ployed.  On this subject I must refer  to what has been said
in chap. xii.  We will also, altogether independently of the
state  of menstruation, naturally consider the condition of the
constitution and habit of body, with regard to plethora, irri-,
tability, torpor,  or debility,  and use varied and persevering
means for  rectifying those states ; always  however, taking
care that we do  not injure  the constitution in  seeking for
a remote good. In the majority of cases,  weakness of uterine
action is the cause,  and the remedies are sea  bathing and
tonics, in various forms;  general stimulants, such as bath
waters, mercury, essential oils, nitrous  acid, &c. when  me-
dicines of  this  description are not contra-indicated by the
state  of menstruation; local stimulants, which  act more di-
rectly on the uterus or its vicinity, as the semicupinm, can- 
168
tharides, balsam of copaiba, &c.   Of all these, the first class
is the safest, and  the most frequently  useful.   The ancients
employed medicated pessaries, which  have long fallen  into
disrepute, rather perhaps from  the  absurdity of their in-
gredients, than from any argument respecting the inefficacy
of gentle stimulants acting on the vagina and womb.
  A temporary separation from the husband is  of service, es-
pecially  when  the menses are profuse, and, in most cases,
frequent intercourse should be  avoided.
  Should a woman, who has been for some years barren, con-
ceive, she must be very careful during gestation, for abortion
is readily excited.
  In some cases, the uterine system is capable of being acted
on by the semen of one person, but not of another.
                     CHAP.  XVII.

               Of Extra-uterine Pregnancy.

          § 1. SYMPTOMS, PROGRESS AND SPECIES.

   It sometimes happens, that the ovum  does not pass down
 into the womb, but is retained in the ovarium, or stops in the
 tube, or is deposited among the bowels.  Of all these species
 of extra-uterine pregnancy, the tubal is the most frequent.
   The symptoms of extra-uterine pregnancy are not, at first,
•very definite; but generally the usual sympathetic effects of
 pregnancy, or the diseases of gestation,  are more distressing
 than if the foetus were  contained in utero, nor do they cease
 so early.  In some cases, they  even increase  in violence, as
 pregnancy advances.*
   The symptoms, though often more violent, are, however,
 similar in kind, to those of common pregnancy.  The belly
 swells, the uterus itself enlarges, and may be felt to be heavy;
 but, after some time, it docs not correspond in its size, and

   * Vide Paper by Dr. Garthshore, Lond. Med. Journ. Vol. VHI. &A4A. 
169
 in the state of its cervix, to the supposed period of gestation,
 or may return to the unimpregnated size.*   The menses are
 often obstructed, though in some cases they have continued to
 appear for  two or three months.  The breasts enlarge, the
 morning sickness takes place about the usual period,1 and the
 child quickens at the proper time, but it is felt chiefly upon
 oiie side.  An obstruction to the free passage of urine is some-
 times produced till the sac rise out of the pelvis.
   Occasionally in the early stage of pregnancy, pains2 resem-
 bling those of colic are felt, and these are often so severe as to
 excite syncope,3 or convulsions ;f  and it has happened, that
 dining these pains, the tube or ovarium has burst, and the
 person died, owing to the internal hemorrhage.   When these
 pains either do not occur, or are removed, we generally find,
 that  at the  end of  eight, nine, or ten months from the com-
 mencement of gestation, appearances of labour4 take place;
 the woman  suffers  much from pain, and  there may be a san-
 guineous discharge from the uterus.  The pains go off more
 or less gradually,:}: the motion of the child ceases, and milk is
 secreted.^   In a few instances, very little farther inconve-
 nience is felt,  the tumour of the belly remaining for many
 years, and the child being converted  into a substance resem-
 bling the gras des cimetieres, whilst the sac which contains  it
 becomes indurated.  More frequently, however, considerable
 irritation is produced,||  inflammatory symptoms supervene,
 and hectic takes place.   The sac adheres to  the peritoneum,
 or intestines; and  after an uncertain  period,  varying from  a
 few weeks or months to several years, it either opens externally,
 or communicates with  the abdominal viscera.  Very foetid

  * Vide Mr. Tucker's case, Med. and Phys. Journ. xxix. 448.
  f Vide Dr. Fern's case, and a case by Mr. Jacob, in Lond. Med. Jour. Vol.
VIII. p. 147.
  $ In  Mr Bell's case, the pains continued, though gradually abating, for
three weeks.   Med. Comment. Vol. II. p. 72.
  §In  Mr. Bell's case, milk continued to be secreted for several years.  In
Mr. Turnbull's case, a fluid was secreted, rather like pus than milk. '
  i| In  the case of a female mulatto, the outlines of wliich 1 was favoured with
by Dr. Chisholm, the pain was so great that, it could not be.  allayed by the
strongest opiates.  It endpd fatally.
  VOL. T.                           7. 
170
 matter, together with putrid flesh, bones, and coagula are dis-
 charged through the abdominal integuments,* or by the rec-
 tum,5 vagina,6 or bladder.7  Sometimes, even an entire foetus
 has been brought away from the umbilicus,8 or by the rectum.'
 It is worthy of  notice, that the placenta, in this process, al-
 ways is  ultimately destroyed,10  and discharged  among the
 putrid fluid.   Often, time is not allowed for this process to he
 accomplished, but the person dies at an early period.
   Thus it appears, that there are different terminations of the
 extra-uterine pregnancy. The  sac may burst, and the person
 die speedily of hemorrhage;11  or the  child may escape into
 the abdomen, and be enclosed  in a kind of cyst of lymph ;f
 or the sac may remain entire, the child being retained many
 years,12 and the parts become hard; notwithstanding this,  the
 menses may return, and  the woman  conceive again.13   But
 the most frequent  termination is that of inflammation ending
 in abscess,  attended with fever and pain, under  which  the
 patient either sinks, or the foetus is expelled in pieces, and
 the cure  is slowly accomplished.  From a  review of cases
 it appears, that a majority ultimately recover, or get the bet-
 ter of  the immediate  injury:  of the rest, some have sunk
 speedily, either  from  hemorrhage or  inflammation, or  ex-
haustion  produced by ineffectual  attempts to expel  the  child;
 or more slowly from hectic fever; or in consequence of some
 other disease being called into  action, by  the violence which
 the constitution  has sustained.
   In  some cases the sac soon rises  quite  out of the pelvis.
 In others, it remains longer and falls down between the rec-
 tum and vagina, forming a tumour, accompanied with symp-
 toms of retroversion14 of the uterus.}:   In such cases, the  sac
 inflames, and bursts into the rectum or vagina.  Dr. Merri-
 man§ is of opinion, that all  these cases are instances of retro-
 verted uterus, and not of extra-uterine pregnancy; but, for
 the present, this must  rest entirely  on  supposition.   The

  • This termination is noticed so long ago as by AlbuGasis, lib. II. c. 76.
  j- Vide a case by La Croix, in La Med. Eelaree, Tome. IV. p. 349.
  $ Vide Mr. Mainwarring's case, in Trans, of a Society, &c. Vol. U. p. 287.
  § Vide Dissert on Retroversion, &c. 1810. 
171
mere circumstance of the pregnancy being complicated with
suppression of urine, or tumour at the back part of the pelvis,
is no proof; as both of these may arise from the pressure of
the sac on the pelvis.
  Sometimes, when parturient efforts are made, the head de-
scends into  the pelvis, though it was not there before ;  but
either  no os uteri can be  felt, or it is felt directed to the
pubis,  and it is not affected by the pains.(i)
  It is curious to observe, that generally the uterus enlarges
somewhat,15 and  in  most instances,  I imagine, decidua16 is
formed.   In a remarkable case, related by  the ingenious Mr.
Hay*  of Leeds, the placenta was formed in the uterus, while
the foetus lay in the tube.
  Tubal pregnancy sometimes does not proceed farther than
the second month, the tube bursting atthat time ; or, to speak
more correctly, I believe the tube slowly inflames, and slough-
ing takes place.   In a great majority of instances, however,
the tube goes on enlurging for nine months, and acquires a
size nearly equal to that Of the gravid  uterus, at the same
stage  of gestation.f  T"ie placenta differs from a  uterine
placenta in being much  thinner and  more extended.  Exter-
nal examination  discovers little difference, at the full time,
between this and common pregnancy.
   Ovarian17 is much more rare than tubal pregnancy, and it
is seldom that the ovarium acquires a great size.  It either
bursts early,18 or inflammation and  abscess take  place; or
the foetus dies, and  is converted into a confused mass; or it
excites dropsy of the ovarium.19  The  ovarian pregnancy,
until inflammation has taken place, produces a circumscribed
moveable tumour, like dropsy of the ovarium.

  (<) It  is very probable that some of these cases have in reality originated
from retroversions of the uterus, which, as Merriman has proved, may even
continue in that state until the full period of utero-gestation.  This subject
shall be more  fully explained, when retroversion of the uterus comes to be
treated  of.  In the meantime  the student is referred to a review of Dr. Mer-
riman's Work, in the Eclectic Repertory, Vol. I. p. 338.
  * Vide Med. Obs. and Inq. Vol. III. p. 341.
  f Among many other cases, in proof of this, I may refer to one very accu-
rately detailed by Dr. Clarke, in the Trans, of a Society, 8ic. Vol. II. p. 1. 
                             172

    In ventral pregnancy, the most rare of the three species,
  the motions of the child are felt more freely, and its shape is
  readily  distinguished through the abdominal integuments:
  The expulsive efforts come on as usual, and the head of the
  child  is sometimes  forced  into the pelvis.  It dies, and the
  usual  process for its removal is carried on, if the woman  do
  not sink immediately  under the irritation.  The placenta is
  found attached to the mesentery or intestines.20  It has been
  supposed, that the examples of this variety are all  in reality
  instances of ruptured uteri:  but this is not supported  by
  satisfactory proof.  At the same time, I have no doubt that
  many of them are.

                      § 2. TREATMENT

    In the treatment of extra-uterine pregnancy, mucn must
  depend on the circumstances of the case.  In the early stage,
  if the  sac be lodged in the pelvis, we must procure stools, and
  have the bladder regularly emptied, as in cases of retrovert-
  ed uterus.   Attacks of pain  during the enlargement of the
  tube, require blood-letting and anodynes, laxatives and fomen-
  tations.  The same remedies are indicated when convulsions
  take place.  Ovarian requires a similar management with
  tubal pregnancy, except that if it be complicated with dropsy,
  relief may be obtained by tapping.
    When expulsive efforts  are made,  and the  head  is felt
  through the vagina, and the nature of the case distinctly as-
  certained, it may be supposed, that much suffering may be
  avoided, by making an  incision through the vagina, and de-
  livering the child; but, as yet, experience has not fully ascer-
  tained the utility of  this practice.*  It  has been  proposed,
  in these and other circumstances, to perform the csesarean
  operation,!  in the usual manner, upon the accession of labour;

~  * In a case, probably of this kind, related by Lauverjat, and quoted by Saba.
< tier, the child was extracted by an incision through the vagina, and the woman
 recovered.  De la Med. Operat. Tome. I. p. 136.
   | M. Colomb, performed the cesarean operation, but it ended fatally.  Re-
 cueil des Actes de la Society de Lyon. 
173
but there is not only great danger from the wound, but like-
wise from the management of the placenta, which if removed,
may cause hemorrhage, especially in ventral pregnancy, and,
if left behind, may produce bad effects. The last, however, is
the safest alternative.
  The result of the numerous cases upon record, will certain-
ly justify, to the fullest extent, our trusting to the powers of
nature rather than to  the  knife of the surgeon.  Allaying
pain  and irritation in the first  instance, by blood-letting,
anodynes, and fomentations; and avoiding, during all the in-
flammatory stage, stimulants and motion, whilst, by  suitable
means, we palliate any particular  symptom, constitute the
sum of our practice.
  A tendency to suppuration is  to be encouraged by poul-
tices ; and the tumour, when it points  externally, is either to
be opened, or to be left to burst spontaneously, according to
the sufferings of the patient, and the exigencies of the case.21
The passage of the bones,  and different parts of the foetus,
may often be assisted;  and  the strength is to be supported  un-
der the hectic which accompanies  the process.  After  the
abscess closes, great care is still necessary, for, by fatigue or
exertion, it may be renewed, and prove fatal.22
  When no process is begun for removing the foetus, but it is
retained and indurated, our practice is confined to the pallia-
tion of such particular symptoms as occur.
                     CHAP. XVIII.

                Of the Signs  of Pregnancy.

  Some women feel, immediately after conception, a particu-
lar sensation, which apprizes them of their situation; but such
instances  are not frequent; and, generally, the first circum-
stances which lead a woman to suppose herself pregnant, are
the suppression of the menses, and an irritable, or dyspeptic
state of the stomach.  She is sick or vomits in the morning, 
174
  and  has returning qualms or fits of languor during the fore-
  noon; is liable to heartburn through  the day or in the even-
  ing,  and to that disturbed sleep through the night, which so
  frequently attends abdominal irritation.  In some instances,
  the mind also is affected, becoming unusually irritable, change-
  able, or melancholy.  The  breasts often at first become
  smaller, but about the third  month they enlarge,  and occa-
  sionally become  painful; the nipple is surrounded with a
  browrn circle or areola; and often, even at an early period, a
  serous  fluid begins to ooze from it,  The woman loses her
  looks, becomes paler,  and the under part of the lower eye-lid
  is of a leaden hue.  The features become sharper, and some-
  times the whole body begins to be emaciated, whilst the pulse
  quickens.   In  many  instances, particular  sympathies take
  place, causing salivation, tooth-aeh, jaundice, &c.  In other
  cases, very little disturbance  is produced, and the  woman is
  not certain of her condition, until the period of quickening.
    In the commencement of pregnancy, the abdomen does not
  become  tumid,  but, on the contrary, is often rather flatter
  than  formerly; and, when it does first increase in size, it is
  rather from inflation  of the bowels, than from expansion of
  the uterus.  As  an increase  of bulk, together with many of
  the other symptoms of gestation, may proceed from suppres-
  sion of the menses, we cannot positively, from those  signs,
  pronounce a woman to be with child.   The enlargement of
  the belly is at first accompanied with tension or uneasiness
  about the navel, which soon becomes rather prominent.
    When women have  any doubt, with regard  to their situa-
  tion, they generally look forward to the end of the second
  quarter of pregnancy, as a period which can  ascertain their
  condition.  For,  at this time,  or a little sooner or later, in
  different woman,  the  uterus  ascends out of the pelvis, and
  the motion of the child  is first perceived, or it is said to
  quicken :(u) and, in some cases,  a  few drops of blood flow

«!•$(") Professor Roederer kept a correct account of one hundred women,
  noting the time when it was presumed they were impregnated, the period at
  which they quickened, and again, the time when they were delivered. %ut
  oftliis number we are informed, that eighty quickened at the fourth month, 
175
from the uterus at this period.  The motion is first felt in the
hypogastrium, and is languid and indistinct, but by degrees
it becomes stronger.   It is possible for women to mistake the
effects of  wind for the motion  of a child,  especially if  they
have never borne children, and be anxious for a family. But
the sensation produced by wind in the bowels is not confined
to one spot, but very often is referred to a  part of the abdo-
men, where the motion of the child could not possibly be felt.
It is not to be supposed, that the  child is not alive till the
period of quickening, though the code of criminal law is ab-
surdly founded on that  idea.   The  child  is alive from the
first moment that it becomes  visible, but  the phenomena of
life  must vary much at different periods.   The  child is not

a portion of the remainder quickened at the third month, and the rest went
on to the fifth.  Therefore, we may with great propriety consider four months
as  the general  time  of  quickening;  and upon finding that a woman has
quickened, within a day  or two, we may with great confidence calculate that
she has five months to go.
  The term quickening, is certainly not the most accurate phrase that could
be selected, to  express the simple fact of the  uterus rising above the brim
or cavity of the pelvis.
  It  is well known, that the  impregnated uterus generally remains in the
pelvis, as we have just observed, until the latter part of the fourth month;
and that after this period, as  it enlarges, it necessarily rises above that cavity
into  the abdomen : but it is to be remarked,
   1. The ascent of the impregnated uterus from its position in the pelvis to
its subsequent  station, is sometimes gradual and unobserved; of course, the
sensation of quickening is not then felt.
  2.  The uterus is sometimes so impacted in the cavity of the pelvis, as not
to reach its final station  within the abdomen without the assistance of art,
producing the disease called retroverted uterus, during which, quickening is
never felt
  3.  At  other times, and those frequent, though not constant/there exists
some slight impediment to the ascent of the uterus, -uldch being suddenly over-
come, tfiis viscus rises at once into the abdominal cavity, constituting what lias been
referred to the foetus, under the term qtrickening.
   The sudden intrusion, therefore, of the volume of the uterus among th«
abdominal viscera, accompanied by as sudden a removal of pressure from the
ihac vessels, is supposed to be equal to produce the sensation we have above  -A<
noticed.                                                           '• ^,
   We may then state, "That the  sensation of quickening is felt in transitu,
at the moment when the  uterus, removing from the  pelvis, enters the abdo-
minal cavity."   Vide Eclectic Repertory, Vol. III. p.  30 October. No. IX.    < 
176
felt to move till after the ascent of the uterus out of the pelvis.
Does this arise from any change in the phenomena of life at
that time in the child itself, or from the muscular power be-
coming stronger, or from the uterus now being in a situation,
where there being more sensibility, the motion is better felt?
All of these probably contribute to the  sensation which be-
comes stronger, as the child acquires more vigour, and as the
relative proportion of liquor  amnii decreases.  This foetal
motion, however, is not to be confounded with the sensation
felt by the mother from the  uterus rising out of the pelvis,
and which precedes the feeling of fluttering.   If this eleva-
tion shall take place  suddenly, the sensation  accompanying
it is pretty strong^'and the woman at the time often feels sick
or faint, and in irritable habits, even  an hysterical fit, may
attend it.   From the time when this is felt, women  are said
to have quickened, and they afterwards expect to he conscious
of the motion of the child. The morning sickness, and many
of the sympathetic effects of pregnancy, generally abate after
this, and the health improves  during the two last quarters.
  Many women suppose, that, by examining the blood drawn
from the veins, their pregnancy may be ascertained.  Very
soon after impregnation, the blood becomes sizy; but it differs
from the blood of a person affected with inflammation.  Ill
the latter case,  the surface of the crassamentum is dense,
firm, and of a buff colour, and more or less depressed in the
centre.  But in pregnancy the surface is not depressed, the
coagulum  is of  a softer texture, of a yellow, and more oily
appearance.  It is not possible, however, to determine  posi-
tively, from inspecting the blood; for a pregnant woman may
have some local disease, giving the blood a truly inflamma-
tory appearance; and,  on the other hand, it is possible for
the suppression of the  menses,  accompanied  with  a febrile
state, to give the blood the appearance which it has in preg-
nancy.
  Examination of the uterus itself is a more certain mode of
ascertaining pregnancy.   About the second month of gesta-
tion, the uterus may  be felt prolapsing  lower  in the vagina
than formerly;  its mouth is not directed so  much forward as 
177
before impregnation ; it is shut up, and the cervix is felt to be
thicker, or increased in circumference.  When raised on the
finger, it is found to be  heavier, or  more resisting.   Some
have advised, that the os uteri should be raised upward and
forward, so as to retrovert the womb, in order that its body
may be felt, but this is not expedient. Examination, at this
period, is liable  to uncertainty, because the  uterus  of  one
woman is naturally different in magnitude from that  of  an-
other.  But in the third  month we can arrive at tolerable
certainty, the womb being  then felt decidedly to be heavier,
and more easily balanced on the finger.  In the beginning of
the fifth month it is found to be higher than when unimpreg-
nated ; a kind of fluctuation may be perceived, and by placing
the hand on the lower part of the belly, so as to press on the
fundus of the womb, it can be made to give more resistance to
the finger applied per vaginam, and may by it be rolled about.
After quickening, if we  pat with the finger on the  cervix
uteri, we can generally make the child strike gently, so as to
be felt. About this time, and still more distinctly afterwards,
we can, if the abdominal muscles be  relaxed, feel the uterus
extending up from  the symphysis pubis, and^in proportion
as pregnancy  advances, can more readily  distinguish  the
members of the child, and feel its jerks  or motions.  Ex-
amination, per vaginam, informs us of those changes of the
cervix and os uteri, which were noticed in a former chapter.
                      CHAP. XIX.

            Of the Diseases of Pregnant Women.

                  § 1. GENERAL EFFECTS.

  Pregnancy  produces  an effect on the general system,
marked often by a degree of fever, and always by an altered
state of the blood.  This state is the consequence of local
increased  action, which irritates  and excites the system, in
  vol. J.                        *  * 
178
the same way as  when  an organ is inflamed.  There would
appear to be, likewise, a tendency to the formation of more
blood than formerly, and  the  nervous system  is evidently
rendered  more irritable.  The gravid uterus, also,  has an
effect by sympathy, on other organs or viscera;  and likewise
produces changes in  them, mechanically, by its bulk  and
pressure.
  The effects of  pregnancy vary much, both in degree, and
in the nature and combination of the symptoms, according to
the constitution of the  woman, and the natural or acquired
irritability of different organs.  In a few cases, a very salu-
tary change  is produced on the whole system, so  that the
person enjoys better health during pregnancy, than at other
times.  But in most  instances, troublesome or inconvenient
symptoms are excited, which are called the diseases of preg-
nancy, and which in some women, proceed so far, as not only
to deprive them of all enjoyment and comfort, but even to
produce considerable fear of their safety.
  As these proceed from the state  of the uterus, it follows,
that when they  exist in  a moderate  degree,  they  neither
admit of,  nor require any attempts to  cure  them ; for their
removal implies a stoppage of the action of gestation, which
is their cause.   But when any of the effects  are carried to a
troublesome extent, then we are applied to, and may palliate,
though we cannot take them away. This we do by lessening
plethora,  if  necessary, by blood-letting, and  allaying  the
increased irritability of the system by the regular use of laxa-
tives, which remove that particular state of the bowels, which
is so apt to cause restlessness and nervous irritation.  If these
are not altogether successful, the camphorated julap, is a use-
ful medicine.*  Besides this general plan, we must diminsh

  • Petit, and many after him, have been of opinion, that opium is hurtful
during gestation; and there can be no doubt that it generally is so when
given frequently.  It is detrimental, both by its effects upon the stomach
and bowels, and on the system at large. In severe  spasms, or great irrita-
tion, it may be necessary, but it sever ought to be often repeated, as it ulti-
mately increases the irritability  and injures the bowels, as it would do in
chorea. 
179
the febrile state of the system, where such exists, by regula-
tion of the diet, and suitable remedies.  Individual symptoms
must be treated on general principles.
  There is a great diversity, both in the effects of pregnancy,
and also in the period at which these manifest themselves;
for whilst some begin to suffer very early from the irritation
of the uterus, and are much relieved from the effects thereof
after the child quickens, others feel very little inconvenience
till towards the end of pregnancy, or the last quarter, when
the womb is greatly enlarged, and the abdominal viscera dis-
turbed.

                § 2. FEBRILE STATE.

   In many cases, the pulse becomes somewhat quicker soon
after impregnation, and the heat of the skin is  at the same
time a  little increased, especially in the evenings.   In the
later months of pregnancy, the febrile symptoms in some in-
stances  are extremely troublesome; the pulse is permanently
frequent, but in the evenings it is more accelerated, whilst
the skin becomes hot, and the woman  restless; she  cannot
sleep, but tosses  about till day-break, when she  procures
short unrefreshing slumber, occasionally  accompanied  with
a partial  perspiration.  In the  morning, the febrile symp-
toms are found to have  subsided; but in the afternoon  they
return,  and the following night is spent alike uncomfortably.
   This  state is attended with  more emaciation,  and greater
sharpness of the features,  than is met with in pregnancy, un-
der different circumstances, but  it is wonderful how well the
strength is kept up in spite of the want of rest, and of the
uneasiness which is produced, from this disease being some-
times conjoined with intolerable heat about the parts of gene-
ration.
   In slight degrees of this febrile state, all that is necessary
is sedulously to keep the^bowels open, and take away a little
blood.  But when it becomes urgent towards the last months
 of gestation,  we  are under  the necessity  of taking  away
blood more frequently, but not in great quantity at a time. 
18G
 The saline julap is of considerable service, by producing a
 gentle moisture, but a copious perspiration is neither neces-
 sary nor useful.  The julap may either be given in repeated
 doses through the day, or merely one  or two  doses  in  the
 morning, or early part  of the  night  according to circum-
 stances.  The bowels are to be kept open by a mild laxative,
 such  as the  alcotic pill,  or rhubarb and magnesia.   The
 sulphuric acid is a very good  internal medicine.   The rest-
 lessness is best allayed by sleeping with  few bed-clothes;  and
 sometimes great relief is obtained, by dipping tiie hands in
 water, or grasping a wet sponge.  Opiates very seldom give
 relief, and ought not be pushed far, as they make the woman
 more uncomfortable,  and are supposed even to injure  the
 child; at all  events, if the occasional exhibition, on   any
 emergency, of a moderate dose of opium or hyocyamus,  fail
 to procure comfortable  sleep, no benefit  is to be  expected
 from increasing the quantity.  Frequently nothing does much
 good, the state continuing until the woman is delivered.
   There is a species of fever, which may affect women about
 the middle of pregnancy, and makes its attack suddenly, like
 a regular paroxysm of ague.   It soon puts on an appearance
 rather of hectic, combined with  hysterical symptoms.  The
 head is generally at first pained,  or the patient complains of
 much noise Within it, sleeps little, has a loathing at food,
 with a foul dry tongue, and a considerable thirst, whilst the
bowels are constipated.  Sometimes she talks  incoherently,
or moans much during her slumber, and has frightful dreams:
occasionally a  cough,  or distressing vomiting supervenes.
This disease  is very obstinate, and often ends  in abortion;
 after which, if the woman do not sink speedily  under the ef-
fects of the process, she begins to recover, but remains long
in a chlorotic state, which if not removed, may terminate in
phthisis.  I strongly suspect that this disease originates from
the bowels, and bears great analogy to the infantile remitting
fever.   It is usually preceded by costiveness,  and is some-
times apparently excited by irregularities in diet.  We ought
on the  first attack of the cold fit to check it by warm dilu-
ents, with the saline julap.  If the proper opportunity be lost, 
                           181

 or these means fail,  we must lessen irritation by detracting
 some blood ; open the bowels freely, and afterwards prevent
 feculent accumulation,  keep the surface moist, and palliate
 troublesome symptoms.   If the tongue be  early loaded,  and
 the patient is sick or squeamish, a very gentle emetic w ill be
 proper.   The strength is to be supported.   In a state of con-
 valescence, gentle exercise and pure air are useful, but every
 exertion must be avoided.

                      § 3. VOMITING.

   Vomiting is  a very frequent effect of pregnancy, and occa-
 sionally begins  almost immediately after conception. Gene-
 rally it takes place only in the morning,  immediately after
 getting up, and hence it has been called  the morning sick-
 ness, but in a few instances, it  does* not come on till the af-
 ternoon.   It usually continues until the period of quickening,
 after which it decreases or goes off, but sometimes it remains
 during the whole of gestation.  Some women  do  not vomit,
 and have  very  little if any sickness; others begin, after the
 fourth month,  to  feel an  irritation about the stomach  and
 other viscera ;  and some remain free from inconvenience till
 the  conclusion  of pregnancy, when the  distension of  the
 womb affects the stomach.  The fluid thrown up is generally
 glary or phlegm, and the* mouth fills with water previous to
 vomiting; but  if the  vomiting  be severe or repeated, bilious
 fluid is ejected.  Generally there  is no occasion to prescribe
 any remedies.   Puzos, and others, even considered vomiting
 as salutary; but in some  cases, it goes to a  very great length,
 recurring whenever the woman eats, or sometimes even when
 she abstains from eating, and continues for days or even weeks
 so obstinate, that she  is in danger of miscarrying,* or of suf-
 fering from want of food.   It is a general rule, in such cases,
 to take away early a small quantity of blood, a quantity pro-
 portioned to the vigour and fulness of the habit and state of the

  * It is worthy of remark, that abortion is very seldom occasioned by this
cause, though emetics arc apt to produce it 
182
pulse.   Of the utility of this practice, the  general testimony
of practitioners, and my own observation,  fully convince me.
Narcotic substances, such as opium or hyocyamus, have been
tried internally, either without blood-letting or subsequent to
it, but uniformly with little advantage.  In a few instances, a
cloth wet with laudanum applied to the pit of the stomach has
done good. The greatest attention must be  paid to the bowels,
and most marked benefit  is  often derived from  a gentle
dose of  Epsom or Cheltenham salts.  The severity of the
vomiting  may  also be greatly  mitigated by effervescing
draughts, or soda water: the last of which, if it do not check
the vomiting, renders  it much easier.  Even cold water has
been employed with advantage.   A light bitter infusion is
sometimes of service.  Obstinate vomiting, especially if ac-
companied with pain, or tension in the epigastric region, may
be relieved by the application of leeches to that part, which
have been much recommended by Dr.  John  Sims, and M.
Lorentz.  I have so often found advantage from this remedy,
that I speak of it with confidence.  If these means fail in pro-
curing speedy relief, it is necessary to refrain for a time eat-
ing, and have recourse to nourishing clysters, or to give only
a spoonful of milk, soup, &c. at a time.  When the vomiting
is bilious, and accompanied with pain in  the right side and
shoulder,  cough, and  other symptoms of hepatitis, a seton
should he immediately introduced into the side, and a very
gentle course  of mercury given; for if the  medicine be given
freely, it produces much debility, or abortion, and sometimes
accelerates the fate of the patient.
  When vomiting is troublesome in the conclusion of preg-
nancy, it  is proper to detract blood; and  confine the person
to bed.   Cloths, dipped in laudanum,  should  be  applied to
the pit  of the stomach, and a grain.of solid opium may be
given internally; but if this do not succeed, it is  not proper
to give  larger and repeated doses.  Gentle laxatives must be
employed. 
k
18.3
                      § 4. HEARTBURN.

  Heartburn  often takes place very  early after conception,
but sometimes not till after the  fourth month.   This  is  a
complaint so very common, and so generally mitigated by
absorbents, such  as magnesia or chalk, that we are  seldom
consulted respecting it.   But when it becomes very severe
and intractable,  it is requisite  to try  the most powerful  of
these means, such as calcined magnesia, combined with pure
ammonia.(a?)  When  these fail, soda water, or the chalk mix-
ture, with a large proportion of mucilage, may  give relief.
Laxatives are alw ays indispensable.  In obstinate cases, vene-
section is useful.  Emetics have been proposed by Dr. Den-
man, but they may sometimes cause  abortion. They are only
allowable where there is a constant screatus of disagreeable
phlegm.   In  every severe case  the diet  must be  carefully
attended to.
   Pyrosis is to be relieved chiefly by  laxatives, such as the
aloetic pill or rhubarb and magnesia, and rubbing the epigas-
tric region with anodyne balsam.

                    §  5. FASTIDIOUS TASTE.

   Women, during gestation, are subject to many bizarreries
 in their appetite, and often have a desire to eat things they  did

  (a:) The late much regretted Dr. Young, of Maryland, in his ingenious ex-
periments on the digestive process, has almost reduced it to a certainty, that
the acid which exists in the stomach is to be referred to the liquor gastricus;
that it is the phosphoric acid,  and that the acidity of dyspeptic and pregnant
women, is owing to the morbid quantity of this acid.  Hence, as he justly re-
marks, the superiority of hme water as a corrector, from its great affinity to
phosphoric acid.
  The following formula is also recommended by experienced practitioners
 for the same purpose.  I have used it with advantage.
                  $». Magnesia ustse         3j-
                     Aqua purse            5VSS-
                     Sp. Cinnamon          giij.
                     Aquae Ammoniac purx    ^j m-
   Two or three spoonsful to be taken either occasionally, or when the symp-
 toms are more continual, immediately after every meal. 
184
not formerly like.   This desire is common in cases of abdo-
minal  irritation, as we see in those who are afflicted with
worms, or have indurated or morbid faeces in the intestines.
These  longings, it has been thought dangerous to deny ;  for
as it was supposed, that they depend upon some peculiar
state of the child affecting the mother, it was imagined, that
if this was not removed, the infant would sustain an injury,
or might  even bear the mark of the thing longed for.  Into
this  doctrine, it is now unnecessary to enter, and it will be
sufficient  to add, that when  the  desire  is placed upon any
article of  diet, it may be safely gratified, and, indeed, gene-
rally the inclination leads to some light and cooling regimen.

        § 6. SPASM OF THE STOMACH AND DUODENUM.

  Spasm  of the stomach, or duodenum,  may often be attri-
buted to some irregularity of diet, to the action of cold, or to
the influence of the mind.  It is necessary to interfere promp-
ly, not  only because  the pain is severe, but also because it
may excite abortion, or kill the child.  A full dose of lauda-
num, with ether, followed immediately by  a saline  clyster,
is almost  always successful; but when the  attacks  are.  re-
newed, then we must endeavour to prevent them by tonics,
such as colomba, oxyde of bismuth, or preparations of steel.
It is at the same time, essential that the bowels be kept open.
Blood-letting is of service.
  When spasm of the stomach takes place in the end of preg-
nancy, or about the commencement of parturition, with a sense
of fulness  or uneasiness in the head, it is necessary to detract
blood, lest the patient be seized with convulsions.  This  re-
medy is likewise proper, when the pain is accompanied with
tenderness about the epigastric region, heat of the skin, full
pulse, and ruddy face.   When pain proceeds from the pas-
sage of a biliary calculus, it is to be treated more solito.

                   $ 7. COSTIVENESS.

   Costiveness is a general attendant on pregnancy, partly
owing  to the pressure of the uterus on the rectum, and partly 
185
owing to the increased activity of the womb producing a slug-
gish motion of the bowels.  We must not, however, neglect
this state, because it naturally attends gestation, for  it may
occasion many and serious evils.   It certainly increases the
irritability of the system, as well  as some of the stomachic
ailments; and is apt to cause irritation of the bowels, which
may either excite premature labour, or give rise to much
inconvenience after delivery, and not unfrequently occasions
convulsions.
   Magnesia is a very common remedy, because it at the same
time relieves heartburn;  but, when it fails, or is  not required
for curing acidity in the stomach, the common aloetic pill, or
a combination of aloes with extract of hyoscyamus, should the
former gripe, may be employed.   Castor oil is also given,
either alone, or made into an emulsion with mucilage.
   It sometimes happens  that indurated  faeces  are accumu-
lated in the rectum or colon, producing considerable irrita-
tion.  This causes  not only pain, but also an increased secre-
tion of the intestinal mucus, which is passed either alone, or
with blood,  together with pieces of hard faeces.   This state,
like dysentery, is  often  accompanied with great tenesmus ;
but it may be readily distinguished, by  examining per vagi-
nam, for the  rectum is found to  be filled  with  faeces.  Our
first object  ought to be to remove the irritating cause, which
might ultimately produce abortion.   Clysters are  of great
efficacy, because they soften the faeces, and assist in emptying
that part of the intestine which is most distended. These are
to be, at first, of a very mild nature, and must be frequently
repeated.  It may even be requisite to break down the fecu-
lent mass,  with the shank of a spoon, or some  such instru-
ment.^)   After the rectum  is  emptied, laxatives,  such as
castor oil, or small doses of sulphate of magnesia must be
given to evacuate the colon; and when the faeces are brought

  (y) The reader is referred, for a very interesting case of alvine concre-
tion, where it became necessary to introduce a long flexible catheter through
the hardened and impacted faeces, occupying the superior part of the pelvis,
for the purpose  of injecting an enema, to Hey's Practical Oservations on
Surgery, chap. XVIII. case 3.
   VOL. I.                         U IS                  / 
180
into the rectum, clysters must be again employed.  After the
bowels are emptied, hyoscyamus should be given, to allay the
irritation; or if this be not sufficient, and the pain and secre-
tion of mucus, with tenesmus, still continue, an opiate must
be administered,  but next  day  it is to be followed by a mild
laxative.  And if there be  fever or considerable pain in the
abdomen  blood-letting will be necessary.   If this costive
state be  neglected  near the time of delivery,  the labour is
often protracted ; and after delivery masses of indurated faeces
come down from  the colon, producing considerable pain and
frequency of pulse.  When there is much irritation  and sen-
sibility, upon pressing on the abdomen, either before or after
delivery,  it will be proper to detract blood, at the  same time
that we use the remedies already pointed out.

                      § 8.  DIARRHOEA.

  The bowels, instead of  being  bound, may be very open;
or costiveness  and diarrhoea may alternate with each other.
The diarrhoea is of two  kinds; a simple increase of  the
peristaltic motion, and increased serous  secretion;  or  a
more obstinate disease, depending on debilitated and deranged
action of  the bowels.  In  the first kind, the discharge is not
altered from  the  natural state, except in being thinner;  the
appetite is pretty good, and the tongue clean, or only slightly
white.  This is not to be checked, unless it go to a consider-
able extent, or continue long, or the patient be weakened by
it, or be previously of a debilitated habit.  Anodyne clysters,
or the confectio catechu, will then be of service.   Should the
pulse be frequent,  and any degree of heat or tension be  felt
in the abdomen, venesection will be useful.   In  the second
kind, the appetite is lost   or diminished, the tongue is foul,
and the patient has a bitter or bad taste,  and occasionally
.vomits ill tasted or bilious matter; the  breath is offensive,
and often the head  aches.   The stools are very offensive,  and
generally dark coloured.   In  this case, small doses of rhu-
barb give great relief, and one grain of ipecacuanha may oc-
casionally be added to each dose  of rhubarb.  A  light bitter 
187
infusion is also a useful remedy.  Attention must be paid to
the diet, which is to be light, and  the food taken in a small
quantity at a time.   Considerable benefit is derived from soda
water, which  generally  abates  the sickness.   When  the
tongue becomes cleaner and the stools more natural, anodyne
clysters may  be administered.  In all  cases of continued
diarrhoea, it is useful  to have the surface  kept  warm with
flannel; and sometimes a flannel roller, bound gently round
the abdomen, gives great relief.

                        § 9. PILES.

  Pregnant wTomen are very subject to piles.  This may be
partly owing to the pressure of the womb upon the vessels of
the pelvis, but is chiefly to be attributed to a sluggish state
of the intestinal canal, communicating a similar torpor to the
hemorrhoidal veins.  As this state is attended with costive-
ness, the  disease has been  considered as  dependent on the
mechanical  action of the faeces; but whatever truth may be
in this opinion in some  cases, yet generally it is without
foundation ; and it is  no unusual  thing  for those  who  are
subject to piles, to be  able to foretell an attack, by the ap-
pearance of peculiar symptoms, indicating diminished action
of the alimentary  canal.  The treatment of this disease is
two-fold.  We are to remove the cause by such means as give
a brisker  action to the bowels such as bitters and laxatives ;
which last are also of great service by removing the irrita-
tion of the faeces from the rectum, and rendering them softer,
by which the expulsion gives less pain.  For this purpose,
cream of  tartar alone, ob combined with sulphur,  has been
generally  employed; but we may, with equal advantage, give
small doses of castor oil, or of  any of the mild neutral salts,
dissolved  in a large quantity of  water.  Besides removing
the cause, we  must likewise lessen  the effect by such local
means as  abate  irritation and sensibility.   When the pain,
inflammation, and  swelling, are great,  it is of service to de-
tract blood topically, by the application of  leeches, or, espe-
cially if there be  considerable  fever, blood-letting  may b« 
188
necessary, as in other cases of local  inflammation.   The
diet should be spare;  all stimulants and cordials  must be
avoided ;  cooling and anodyne applications to the tumour are
also very proper, such as  an ointment containing a small
quantity of acetate of lead,  or a weak solution  of the acetate
of lead in rose water, or a mixture of the acetum  lithargyri
and cream.  Sometimes astringents are of  service, such  as
the gall ointment; or narcotics, such as opium* or belladona.
If these means fail, it will be proper to give an anodyne clyster,
and apply fomentations or emollient poultices to the tumour,
but e^evy practitioner can tell how often all topical  applica-
tions have disappointed him.  In some cases, the tumour be-
comes slack, and subsides gradually; in other instances  it
bursts, and more or less blood is discharged.  If the hemorr-
hage  be moderate, it gives relief; but if profuse, it causes
weakness, and must  be restrained  by pressure and astrin-
gents.   Great pain,  or much hemorrhage,  are both apt to
excite abortion.

            § 10. AFFECTIONS OF THE BLADDER.

  The bladder is often affected by pregnancy.  In some in-
stances like the intestines, it becomes more  torpid than for-
merly ; so that the woman retains her water long,  and expels
it with some difficulty, and in considerable quantity at a time.
This state requires great attention, for retroversion of the
uterus may, at a certain stage of gestation,  be readily occa-
sioned.   There is not much to be done with medicines in this
case; for, although soda,  and similar remedies,  sometimes
give relief, yet more reliance must be placed on the regular
efforts of the patient. Should these be delayed  too long, then
the catheter must be employed.
   More frequently the bladder is rendered unusually irritable,
especially about its neck, and the urethra participates in this

  * Dr. Johnson advises  the following  ointment to be apphed, and then
a poultice to be laid over the tumour.  R.  01. Amygd. 5i. 01. Succini
§ss. Tr. Opii.3«. M. System?. US. 
189
state. There is also, in many instances, an uneasiness felt in
the region of the bladder itself.   This state requires a very
different treatment from  the former, for here it is our object
to avoid every saline medicine which might render the urine
more stimulating.  Relief is to  be expected by taking away
blood,  giving small doses of castor oil, and, occasionally, the
extract or tincture of hyoscyamus, and encouraging the pa-
tient to drink mucilaginous fluids, which, if they do not reach
the bladder as mucilage, at least afford a bland addition to
the blood, from which the urine is  secreted.  This state of
the bladder is sometimes productive of a light irritation about
the symphysis of the pubis, rendering the  articulation less
firm and more  easily  separated.  In such  circumstances,
when the pubis is tender, blood-letting and rest are the two
principal remedies.
   A very distressing affection,  which is often conjoined with
this state of the bladder and urethra, but which may also take
place without it, is  a tender and irritable state of the vulva,
producing great itching about the pudendum, especially dur-
ing the night, and generally the urine is felt very hot.  This
distressing condition is often alleviated by blood-letting and
laxatives; and when the itching is great, a sponge, dipped in
 cold water, or in cold solution of cerussa acetata, should be
 applied. If much fever exist, the saline julap, combined with
 a little tincture of opium, is useful.
   Incontinence of urine is not uncommon, in the end of ges-
 tation, and is produced by the pressure of the uterus on the
 bladder, by which the urine is forced off involuntarily, when-
 ever the woman coughs or moves quickly; or at least she can-
 not retain  much of it,  being obliged to void it frequently,
 but without strangury.   For this complaint there is no cure;
 and many consider it as a  favourable omen, that the child's
 head is resting on the os uteri.  When the uterus is very
 pendulous, some advantage may be obtained, by supporting
 the belly with a proper bandage attached to the shoulders. 
190
                     § 11. JAUNDICE.

   Connected with the state of the alimentary canal, is the
jaundice of  pregnant women.   This disease  appears  at  an
early period, and is preceded by dyspeptic symptoms,  which
generally increase after the yellowness comes on.  In some
instances, the tinge is very slight, and soon disappears.   In
other cases, the yellow colour is deep and long continued, and
the derangement of the stomach  and bowels considerable.
Emetics, and other violent remedies, which  are  sometimes
used in the  cure  of the jaundice, are not allowable in this
ease,  and in every instance, when young married women are
seized with jaundice, we should be very cautious in our pre-
scriptions.  Gentle doses of calomel, or  of other laxatives,
with some light bitter infusion, are the most proper remedies;
and generally the complaint soon  goes off.  Jaundice may
also take place in the end  of gestation; and  in this case, it
proceeds most frequently  from pressure on  the  gall duct.
Sometimes, however, it is dependent on a disease of the liver
itself, which may occur  at any period of gestation,  and is
marked by the usual symptoms.  In  this case the danger is
very great, and can only be averted by taking cautious mea-
sures for removing the hepatic disease.

                  §*12. COLOURED  SPOTS.

  In some cases, the skin  is partially coloured; the mouth,
for instance, being surrounded with a yellow or brown circle,
or irregular patches of these colours  appearing on different
parts of the  body.  This is an affection quite  independent  of
the state of  the bile, and  seems rather to be  connected with
certain conditions of the alimentary canal.  It goes off after
delivery,  and does not require any peculiar treatment.

                    § 13. PALPITATION.

   The thoracic viscera not unfrequently suffer during preg- 
191
nancy.  Palpitation of the heart is a very common affection,
and extremely distressing. It is a disease so well known, that
it is needless here to describe it; but it may not be improper
to observe, that women themselves sometimes mistake for it a
strong pulsation of the arteries, at the upper part of the abdo-
men.   It may make its attack repeatedly in the course of the
day;  or only at night, before falling asleep; or at the interval
of two or three days; and is very readily excited by the
slighest agitation of the mind. It is generally void of danger;
but in delicate women, and in those  who  are  disposed to
abortion, it sometimes occasions that event; and if long con-
tinued, it may excite pulmonic disease in those who are pre-
disposed to it.  Absolute  rest, with antispasmodics, are re-
quisite during the paroxysm.  Hartshorn,  ether, and tinc-
ture of opium, may be given, separately or combined.  Ro-
deric  a  Castro  prescribes a  draught of hot water.   The
attacks are to be prevented by the administration of tonics,
such as tincture of muriated iron; and  of foetids, such as
valerian and asafoetida. Fatigue and exertion must be avoid-
ed, and the mind kept tranquil.  If the person be plethoric,
it is sometimes useful to  take away  a little blood.   The
bowels are to be carefully kept open.   The diet must be at-
 tended to ; for it is often produced by a disordered stomach.
   A tendency to nervous or hysterical diseases is to be pre-
 vented, in those who are  liable to them, by occasional blood-
 letting, the use of laxatives, and camphor, or foetids. Opiates
 are only to be given for the immediate relief of urgent symp-
 toms.

                       § 14. SYNCOPE.

   Another distressing affection of the heart, attendant on
 pregnancy, is syncope.   This  may take place at any period
 of gestation, but is most frequent  in the three first months,
 or about the time of quickening.  It  often  occurs in those
 who are otherwise healthy, but it also may occur daily for
 sometime  in those who are weakened by a loose state of the
  bowels, alternating with costiveness, or by want of sleep oc- 
193
casioned by tooth-ach.   It may succeed some little exertion,
or speedy motion, or exposure to heat; but it may also come
on  when  the person is at perfect rest.  The paroxysm is
sometimes complete, and of long duration; at other times,
the person does not lose her knowledge of what is going on,
and soon recovers.  A  recumbent posture,  the admission of
cold air, or application of cold water to the face, the use of
volatile salt, and the cautious administration of cordials, con-
stitute the practice during the attack.  Should the fit remain
long,  we must preserve the heat of the  body, otherwise a
protracted syncope may end in death.  Those ,vho are sub-
ject to fainting fits, must avoid  fatigue,  crowded or  warm
rooms,  fasting,  quick  motion, and agitation  of the  mind.
Tonics are useful when the system is  weak, and the bowels
must be regulated.
  There is  a species of syncope, that I have oftener than
once found to prove fatal in the early stage  of  pregnancy,
which is dependent, I apprehend, on organic affections of the
heart, that  viscus  being enlarged, or otherwise diseased,
though perhaps so slightly as  not  previously to give rise to
any troublesome,  far  less  any  pathognomonic  symptoms.
Although I have met with this fatal termination most fre-
quently in the early stage,  I  have also seen it take place so
late as the sixth month of pregnancy.

               § 15. DYSPNCEA AND COUGH.

  Sudden attacks of dyspnoea in those who were previously
healthy, are generally to be considered as hysterical, and are
readily removed by antispasmodics.  There is, however, a
more  obstinate  and  protracted symptom,  not unfrequently
connected with pregnancy, namely cough.   This may come
in paroxysms, which are generally severe, or it may be al-
most  constant, in which case it is short and teasing.   Some-
times a viscid fluid is expectorated, but more frequently the
cough is dry. During the attack, the head is generally pain-
ful, and the woman complains much of  the shaking of her
body,  especially  of the belly.  All practical writers are 
193
agreed with respect to the danger of this disease, for it is ex-
tremely apt to induce abortion; and it is worthy of remark,
that after the child is expelled, the cough  often  suddenly
ceases.  But exposure to cold frequently brings it back; and
should there be a predisposition to phthisis, that disease may
be thus excited.  Blood-letting must be early, atid sometimes
repeatedly employed; the  bow els kept open; and  lozenges,
containing opium or  hyoscyamiis, must be occasionally used,
to allay the cough.   A large burgundy pitch plaster, applied
betwixt the shoulders, is of service.  Should abortion  take
place, and the cough continue, tonics, such as myrrh and oxyde
of zinc, ought to be administered.

          § 16. HEMOPTYSIS AND II.EMATEMESIS.

   In some instances, haemoptysis or haematemesis take place
in pregnancy,  especially  in the last months,  and these are
very dangerous affections. Blood-letting is the remedychiefly
to be depended on ;  and afterwards purgatives should be given;
acids and hyoscyamiis may be employed to allay irritation.  If
these  means do not succeed,  the patient dies.   Should the
hemorrhage take place during labour, or should pains come on
prematurely, and the os uteri dilate, as sometimes happens, it
will be prudent to accelerate the delivery.

           § 17. HEAD-ACHE AND CONVULSIONS.

   Head-ache is a very alarming symptom, when it is severe,
constant, and accompanied with symptoms of plethora.  If
the eye be dull or suffused, and the head giddy, especially
when the person stoops or lies down, with a sense of heavi-
 ness over the eyes, or within the skull, great danger is to be
 apprehended, particularly if the woman be far advanced in
 her pregnancy.  This is still  more the case, if she complain
 of ringing in  the ears, and flashing of fire in the eyes,  or in-
 distinct vision.  In  such  circumstances, she is seized  either
 with apoplexy or epilepsy. These diseases are to be prevent-
 ed by having immediate recourse to blood-letting and purga-
   vol. T.                        c c 
194
tives;  and the same remedies are useful,  if either one or
other of these diseases have already taken place.   The quan-
tity of blood which is to be detracted, must be determined
by the severity of the symptoms, the habit of the patient,
and the effect of the evacuations; but, generally,  moderate
evacuation will prevent, whilst very copious depletion is re-
quisite to cure these diseases. If the head-achebe accompanied
with oedema, the digitalis is a useful addition to the practice.
I shall not at present enter more minutely into the treatment
of epilepsy.   I shall only remark, that the  first  thing to be
done is to detract blood from a vein; next, the bowels are to be
immediately opened by a clyster, and then  a purgative  is to
be administered.
  If the patient is seized with apoplexy,  there is seldom any
attempt made to expel the child,* and, in my own practice,
I have never known that event take place.   In epilepsy, on
the contrary, if the paroxysm be  protracted there is gene-
rally an effect produced on the uterus; its mouth opens, and
the child may be expelled, if the patient  be not early cut off
by a fatal coma.   Whenever expulsive  effects  come on, we
must conduct the  labour according to rules hereafter to be
noticed. In some instances, palsy  either succeeds an apoplec-
tic attack, or follows head-ache and vertigo.  This disease docs
not commonly go off until delivery have taken place; but it
may be prevented from becoming severe, by mild  laxatives
and  light diet; and, after the woman recovers from her la-
bour, the  disease gradually abates, or yields to appropriate
remedies.
  All head-aches, however, do not forbode these dismal events,
for often  they proceed from the stomach, and evidently de-
pend on costiveness, dyspepsia, or nervous irritation. These
are generally periodical, accompanied with a pale  visage,
they feel  more external than the former, and are often con-
fined to one side of the head.   They are attended with aci-
dity in the stomach, eructations, and sometimes considerable
giddiness pr slight sickness, with bitter taste in the  mouth.

  * Mr. Wilson's case is an exception to this. Vide Med. Facts, vol. v. p. 96. 
195
They are relieved by the regular exhibition of laxatives, by
sleep, the  moderate  use of volatiles,  and the application of
ether externally.
  Hysterical convulsions are not uncommon during gestation,
and  more  especially during the first four months.   They
occur in irritable habits, or in those  who are naturally dis-
posed to syncope, or who have been exhausted by any pain,
depriving them of rest, or by alvine discharges.  They are
distinguished  by the face usually being pale during the  at-
tack, the countenance is very little distorted, there is no foam
issuing from  the mouth, the patient for a time lies as  in a
faint, and then has convulsive motions, or screams and sobs,
and the fit generally is terminated by shedding tears.  The
treatment,  in the  first instance,  consists in  administering
 antispasmodics, particularly opiates and volatile foetids.  Af-
 terwards, the returns are to be prevented by bringing the
 bowels into a correct state, and keeping them so.   The ex-
 ercise is to be gentle, but taken regularly.  The diet mild but
 nourishing.  Sleep is to be procured, if necessary, by opiates;
 and tonic medicines, with the assistance of ammoniated tinc-
 ture of valerian, must complete the cure.

                      § 18. TOOTH-ACftE.

    Tooth-ache not unfrequently attends pregnancy, and, some-
  times, is a very early symptom of that state.  The tooth may
  be sound or diseased, but in neither case, ought we to extract
  it, in the early months, if it be possible to avoid the opera-
  tion.  I  have known the extraction followed in a few minutes
  by  abortion.  Blood-letting  frequently gives relief,   and,
  sometimes, a little cold water taken  into the mouth abates
  the pain.   In other cases, warm water gives more relief.

                      § 19. SALIVATION.

     Salivation is, with some women, a mark of pregnancy. It
  has been supposed that there is a sympathy existing between
  the pancreas  and salivary glands, and that the phlegm re- 
196
jected by vomiting proceeded from  the  former, whilst, in
many instances, the latter yielded an increased quantity of
viscid saliva.  This is a symptom which  scarcely demands
any medicine, but, when it does, mild laxatives are the most
efficacious.

                  § 20. MASTODYNIA.

   Pain and tension of the mammae frequently attend  gesta-
tion,  and these symptoms are often very distressing.  If the
woman have formerly had a suppuration of one mamma, that
breast is generally most painful, and she is afraid  of abscess
again forming.  In other instances, the pain, being accompa-
nied with increased hardness of the breast, produces appre-
hension of cancer.  These fears  are  generally groundless;
but if suppuration do take place, it is to be treated on general
principles.  Blood-letting often relieves the uneasy feeling in
the breast, which is  also mitigated by gentle friction with
warm oil.  Nature often gives relief, by the secretion of a
serous fluid  which runs out from the nipple; but if this be
much encouraged  by suction, Chambon remarks, that the
foetus may be injured.  ' The discharge is in some instances
so great about the seventh month, or later, as to keep the
woman very uncomfortable.   The diet in  this case should
be dry.
  The sudden abatement  of the  tension, and fulness of the
breasts, with a diminution of size, are unfavourable circum-
stances, indicating either the death of the child, or a feeble
action of the womb.

                     § 21. 03DEMA.

  In the  course of gestation, the feet and legs very generally
become oedematous;  and sometimes the thighs,  and labia
pudendi participate in the  swelling.  The swelling  is by no
means proportioned always to the size of the womb, for, as
has been  remarked by Puzos, those who have the womb un-
usually distended with water, and those who have twins, have 
197
frequently  very little  oedema of the feet.  This  disease is
partly owing to the pressure of the uterus, but it also seemi
to be somewhat  connected with the pregnant state,  inde-
pendent of pressure; for in some instances, the oedema is not
confined to the inferior extremities, but affects the whole body.
A moderate degree of oedema going off in a recumbent pos-
ture is so far from being injurious, that it is occasionally re-
marked, that many uneasy feelings are removed by its acces-
sion ; but a greater and more universal effusion indicates a
dangerous  degree of irritation, and may be followed  by epi-
lepsy.   In ordinary cases, no medicine  is necessary except
aperients;  but, when the oedema is extensive or permanent,
remaining even after the patient has been for several  hours
in  bed, it may be attended  with  unpleasant or dangerous
effects, such as convulsions; or, it may predispose to puerpe-
ral diseases ;  we must therefore  lessen it by means  of those
agents  which  alleviate  the  other  diseases of pregnancy,
namely,  blood-letting  and  purgatives.  These means  are
always proper, unless the strength be much reduced; in which
case, we only employ the purgatives and cordials prudently,
with acetate of potash, or sweet spirit of nitre.   Diuretics,
generally,  are not successful, and many of them, if  given
liberally, tend to excite abortion.  Friction  relieves  the feel-
ing of tension.

                      § 22. ASCITES.

   Ascites  may, like oedema,  be  excited, in consequence of
some condition  connected with  gestation, or may be inde-
pendent of it, arising from some of  the ordinary causes of
dropsy, especially from  a disease of the liver.  In the last
case, medicine has  seldom much  effect  in palliating or re-
moving the disease ; and  the woman usually dies,  within a
week or two after her delivery, whether that have been pre-
mature, or delayed till  the full  time.   When ascites is not
occasioned by hepatic disease, and appeals for the first time
during gestation, it is generally connected with the  oedema-
tous state above-mentioned, and seldom comes  on until the 
198
 woman has been at least three months pregnant.  If it be not
 attended with other bad symptoms, such as head-ache, feverish-
 ness, drowsiness, &c. it abates and goes off, a little before, or
 soon after delivery, which is  often premature.  I have seen
 diuretics given very freely in these cases, but most frequently
 without any  benefit.  On this account, and  also from the
 danger of these exciting abortion, or premature labour, I am
 inclined to dissuade from their use, except  in urgent cases.
 Then the  mildest ought to be employed, such as cream of tar-
 tar, juniper tea, acetate of pot-ash, &c. If any of these produce
 much irritation of the urinary organs, they must be exchanged
 for others. Purgatives and blood-letting are more useful.
   Ascites  may have existed previously to pregnancy, and the
 two causes combined, may produce a very great enlargement
 of the belly.   In this case, the uterus may be felt through the
 teguments, sometimes very much compressed, as if the child
 lay across.   Mild diuretics tend to keep the disease at bay;
 and if  the distension be  very great, especially at an early
 stage, my  experience leads me to conclude, that after quick-
 ening, a great part of the fluid may be drawn off safely, pro-
 vided, during the operation and afterwards, the abdomen be
 carefully and uniformly supported by a bandage.   It is useful
 to know this,  as the distension is sometimes so great, that life
 could not go on, without much distress, till the end of gesta-
 tion.  The operation, I think, is more apt to be succeeded
 by labour, if performed in the last month, than earlier.(«)

  (z) Instances have occurred, where in cases of ascites combined with
pregnancy, the operation of paracentesis has been performed, although this
is a practice by no means to be commended.  In the eighth Vol. of the Lon-
don Med. Facts and Observations, there is a case related by Mr. Simmons, of
a pregnant woman with symptoms of ascites being twice tapped, first, in
the second month of pregnancy, when fourteen quarts of water were drawn
off, and the second time, when  five  months advanced,  when only a few
ounces of blood followed the withdrawing of the trocar; at the full time she
was delivered of a healthy child, having suffered no inconvenience from the
operation.
  Another case is related in the seventh Vol. of the London Med. and Phys.
.lournal, by  Dr.  Vieusseux, of Geneva, where a  woman in the fifth month
 of pregnancy wai tapped, but it appears that the consequence of this opera- 
199
            § 23. REDUNDANCE OF LIQUOR AMNII.

   When  the liquor amnii is in too great quantity, much in-
convenience is  produced,  and  not  unfrequently  the  child
perishes.  This disease is known, by the woman being un-
usually large at an early period of gestation, for generally by
the seventh  month, she  is as big  as she ought to be in the
ninth.  It is distinguished from ascites, by the motion of the
child being  felt, though obscurely, by the  mother, and the
breasts enlarging.  Per vaginam we can ascertain, that the
uterus contains  a substance, which  alternately recedes and
descends as the finger strikes on the lower part of the womb.
This is to be considered as a dropsical affection of the ovum,
but the health of the woman seldom suffers so much  as  in
dropsy; the tongue,  however, is  white, and the urine is di-
minished in quantity.  The legs are less apt to swell than in
a common pregnancy.  The distension may, in the advanced
stage, prove troublesome.  When the quantity of water is
greatly increased, the child is  seldom kept till the full time,
but is generally expelled in the eighth month, or sooner, and
the labour is apt to be  accompained or succeeded  by uterine
hemorrhage. In some instances, the child occupies the upper
part of the  uterus,  and the water the under, at least during

tion was an abortion, although the patient soon recovered.  Both these cases
are related by the gentlemen under whose observation they fell, to prove
that the paracentesis has been performed, and even the uterus perforated,
[which they suppose was the case in both these instances,] without material
injury to the patient.
  In the same work is related a case of a woman, who was tapped no less
than five times during pregnancy : at the full period she was, notwithstand-
ing, delivered of a fine child, and recovered  completely from the puerperal
state.
  These cases  prove, how much the system  will sometimes suffer with im-
punity, but at the same time we must acknowledge, that it is best not to pre-
sume too far on the preservative energies of nature.
  Sometimes pregnancy has been, from gross inaccuracy, mistaken for drop-
sy, and the paracentesis been performed with a fatal effect; the patient in
one instance fainting, and expiring almost  instantaneously. Upon examina-
tion after death, it was found that the  trocar had not only perforated the
uterus, but had also penetrated the foetus! 
soo
labour.   Twice in the same woman, in succeeding pregnan-
cies, I found the child  contained  in the  upper part of the
uterus, and embraced by it as if it were in a cyst, whilst se-
veral pints of water lay between it and tfce os uteri.  When
the water came away, filling some basons, then the child de-
scended to the os uteri, but was born  dead, with the thighs
turned firmly up over the  abdomen, and  other marks of de-
formity.
   This is a disease of the ovum and not of the mother, un-
even the foetus itself is often malformed, or at least  blighted.
The  affection  in toto, may be considered as a sp. cies  of
monstrous conception.    Some particular condition ot the
parent may, however, in certain cases, occasion it.   For in-
stance, it may be connected with a syphilitic taint  in either
the father or mother;  or  with some  less  obvious cause im-
pairing the action of the womb, but not directly producing a
miscarriage; with lunacy or idiotism; or with a state  of ge-
neral or uterine debility; or with an original imperfection of
the ova  in the ovarium : for a woman may, without any ap-
parent cause, have repeatedly this kind of pregnancy.  All of
these causes do not operate uniformly to the same extent, but
 the foetus suffers in proportion to their operation. It is either
 born very feeble and languid,  and is reared with difficulty or
 it dies almost immediately, or it perishes before labour com-
 mences ; and this is generally the case when the diseased state
 exists to any great  degree. The period of the child's death is
 usually  marked by a shivering fit, and cessation of motion in
 utero, at the same time that the breasts become flaccid.  Af-
 terwards irregular pains come on, with or without a watery
 discharge.  Sometimes the  woman  is sick or feverish for a
 few days before labour begins.
    If the liquor amnii be not increased greatly beyond  the
 usual quantity, the  woman may go the full time, but, from the
 distension of the uterus,  is apt to have a lingering  labour.
    Tonics, the  cold bath, dry diet, with  occasional venesec-
 tion, and the use of laxatives, during pregnancy, may be of
  service, but frequently fail.  Diuretics do no good.  A course
  of mercury conducted prudently, previous to  conception, is 
201
the only remedy, when we suspect a syphilitic taint.  It may
be necessary to prescribe it to both parents.  When it pro-
ceeds from some more latent cause, I think it is useful, for
preventing a repetition of the disease, to  make the mother
nurse, even although her child be dead.   Mercury ought also
to be tried.
  When  the distension produces much distress, it has been
proposed to draw off the water by the os uteri;  or this has
been done in one case by the common operation of paracen-
tesis, the woman surviving, and  labour  taking place on the
twenty-first day.*  This practice is, however, generally im-
proper, and is  seldom  requisite, pains usually  coming on
whenever the symptoms become  severe.  When the  os uteri
is considerably dilated by the pains, it may be proper to rup-
ture the membranes, as has been advised by Puzos.

                 § 24. WATERY DISCHARGE.

   Discharges of watery  fluid from the vagina arc not unfre-
qucnt during pregnancy,  and generally depend  upon secre-
tion from the glands  about the  cervix uteri.  It has  been
supposed, that in every case they proceeded from this cause,
or from the rupture of a lymphatic,  or  the evacuation of a
fluid collected between the chorion and amnion, or the water
of a blighted ovum, in a case of twins; for in every instance,
where the liquor amnii has been artificially evacuated, labour
has taken place.  But we can suppose, that the action of ges-
tation may, in some women, be so strong, as not to be inter-
rupted by  a partial evacuation  of the liquor amnii.  Even
granting the water to  he collected  exterior to the chorion,
there must be a strong tendency to excite labour, if the quan-
tity discharged be great ;f and if the uterus can  resist this,
it may also be unaffected by the evacuation of liquor amnii.
I have known instances,  where after'a fright or exertion, a

  * Vide case by Noel Desmarais, in Recueil Period. Tom. VI. p. 349. M.
Baudelocque gives a memoir on this subject in the same volume.
  f Vide Dr. Alexander's case, in Med. Comment.  Vol. III. p. 187.
   VOL. I.                         D D 
202
considerable quantity of water has been suddenly discharged,
with subsidence of the abdominal tumour, or feeling of slack-
ness ; and even irregular pains  have taken place, and yet
the woman has gone to the full  time.*  These prove, as  far
as the nature of the case will admit of proof, that the water
has  been evacuated.   Sometimes,  only one discharge  has
taken place, but oftener the first has been followed by others;
and these are often tinged with blood.  The aperture seems to
heal, if gestation go  on ; for during labour, a discharge of
water takes place.  Much more frequently labour does take
place.   Even wheu the discharge  proceeds  only  from  the
vessel op glands about the os uteri, if the woman be not care-
ful, a hemorrhage may take place, followed by labour.  This
is most likely to happen if there have  been  a copions  dis-
charge.
   The practice in  these cases,  is to confine the patient  for
some time to bed.  An anodyne ought  also to be given,  and
may be  repeated occasionally, if she be affected either w ith
irregular pain, or nervous irritation;  previous  venesection
often renders this more useful.   The bowels  are to be kept
open.   If we suppose the discharge to be from the glands or
vessels  about the  os  uteri,  we  may, with  advantage, inject
some astringent fluid,  such as a solution of  sulphate of alu-
mine.
   It sometimes happens, that a large hydatid is  lodged be-
tween the ovum and the os uteri, and it may be expelled se-
veral weeks before parturition.  If care be not taken,  this
may be followed by hemorrhage.

  * Dr. Pentland  relates a very distinct case, where the liquor was, in the
third or fourth month, discharged in a  fit of coughing.  The belly fell, but
she still went on to the full time, and had a good labour.  Dublin Med. and
Phys. Essays, No.  I. art. 3.—1 have known a discharge of water take place,
at short intervals,  for some weeks; and then the funis umbilicalis protruded,
without  any exertion, or any pains to rupture the membranes,  which is a
demonstration that the membranes had been previously open,  and that the
discharge of liquor did not  speedily excite labour. 
803
                  § 25. VARICOSE VEINS.

  Varicose tumours sometimes appear on the legs.  They are
not dangerous, but are often painful.   By pressure, they can
be removed ;  but I am not sure that it is altogether safe  to
apply a bandage round the legs, so tight as to prevent their
return.  It is better, in ordinary cases, to do nothing at all;
but where there is much pain, a recumbent posture, and mo-
derate pressure, give relief.

                  § 26. MUSCULAR PAIN.

  From the distension of the abdominal  muscles, pain may
be produced, either about the extremities of the recti muscles,
or the origins of the oblique or transverse muscles.  These
pains are  not dangerous, but give unnecessary alarm if the
cause be not known.  It is impossible to remove them, but
they may be mitigated by anodyne embrocations.  If the pain
be severe  along the edge of the ribs, relief may  be obtained
by applying round the upper part of the abdomen a narrow
band of leather, spread with adhesive plaster.
   There is  another cause  of pain,  which sometimes affects
these muscles,  but  oftener those about the  pelvis and hips.
This seems to consist in a diminished power of the muscles, in
consequence of the uterine action, and thus the fibres are not
capable of the same exertion as formerly.  A long walk, or
some little fatigue,  may produce such an effect, as  to render
them painful for a long time: or even  without any unusual
degree of  motion, they may ache, and produce the  sensation
of  weariness.  These pains have been supposed to be  most
frequent  when the  woman has twins, but this  is  far from
being a general rule.  They may occasion an apprehension
that she is going to miscarry. Rest is the principal  remedy;
but if they he severe, relief may often be obtained by vene-
section.
   Pain in the side, particularly the right side, is sometimes
 at an advanced period of gestation, both muscular, and also
 connected with the state of the bowels, especially of the colon. 
204
It is frequently most severe, and may be rendered still more
distressing by  being combined with violent heartburn, or
water  brash.  It comes on  chiefly at night, and instead of
being relieved by lying down, is often increased on going to
bed.  It  is usually accompanied with much motion of the
child.  Venesection  sometimes gives relief,  but generally
more advantage is derived from rubbing with anodyne balsam,
attending to the state of the bowels, and regulating the diet.
Although the pain be very severe, it seldom brings on labour.

              § 27. SPASM  OF THE URETER.

   Spasm of the ureter, or  some violent nephritic affection,
may occur during gestation.  The pain  is severe, the pulse
slow and soft, and the stomach often filled with wind.  The
symptoms  are attended with  distressing strangury, and, if
not soon removed, may cause premature labour.   Decided
relief  is  obtained by giving a saline clyster, and, after its
operation, injecting eighty  drops of laudanum, mixed with a
little starch.  A sinapism is to be applied to the loins, and if
these means fail, blood must be taken away.

                      § 28. CRAMP.

   Spasms in the inferior extremities are often very  distress-
ing.   These may come on suddenly, but occasionally, they
are preceded by a sense of coldness, and accompanied with a
feeling of heat.   They are  removed by change of  posture,
and gentle  friction.  They have, by some, been thought to
indicate a wrong presentation of the child, but this opinion is
not supported by  experience.  They proceed from the pres-
sure of the uterus on the nerves in the pelvis.

            § 29. DISTENSION OF THE ABDOMEN.

   In a first pregnancy, the  abdominal muscles generally
preserve a greater degree of tension than they do afterwards;
and therefore the belly is not so prominent as  in  succeeding 
205
pregnancies.   Sometimes the muscles and integuments yield
so readily to  the uterus, that it falls  very  much  forward,
producing a great prominence  in  the  shape, inconvenience
from the pressure on the bladder, and pain in the sides, from
the increasing weight of the projecting  uterus.  In  such
cases, benefit  may be derived from supporting the abdomen
with a bandage connected with the shoulders.  In other in-
stances, the muscles and integuments do not yield freely, but
the belly is hard and tense;  the woman feels shooting pains
about the abdomen, and sometimes miscarries. This state is
relieved by blood-letting and tepid fomentations.  When the
skin does not distend freely, and becomes tender and fretted,
or when these effects  are produced by very great distension,
benefit is derived from fomenting with decoction of poppies,
and afterwards applying a piece of soft linen,  spread very
thinly with some emollient ointment.
   There is sometimes a disposition to distend unequally,  so
that one side yields more  than  the other, or even part of one
side, or one muscle more than the rest, producing a peculiar
shape.  This is attended with no inconvenience.

                       § 30. HERNIA.

   It is very usual for the navel of pregnant women to become
 prominent, even at an early  stage.  In some instances, such
 a change is produced, as to  allow the intestine  or omentum
to  protrude,  forming an umbilical hernia; or if the woman
have been  formerly  subject to that disease, pregnancy tends
to increase it, whilst, on the  other hand, the intestines being
 soon raised up by the ascending uterus, inguinal and femoral
hernia are not apt to occur, or are even removed if they for-
 merly existed.  Umbilical hernia ought to be either kept re-
 duced by  a proper bandage, or at least prevented, by due
 support, from increasing;  and during delivery, we must be
 careful that the intestine be  not forcibly protruded, as it
 might be difficult to replace it.   After delivery,  a truss must
 be applied, with spring wings which come round by the side
 of th© belly. 
                          206

   In some cases, during gestation,  the fibres of the abdomi-
nal muscles separate, so that a ventral hernia is formed. The
same circumstance may take place during parturition ; and
the laceration is sometimes so large, that afterwards, when-
ever the  muscles contract, as, for  instance, in the act of
rising, a quantity of intestine  is forced out, forming a hard
tumour like a child's head.  It is necessary  in this, and in
all other cases of large hernia, to be careful that compression
be  applied immediately after delivery, and also during the
expulsion of the child.  By  neglecting this,  syncope and
uterine hemorrhage have been occasioned.
   Hcrniee of the bladder should always be reduced in the
commencement of labour, for  it may interfere with the pro-
cess of parturition, or the bladder may be exposed to injury.

                    § 31. DESPONDENCY.

   It is not uncommon to find  women very desponding dur-
ing pregnancy, and  much  alarmed respecting the issue of
their confinement.   This apprehensive state may be the con-
sequence of accidents befalling others in parturition; but not
unfrequently it proceeds from a peculiar state  of mind, de-
pendent on gestation.   Some, who at other times enjoy good
spirits, become always melancholy during pregnancy, whilst
others  suffer chiefly during lactation.  Little can be done by
medicine, except to obviate all cause of disease or uneasiness
of the body; the mind  is  to be  cheered  and supported  by
those who have most influence with the patient.

             §32. RETROVERSION OF UTERUS.

   Retroversion of the uterus was described by Gregoire and
Levret, but was in this country first accurately, explained by
Dr. Hunter, in 1754.   It is an accident, which  is always at-
tended with painful, and sometimes fatal consequences, chiefly
owing to the effect produced on the bladder.  If the pelvis he
of the usual size, it  may take place at any time during  the 
207
third and fourth months of pregnancy ;(a)  or if the pelvis be
large, or the ovum not much  distended with water,  it may
occur in the fifth month.  It may also be produced, when the
womb is enlarged to a certain degree by disease.1  We recog-
nise retrovei'sion of the uterus chiefly by its effects on the blad-
der, and also by difliculty in voiding the faeces; for although
the patient may be distressed  sometimes with tenesmus, she
usually passes little at a time. When the retroversion is com-
pleted, bearing-down pains may be excited, as if  an  attempt
were made to expel or force down the uterus itself.  These are
much connected also with the state of the bladder, being most
severe when it is distended, and abating when the  urine is
evacuated.   The acute symptoms produced by the distension
of the bladder, or the inability to  pass the urine freely, first
of all call  the attention  of the woman to the disease;  and
 when we come to examine her, we find a tumour betwixt the
 rectum  and  vagina.2   This is formed by  the fundus uteri,
 which  is  thrown backwards  and downwards, whilst the os
uteri is directed forward, and sometimes so much upwards, as
 not to be felt by the finger. This is a disease which we would

   (a) A suppression of urine from retroversion of the uterus, may arise at
other periods, as well  as during a state of pregnancy, and generally from
the same cause, viz. over-distension  of the bladder.  Thus, after delivery,
the uterus sometimes becomes retroverted, occasioning an entire suppres-
sion of urine, and excessive pain; and the same thing, not uncommonly, takes
place when the uterus is in a state of disease ; and sometimes at the period
of life when the Catamenia usually cease.  At this period the uterus is apt
to enlarge and grow heavy, without manifesting any other  indications of
disease ; and in this state more than one instance  have occurred  of its be-
 coming retroverted.
   Di. Merriman says, that the cases of retroversion of the uterus after deli-
 very, which have fallen under his observation, have principally occurred on
 the second day after the birth of the child; probably because  the degree ol
 contraction, which the womb has by that time undergone, has reduced it to
 a size the most fit to suffer such a displacement.  It has happened after easy
 labours, and notwithstanding the  patients had passed their urine once or
 twice. The second day after delivery has not, however, been invariably the
 period of this occurrence ; for a case occurred to Dr. Merriman, where the
 patient was attacked with a suppression of urine from this cause on the
 ninth diy after delivery.  " Vide Merriman's Dessertation on Retroversion of
 the womb," p.p. 19,20. 
208
think cannot be mistaken, and yet it is sometimes difficult to
distinguish it; for in  extra-uterine  pregnancy, it has hap-
pened, that the symptoms have  been nearly  the same with
those of retroversion ;* and tumour of the ovarium has some-
times produced similar effects.  Perhaps the  diagnosis can-
not, in every case, be accurately made, but this is of less im-
mediate importance, as the indication in such instances must
be  the  same, namely, to draw off  the urine, and procure
stools.
  Retroversion may take place slowly, and it has been said
that its progress could be ascertained from day to day ;3 but
in most instances, and in every case  that I have seen, it has
taken place pretty quickly ; and occasionally the woman has
been sensible at the time, of a tumbling or motion within
the pelvis.  Sometimes the urine dribbles away involuntarily,
or can be passed in small quantity, especially during the com-
mencement of the disease; but often, within a few hours, it
becomes almost completely obstructed,  with  pains about the
loins, tenderness  in the lower belly when it is touched, and a
severe bearing-down sensation.  The great danger proceeds
from the distension4 of the bladder,  which either hursts5 or
inflames,6 and an opening takes place, in consequence of gan-
grene;  or the bladder adheres to the abdominal parietes, its
coats becoming thickened and diseased.7  If the urine cannot
be drawn  off, of which I have never yet met with an instance,
death is preceded by abdominal pain, vomiting,  hiccup, and
sometimes convulsions.  These effects are chiefly produced
by mistaking the nature of the complaint.   Their duration is
variablc.|  Inflammation and gangrene of the  vagina and
external parts have also been produced.  If the disease do
not prove rapidly fatal, so much urine escaping as to prevent
a speedy  termination, it occasionally  happens,  that hectic
fever is produced.  The  pulse becomes frequent, the  body

  * Vide Mr. Giffard's case, in Phil. Trans. Vol. XXXVI. p. 435, and Mr.
White's very instructive case, in Med. Comment. Vol. XX. p. 254.
  ■j Dr. Perfect's patient died thus on the sixth day. Cases in Midwifery, VoL
1 .p. 394. 
209
wastes, and purulent urine is voided ;8 or the person may
become adematous, and the disease pass for dropsy ;°  occa-
sionally the water is not quite obstructed,  but it is voided
with difficulty for a week  or two,  and then the symptoms
become nv»re acute, and forcing pains are excited.  .
  Our first object is to relieve the bladder, by introducing a
catheter,10 which may be slightly  curved, the coneavitybcing
directed to the sacrum; or we may employ an elastic catheter;
but in general, the common instrument succeeds.   If  it do
not pass  easily, we may derive advantage from introducing
the finger into the vagina,  and endeavouring to depress  the
os uteri, or press back the vaginal tumour.11  If the catheter
cannot be introduced, we have been  advised to tap the blad-
der;12  but this, fortunately, is never requisite.
  We must not be  deceived with regard to the state of  the
bladder, by observing that  the woman is able to pass a  small
quantity of water, for it may, nevertheless, be much distended.
We must examine the belly, and attend to the sensation pro-
duced by pressure on the hypogastric region.   Even  although
the catheter have been employed, only part of the urine may
have been drawn off, particularly if the complete evacuation
has not been assisted by moderate pressure over the bladder.
It has happened, that only  so much has been taken away as
to give a little relief, and alter the position  of  the uterus so
much as to lessen the pressure on the orifice of the bladder.
In  this case, on getting up, a great quantity of urine  has
flowed spontaneously, and the womb immediately returned to
its proper state.
  The urine being evacuated, and the most immediate source
of alarm being thus removed, we must, in the next place, pro-
cure a stool, by means of a clyster; detract blood, if there be
fever or restlessness; and give an anodyne injection, if
there be strong  bearing-down efforts.  This is, in general,
all that is requisite ; and I wish particularly to inculcate the
necessity of directing the chief attention to the bladder, which
ought to be emptied  at least morning and evening.   By this
plan, we generally find,  that the uterus resumes its proper
situation in the course of a short time, perhaps in forty-eight
  vox. I.                        K Fi 
210
hours ;13 and the retroversion is seldom continued for  more
than a week, unless the displacement has been very complete.
The precise time, however,  required for the ascent of the
womb will be determined cseteris paribus,  by the  degree to
which it has been retroverted,  and the attention which is
paid to the bladder.   If the fundus be very low, the ascent
may be tedious; but I consider myself  as warranted from
experience to say, that in every moderate degree of retrover-
sion, in every  recent case, it is sufficient to empty the blad-
der regularly  without making any attempt to push up the
womb.  But if the uterine tumour be very low, and near the
perineum, it may be necessary,  and certainly it is allowable,
to endeavour to replace the womb.   This is  also  proper, if
there be much irritation excited by the  state of the womb,
and which does  not give way to the use  of the catheter, and
of anodyne clysters.  I fear, however, that these efforts shall
seldom succeed, and that more  harm than good is generally
done by them.   It may be said, that although the immediate
danger be done  away by the regular use of the catheter, yet
the womb may remain forever  in  its malposition, and give
rise to great difliculty in labour, or to  the same event as in
extra-uterine pregnancy.  I can only reply, that in almost
every instance where the bladder has been regularly emptied,
the case has done well; and I do believe, that in those where
the uterus did not rise spontaneously, very  little good could
have been done by mechanical efforts.
   The attempt to replace the uterus is to be made by intro-
ducing two  fingers  of one hand into the rectum, and a suffi-
cient number  of those of the other  hand, or the whole hand
itself, into  the  vagina.   The  uterine tumour is then to be
pressed up slowly, firmly, and steadily ;  and this may some-
times be  assisted by elevating the breech of the woman.
Forcible and violent attempts are, however, to be strongly
reprobated; they give great pain,  and may even excite abor-
tion, inflammation, or convulsions.   They can only be justifi-
 ed on the principle of preventing a great danger.  Now we
 know that the chief risk proceeds from the distension of the
 bladder;  if, therefore, it can be emptied, the danger is usually 
211
 at an end.   When the retroversion ceases, the uterus usually
 resumes  completely its proper situation;  but  it  sometimes
 happens, especially if the vagina have been much relaxed,
 that when the retroversion is  removed, the uterus is found
 very low, forming a prolapsus, which continues for some time.
 It requires, chiefly, attention  to the urine and stools; for it
 may occupy the pelvis fully, and pretty firmly;  and almost
 the whole fcetus can be felt by  the finger through the uterus.
   When  the uterus ascends, occasionally a little blood is dis-
 charged ;* but abortion does not take place unless  much  in-
 jury has  been sustained.   Thus the  woman has miscarried
 quickly after the bladder had burst, as in Mr. Lynn's patient;
 or when  inflammation had taken place, as in the cases related
 by Drs. Bell and Ross.  When this happens, the uterus rises
 indeed, but the patient is cut off by peritoneal inflammation,14
 followed  by vomiting of dark  coloured stuff.  Abortion will
 generally take place, if the liquor amnii have been discharged.
   That the uterus  does generally rise spontaneously, if the
 urine be regularly evacuated, is a fact of  which  I am fully
 convinced from my own experience,  as well as from the  ob-
 servations of others.  But it is nevertheless possible for it to
 continue  in a certain degree of malposition even to the end of
 gestation.1*   In this case, the uterus cannot, indeed, at last
 be said exactly to be retroverted; for it has enlarged so much,
 that it occupies nearly as much of the abdomen as usual;  but
 it has enlarged in  a peculiar way, the os uteri being still
 directed to the symphysis pubis, or even perhaps raised above
 it.   In such a case, which is exceedingly rare, the labour will
 be  very tedious and severe.  The os  uteri will be very long
 of being felt, and will he first perceived at the pubis.(fr)  We

  *  M. Roger's case, in Act. Havn. Tom. H. art. 17.
  (6) The first case of this kind that has been accurately  stated as such, is
to be met with in a small, but judicious work, by Dr. H. S. Jackson, entitled,
 "Cautions to Women respecting the State of Pregnancy.  London, 1798,"
 and was attended by several of the most respectable  practitioners of Lon-
 don ; the next case which has been made public, was that  which fell under
 the immediate notice of Dr. Merriman, and by him minutely detailed in the
London Medical and Physical Jounial, for 1806; and afterwards published
In a distinct and separate work, entitled, " A dissertation on Retroversion »f 
212
 are indebted to Dr. Merriman for an explanation of this fact,
 and likewise for  the  observation  that it is  possible for the
 termination to be similar to that of extra-uterine pregnancy,

the Womb, including some Observations on Extra-uterine Gestation.  Lon-
don, 1810."
  It will be found by consulting Dr. Merri man's paper and work above al-
luded to, that he considers, and with some appearance  of probability, that
certain of those cases of difficult labour, which by Deventer have been re-
ferred to his supposed obliquity of the  uterus,  and others, which  have by
different authors, been considered as cases of extra-uterine conception, were
in fact, cases of retroversions ol the uterus continuing, in a certain degree,
until the full period of utero-gestation, and then impeding delivery.  He
likewise observes, that it is not unlikely, that some of those cases which are
found in Smellie's and other collections, where the os uteri is described as
grown together and impervious, were actually retroversions of the uterus. In
these cases, incisions have  been frequently made within the vagina,  into the
Uterus.  [Vide Sabatier Medicine Operatoire, Vol. I. p. 310.]
  There is also another  class of cases, of which  many are recorded by
writers on Midwifery, which may probably owe their orign and cause  to a
retroverted state of the uterus.  We here allude to those cases of extra-ute-
rine foetuses discharged per anum, or through an  ulcerated opening in the
vagina, after having remained for many years in the abdomen of the mother.
[Vide Mainwaring, in 2d  vol. of Transactions  of the Society for  the  Im-
provement of Med. and  Chirurg.  Knowledge, and Coleman in 2d vol. of
Med. and Phys. Journal, and Giffard, in Eclectic Repertory, vol. 1. p. 346,
 & seq.]
  When foetuses have been found in the cavity of the abdomen entirely dis-
engaged from the uterus, it is probable that a rupture of this viscus, or an
ulcerated opening through its parietes, in consequence of its deranged situa-
tion, had permitted the escape of the  foetus  after it had ceased to  five, and
 not that the conception had advanced to maturity, in a part apparently so
 illy adapted to such a purpose.
  By this explanation, we may solve what has hitherto been to many a diffi-
 culty in the history of these cases,  it has, for instance, been observed in
 every case of foetus carried, as it was supposed, in the abdomen beyond the
 period of nine  months, that  near the usual time of parturition, the pains of
 labour have regularly come on, and strong efforts  appear to have been made
 by the uterus, as if for the expulsion of the child.
 .  Now, as it has been well observed, it is difficult to assign any reasons for
 these contractions of the  uterus, if the fortus  has no connection with  that
 organ ; but if the foetus is contained in the partially retroverted uterus, or in
 any of the appendages of the uterus,  the occurrence of these  contractions
 might naturally be expected.  Vide Dr. Merriman's paper and work above
 referred to. 
213
namely, by suppuration.   A case of this kind, well marked
in all respects, except suppression of urine, is related by Dr.
Barnum* as an instance  of extra-uterine gestation.  In the
fifth month, after some imprudence, the patient had pain ac-
companied with a discharge of water and some blood, a mark
that the ovum was in the uterus. She got relief at this time;
but next month, (Nov.) she had a return of pain, and the os
uteri was felt  directed to the  pubis, and  the fundus to the
sacrum.   All  attempts to reduce it failed, as they generally
do, suppuration took place, and foetal bones were discharged
by the anus.   She died in March.
   In order to prevent retroversion,  we must  understand its
cause, which most frequently,  if not always consists in dis-
tension of the bladder.  The os uteri is thus elevated, and
the fundus falls in the same proportion backward.  Now in
the unimpregnated state, the uterus is not sufficiently large
to remain retroverted ; and after the fourth month of preg-
nancy, the uterus is too heavy to be much raised by the blad-
der, and too large  to fall into  the pelvis.  If,  however,  the
pelvis be very wide, and the uterus have  consequently been
longer, than usual of rising, it may be retroverted at a later
period.   It would  appear,  that agitation, or violent exer-
tion,16 may cause  this state to take  place  more readily than
would otherwise happen;  hut whether concussions, or other
circumstances, can produce retroversion, without some pre-
vious distension of the  bladder, is not  positively proved,
though some  facts favour the supposition.
   The same woman has  been known to have the uterus retro-
verted in two successive pregnancies.!

                   § 33.  ANTIVERSION.

    The uterus is also said to be sometimes  antiverted, that is,
 the fundus is thrown forward, so as to compress the neck of

   • Vide New York Med. Rep. V. 40.
   I Vide case by Dr. Senter, in Trans, of Phys at Philadelphia, p. 130.
Both times it was reduced by the hand. 
214
the bladder, and its  mouth  is turned to the sacrum.17  Of
this accident I have never seen an instance, and, from the
nature of the case, it must be very rare.   The  urine should
be evacuated, and the fundus raised up.

                § 34. RUPTURE OF UTERUS.

  Rupture of the gravid uterus may take place at any period
of gestation.   The moment of the accident is generally mark-
ed by severe pain, occasionally by vomiting, and frequently
by a tendency to syncope, which, in some instances,  con-
tinues for a length of time to be the most prominent  symp-
tom.*   The pain sometimes resembles labour, but more fre-
quently colic, and its duration is variable.  In  some  cases,
hemorrhage  takes place from the vagina,  but   the greatest
quantity of the blood18  flows into the abdomen.   At the time
of the accident, and for a little thereafter, the child is felt to
struggle violently.   Then the  motion ceases, the woman
feels a weight in the belly, and, if the pregnancy be far ad-
vanced, the members of the child can be traced through the
abdominal parietes.19  The  tumour of the belly generally28
lessens,  and milk is  secreted,  indicating the  death of the
child.
  If hemorrhage, or peritoneal inflammation, do not quickly
carry off the patient,  we find, that at the end of some  time,
occasionally of the ninth month of gestation, pains like those
of labour come on, which either gradually go  off, and the
child is retained for many years, f being inclosed  in  a kind
of cyst; or inflammation and  abscess take place, and the
child is discharged piece-meal.21                 ■
  In some instances, it would appear, that the ovum may be
expelled entire into the abdomen ; and in that case, it is pos-
sible for the child to live for some time, and even to grow,
although  out of the uterus.  When this happens, its motions

  * Vide Dr. Underwood's case, in Lond. Med. Journ. Vol. VII. p. 321.
  f In Dr. Percival's case, the foetus was retained for 22 years, and then dis-
charged by the rectum. 
215
are felt more freely and  acutely than formerly.   As  the os
uteri opens a little after the expulsion, and a sanguineous dis-
charge takes place, the woman has sometimes been supposed
to miscarry.   If she survives, the womb slowly decreases in
size,  and returns to the unimpregnated state,23 which will as-
sist materially in the diagnosis, between this and extra-ute-
rine pregnancy existing from the first.  The  menses return,
and though the  belly does not  subside completely,  yet the
person continues tolerably well,  unless inflammation come on.
She may even bear children before the extra-uterine foitus
be got rid  of.*  If the case is to  prove fatal,  the pulse be-
comes quick  and small, the belly painful, the strength sinks,
and sometimes continued vomiting ushers in dissolution.23
   Rupture of the uterus may be the consequence of mental
agitation,! but  in  most cases it  is owing to  external vio-
lence.24^
   Three modes  of treatment present themselves.  To leave
the case to nature; to deliver per vias naturales ; and to per-
form the cesarean operation.  To dilate the os uteri forcibly,
and thus extract the child, is a proposal so rash and hazard-
ous, that  I know none in the  present  day who would adopt
it. I question if the woman would live till the delivery were
accomplished. The csesarean operation is safer, and in every

  • Vide Journ. de Med. Tom. V. p. 422.
  f Dr. Percival's patient attributed her accident to a fright; Dr. Underwood's
referred her's to mental agitation.
  $ The uterus  may be ruptured by a variety of causes.
  1. By external violence, as by blows, falls, pressure, &c.
  2. By rude attempts to turn the child, and especially, after the waters are
discharged.  This has often happened.
  3. By convulsions.
  4. By the inordinate action of the uterus, constituting what is termed spon-
taneous rupture.  This last is, by much, the most common cause. But when
rupture is thus produced, we may suspect that an improper treatment has
been pursued.  We can, undoubtedly, by copious bleeding, and the subse-
quent administration of opium, so far overcome the resistance, and mitigate
the violence of the pains, as to prevent its occurrence. The same remedies
will, moreover,  obviate, in most instances, rupture from convulsions;  and
should never be neglected as precautionary means,  where there are any ap-
prehensions of the accident from turning the child.  C. 
216
 respect preferable; but we cannot yet, from experience, de-
 termine its advantages, and certainly it ought not to be per-
 formed, unless we can thereby  save  the  child.   The third
 proposal, therefore, to leave the case to nature, like an extra-
 uterine pregnancy, is most likely to be successful, more espe-
 cially when the rupture happens  in the  early months of ges-
 tation.   We find, from the result of cases, that  the woman
 has the best chance of recovery, if we are satisfied with ob-
 viating  symptoms, and removing inflammation in  the first
 instance;  and  supporting the strength of the patient through
 the progress of the disease, should it not prove rapidly fatal;
 enjoining rest, giving mild diet, and favouring the expulsion
 of the bones, by poultices and fomentations, and, if necessary,
 by enlarging the abscess if it point externally.*

  * This negative sort of practice has, undoubtedly, met with many very re-
 spectable advocates.  There are, at the present  day, several eminent prac-
 titioners,  besides  Mr.  Burns,  who strenuously recommend it.  Notwith-
 standing, however, the weight of authority in its favour, I cannot believe it
 to be right.  The powers of nature seem to me to be totally incompetent in
 such cases.  By prompt delivery only we can hope to do good.   This, then,
 we  should always attempt.  In some cases  the forceps may be used, but
 they are few, as the rupture commonly takes place before labour is suffi-
 ciently advanced to admit  of their  application.  We, therefore, turn the
 child, and bring it away by the feet.  Delivery in this manner has been more
than once effected, and the woman preserved, even where  the child had
 escaped through the rupture of the uterus into the abdominal cavity. I al-
 lude now, more particularly, to the case recorded  by Dr. Douglass, and to
 one which occurred to Dr. J. Hamilton.   To these,  I may also add, as show-
ing, at least, the practicability of delivery under such circumstances, a case,
related by my friend Dr. James, in the Medical Repository of New York.
  Were the rupture to happen  in the  earliest stage  of labour, I should
 nevertheless not be deterred from adopting this practice.  I would forcibly,
but not violently, dilate the uterus.  It does not strike me that the  attempt
 would be " rash and hazardous." We often in other emergencies do it with
 advantage, as in labour attended with  hemorrhage or convulsions.  Why
 may it not also be done in lacerated uterus ?
  But if,  by deformity of the pelvis, or contraction  of the uterus, (the child
being in the cavity of the abdomen) or indeed from any other circumstances,
there exists insuperable impediments to delivery per vias naturales, 1 would,
 without hesitation, resort to the cesarean section.  In deliberating on the ex-
 pediency  of adopting this dreadful alternative, we should constantly bear
 in recollection that we are not without examples of the success of the ope-
 ration. 
817
  § 35. ABORTION AND TREATMENT OF PREGNANT WOMEN.

  The usual period of utero-gestation is nine months, but the
foetus may be expelled much  earlier.  If the expulsion take
place within three months of the natural term, the woman is
said to have a premature labour; if before that time, she is
said to miscarry, or have an  abortion.  The process of abor-
tion consists of two  parts, detachment and expulsion;  but
these do not always bear a uniform relation to each other in
their degree.  The first  is  productive of hemorrhage, the
second of pain; for the one  is attended with rupture of ves-
sels, the other with contraction of the muscular fibres.   The
first may exist  without being  followed  by  the  second,  but
the second always increases, and  ultimately completes  the
first.  The symptoms then of  abortion, must be those pro-
duced by separation  of  the  ovum,  and  contraction of  the
uterus.  To these, which are essential, may be added others
more accidental, induced by them, and varying according to
the constitution and habits of the patient.
  The ovum may be  thrown off at different stages of its
growth; and the symptoms, even at the same period, vary in
duration  and degree.  The process of  gestation  may be
checked, even before the fcetus or vesicular part of the ovum
has descended into the uterus, and when the decidua only is
formed.   In this case, which ocelli's within three weeks after
impregnation, the  symptoms are  much the same with those
of menorrhagia.  There is always a considerable, and often

  Two cases with favourable results are related, one by Dr. Barlow, and the
other by Dr. J. Hamilton.  In the latter case, the bones of the pelvis were so
mashed by the wheel of a cart as altogether to prevent dehvery by the na-
tural passages.  On  opening the abdomen, the child was found in the cavity,
and the uterus considerably lacerated. But notwithstanding the extent and
severity of the injury, the woman entirely recovered.
  Let it not, however, be understood that I am at all sanguine as regards the
two remedies which 1 have proposed. I am, on the contrary, persuaded that
in most instances, they will wholly fad.  But what else can be done in these
tremendous cases ?  To leave them to nature, " like an extra-uterine concep-
t,on," would be, either to consign the woman to immediate death, or what re
-still worse, to death from protracted and  torturing illness.  C.
   VOL. J.                          V V 
218
a copious discharge of blood, which coagulates or forms clots.
This is accompanied with marks of uterine irritation, such as
pain in the back and loins, frequently spasmodic affections
of the bowels, and occasionally a  slight febrile state of the
system.  In plethoric habits, and  when  abortion proceeds
from over-action, or  hemorrhagic  action of the uterine ves-
sels, the fever is idiopathic, and precedes the discharge.  In
other circumstances it is either absent, or, when present; it is
symptomatic and  still more inconsiderable, arising merely
from pain  or  irritation.  As the primary  vessels are very
small, and  are soon displaced, they cannot be detected in the
discharge.   Nothing  but coagulum can  be perceived; and
this, as in other cases of uterine hemorrhage, is often so firm,
and the globules and lymph so disposed, as to give it, more
especially if it have  been retained for some time about the
uterus  or  vagina, a  streaked  or  fibrous appearance, which
sometimes  gives rise to a supposition, that it is an organized
substance.   The discharge does not cease when the primary
vessels are destroyed, but generally continues until the small
vesicle passes out of the fallopian tube.   Then it stops, and
an oozing of serous fluid finishes the process.
  The only interruption to the discharge in  this case of abor-
tion, proceeds from the formation  of  clots, which, however,
are soon displaced.  Women,  if plethoric, sometimes suffer
considerably from the profusion of the discharge; but, in ge-
neral, they soon recover.
  If the vesicle have descended into the uterus, the symptoms
are somewhat  different.  We have an attempt  in the uterus
to contract, which formerly was not necessary; we have pains
more or less regular in the back and hypogastric  region; we
have more  disturbance of the abdominal viscera, particularly
the stomach.  The discharge is copious, and  small bits of
fibrous substance can often be observed.  Sometimes the vesi-
cle may be detected in the first discharge of blood, and will
be found to be streaked over with pale vessels, giving it an
appearance as if it had been slightly  macerated.   When all
the contents are expelled, a bloody discharge continues for a
few hours,  and is then succeeded by a serous fluid.   At this 
219
lime, and in later abortion, if the symptoms take place gra-
dually, we  may sometimes observe a  gelatinous matter to
come away before the hemorrhage appears.
  If to# uterus contain more vascular and organized matter,
as in the beginning of the third month, the vesicle never
escapes first; but we have for some time a discharge of blood,
accompanied or succeeded by uterine pain. Then the inferior
part or short stalk of the ovum may be  expelled, gorged with
blood,  and  afterwards the upper part equally injured. Some-
times the whole comes away at  once and entire; but this is
rare.   As  considerable contraction  is now required in the
uterus, the pains are pretty severe.  The derangement of the
stomach is also greater than formerly, giving rise to sickness
or faintness, which is a natural contrivance for abating the
hemorrhage.
   When the membranes come to  occupy more of the uterus,
and a  still  greater difference exists betwixt the placenta and
decidua, we have again a change of the process;  we  have
more bearing-down pain, and greater regularity in its attack;
we have a  more rapid  discharge,  owing to the greater size of
the vessels; but there is  not always more blood lost now than
at an earlier period, for coagula form readily from temporary
fits of faintness, and other causes, and interrupt the flow until
 new and increased contraction  displaces them.  Often the
 membranes give way, and the foetus escapes with the liquor
 amnii, whilst the rest of the ovum is retained for some hours
or even days,* when it is expelled  with coagulated blood se-
parating and confounding its different parts or layers. At
 other times the foetal and maternal portions separate, and the
first is expelled before the second, forming a very beautiful
 preparation.  In some rare instances we find the whole ovum
 expelled entire, and in high preservation.   After the  expul-
 sion,  the  hemorrhage goes off,  and  is succeeded by a dis-
 charge, somewhat resembling the lochia.
   In cases of twins, after one child  is expelled, either alone
 or with its secundines, the discharge sometimes stops, and the

   * In all cases the placenta is retained much longer after the expulsion of the
child in abortion, than in labour at the full time. 
                          220

woman continues pretty well  for some hours, or even for a
day or two, when a repetition of the process takes place, and
if she has been using any exertion, there is generally a pretty
rapid and profuse discharge.   This is one reason, amongst
many others, for confining women to  bed for several days
after abortion.
  There is frequently, for a longer or  shorter time before
the commencement of abortion, pain  and irregular action
in the neighbouring parts, which give warning of its approach,
before either discharge  or contraction take place ;* unless
when it proceeds from violence,  in which case the  discharge
may instantly appear.  This is  the period at which we can
most effectually interfere for  the prevention of abortion.  I
need not be particular in adding, that we are not to confound
these symptoms with the more chronic ailments which accom-
pany pregnancy.
  A great diversity obtains in different instances with regard
to the symptoms and duration of abortion.   In some cases the
pains are \ery severe and long continued ; in others, short
and trifling; nor is the degree of pain always a correct index
of the force of contraction.   Sometimes the hemorrhage is
profusef  and alarming; at  other times,  although  circum-
stances may not be apparently very different, it is moderate or
inconsiderable.  Often the sympathetic effects on the stomach
and bowels are scarcely productive of inconvenience, whilst
in a greater number of instances  they are very prominent
symptoms.
  I may only add, that, cceteris  paribus, we shall  find, that
the farther the pregnancy is advanced beyond the third month,
and the nearer it approaches to  the end of the sixth, the less
chance is there of abortion being accompanied, but the great-
er of its  being succeeded, by  nervous affection.
  As there is a  diversity in  the symptoms, so is there also

  •  In some cases, shooting pains and tension are felt in the breasts before
abortion, and the patient is feverish.
  |  Those who are plethoric generally lose much blood, unless the contrac-
tion have been brisk.  In  some cases six  or seven pounds of blood have been
lost in a few hours. 

in the duration of abortion; for, wiiilst a few hours in many,
and not above three days in the majority of cases, is sufficient
to complete the process, we find other instances in which it is
threatened  for a  long time,  and a number of weeks elapse
before the expulsion takes place.
  In some cases the child appears to be dead for a consider-
able time before the symptoms  which  accompany expulsion
occur.   But in a  great majority of cases it is living, when
the first  signs of abortion are perceived,  and in some  in-
stances is born alive.   The signs by which we judge that the
child in utero  is dead, are the sudden cessation of the morn-
ing sickness,  or  of any other sympathetic symptom which
may have  been present.  The breasts become flaccid.  If
milk had been formerly secreted, it sometimes  disappears,
but in other instances the contrary happens, and no evident
secretion takes place until the action of gestation, or at least
the life of the child be lost,   In almost every case, however,
the breasts will be found to have lost their firmness.   If the
pregnancy  had advanced  beyond the period of quickening,
the motion  of the  child will be lost, and a feeling of heaviness
will be felt  about the pelvis.  When all these  signs are ob-
served, and when they are followed by discharge, and  espe-
cially when this is attended with pain, there can be no doubt
that expulsion will take place,  and it would be improper to
prevent it.   We are not, however, to conclude that the child
is dead, merely because it does not move; and when abortion
is threatened before the term of quickening, this sign cannot
enter into our consideration.
   When the ovum perishes at a very early period, and is not
immediately discharged, we find  that the sympathetic  signs
of pregnancy  disappear, and not unfrequently a serous or
milky fluid comes from the  nipples.  The woman feels lan-
guid and hot at night, or  has fits of sickness,  or hysterical
symptoms; a  discharge of foetid dark coloured fluid  takes
place from  the vagina, and is often mixed with particles like
snuff.  This continues till all the remains of the ovum have
come away, and then  the health and spirits are restored.
   If at a more advanced period, the ovum  remains after the 
222
child dies, it is converted either into a mole or hydatid ; and
this may also happen even at a very early stage of pregnancy.
These cases  have already been considered.   It is generally
most prudent to obviate symptoms, and wait until the os uteri
open and pains come on.  Then we are to be directed by ex-
isting circumstances.   Whether the ovum become putrid, or
undergo a change into hydatids,  it is  reasonable  to expect
that the vessels of the uterus being no longer employed in the
growth of the foetus should diminish, and become in the first
case merely sufficient to nourish the uterus ;  and, in the se-
cond, to supply the necessities of the substance attached to
the inner surface of the womb; for there is a communication
between them, and a discharge of blood attends the expulsion
of either a mole or hydatid; whereas, on the other hand, if
the  ovum has  perished completely and  become putrid, the
discharge is rather a foetid sanies than red blood.
  Abortion may \ery properly be divided into accidental and
habitual.  The exciting causes of the first class may, in ge-
neral, be easily detected; those giving  rise to the second are
often more obscure;  and, without great attention, the woman
will go on to  miscarry, until either sterility, or some fatal dis-
ease, be induced.
  In many cases there can be no peculiar pre-disposing cause
of abortion ;  as, for instance, when it is produced by blows,
rupture of the membranes, or accidental separation of the de-
cidua: but when it occurs without any very perceptible excit-
ing cause, it is allowable to infer,  that some pre-disposing
state exists; and this frequently consists in an imperfect mode
of uterine action,  induced by age, former miscarriages, and
other causes.  It  is well  known, that women can only hear
children until a certain age;  after  which, the uterus  is no
longer capable of performing the action  of gestation, or of
performing it properly.   Now, it is observable, that this in-
capability or imperfection takes place  sooner in those  who
are advanced in life before they marry, than in those who
have married and begun to bear children earlier.  Thus we
find, that a woman who marries at forty, shall be very apt to
miscarry; whereas, had she married at thirty, she might have 
S23
 borne children when older than forty; from which it may be
 inferred, that the organs of generation lose their power of act-
 ing properly sooner, if not employed, than in the connubial
 state.  The same cause which tends to induce abortion at a
 certain age in those who have remained until that time sin-
 gle, will also, at a period somewhat later, induce it in those
 who have been younger married;  for  in them we find, that,
 after bearing several children, it is not uncommon to con-
 clude with an abortion; or, sometimes after this incomplete
 action, the uterus, in a considerable time, recruits, as it were,
 and  the woman  carries a child to the full time, after  which
 she ceases to conceive.
   In  the next place, 1 mention that one abortion paves the
 way for another; because, setting other circumstances  aside,
 it give the uterus a tendency to stop its action of gestation at
 an early period after conception, and  therefore it is difficult
 to make a woman go to the full time, after she has miscarried
 frequently. This fact has also been explained upon the prin-
 ciple  of repeated abortion weakening the uterus*, and this
 certainly may have some influence.  The renewed operation
 of those causes which formerly induced  abortion, may like-
 wise account in  many cases for its repetition.  But I am also
 inclined to attribute the recurrence, sometimes, to habit alone,
 by which I understand that tendency which a part has to re-
 peat or continue those modes of acting which it has frequent-
 ly performed, as we see in many diseases of the stomach and
 windpipe; spasmodic  affections of these and other organs,
 being apt to return at the same hour, for a long time.  With
 regard to  the uterus, one remarkable instance is related by
 Schulzius, of a woman, who, in spite of every remedy, mis-
 carried twenty-three times at the third month.   In this, and
 similar  cases,' slighter  causes  applied at  the  period  when
 abortion formerly happened, will be sufficient to induce it,
 than would be required at another time.
   We also find that an excessive or indiscriminate use of ve-

  * Perhanc vero consuetudinem nihil aliud intelligo, quam pravam vasorum
uteri laxitatem et inde provenientem humorum  stagnationem, ex aborticndi
labore sxpius repetito inductam.  Hoffmax, Tom. iii. p. 180. 
224
nery, either destroys the power of the organs  of generation
altogether, making the woman barren, or it disposes to abor-
tion, by enfeebling these organs.
  Some slight change of structure in part of the uterus, by
influencing its actions, may, if it do not prevent conception,
interfere with the  process of gestation,  and produce prema-
ture expulsion.   If, however, the part affected be very small,
and near the os uteri, it is possible for pregnancy to go on to
the full time.  Indeed, it generally does go on, and  the la-
bour, as may be foreseen, will be very tedious; but the opera-
tion of cutting the indurated os  uteri, which has been pro-
posed, is seldom necessary.   I have known one instance, in
which a very considerable part of the uterus, I may say al-
most the whole of it, was found, after delivery, to be extreme-
ly hard, and nearly  ossified; but this  state could not have
existed before impregnation took place, for I cannot conceive
that so great a proportion  of the uterus should  have  been
originally diseased, and yet that conception, and its conse-
quent actions, should take place ; but there is less difficulty
in supposing, that, during the enlarging  of the  uterus, the
vessels deposited osseous or cartilaginous matter, instead* of
muscular fibres.
  A general weakness of the system, which must affect the
actions of the uterus, in common  with those of other organs,
is likewise to be considered  as giving rise to abortion, though
not so frequently as was at one time supposed.
  A local weakness of the uterus sometimes exists when the
general system is  not very  feeble;  or when the constitution
is delicate, the uterus may  be weaker in  proportion  than
other organs.  In this case, it  cannot perform its function
with the necessary activity  and  perfection, but is very apt,
after a time, to flag.  We cannot operate with medicines di-
rectly upon the womb, for the  purpose of strengthening it,
hut must act on it by invigorating the general system, and at-
tending to all the other functions.  Sea-bathing  is of great
service; and after  impregnation,  every exciting cause of
abortion must be guarded against.   Women of this descrip-
tion are generally pale, of a weakly, flabby habit, and sub- 
225
ject to jirregular, often to copious menstruation, or fluor al-
bus.  When  they  conceive, the cold bath, light digestible
food, open bowels, and free air, should be enjoined; and if
any uneasy sensation be felt about the uterus or back, or the
pulse throb, a little blood  should be slowly taken away, and
the woman keep her room for some days.  Bleeding prevents
the womb from being oppressed, and it is as necessary to at-
tend to this, as it is to prevent the stomach from being load-
ed in a dyspeptic patient.   But, on the other hand, were we
to bleed copiously, we might  injure the action of the uterus,
and destroy the child.
  It has been supposed that abortion might arise from a rigi-
dity of the uterus, which prevented its distension.  But the
uterus does not distend  like a dead part,-upon which  pres-
sure is applied, but it grows, and therefore I apprehend that
an  effect is here considered as a primary cause.
  The uterus is not only affected by the general  conditions
of the system, more especially with regard to sensibility, and
the state of the blood vessels; but  it likewise sympathizes
with the principal organs, and may undergo changes in con-
sequence of alterations in their state.
   Thus we often find that loss of tone, or diminished action
of the stomach, produces  amenorrhoea; and it may also on
the same principle induce abortion ; on the other hand, the
action of the uterus may influence that of other viscera, as we
see in pulmonary consumption, which is sometimes  suspend-
ed  in its progress during  pregnancy; or, if there be any dis-
position in an organ to disease, frequent abortion, partly by
sympathy betwixt the uterus and that organ, and partly by the
weakness which it induces, and the  general injury which it
does to the system at large, may excite the irregular or mor-
bid action of the organ so disposed.
   As the action of the uterus is increased  during pregnancy,
 it must require more nervous  energy; but the size  of the
 nerves of the uterus is not increased in proportion to the ac-
 tion ; we must therefore depend for the increased supply upon
 the trunks, or larger portion of the nervous substance, from
 which they arise, for we well know that the quantity of energy
    VOL. I.                        6 G 
226
  expended in an organ, does not depend upon  the size of the
  nerve in its substance, but  on the trunk which furnishes it.
  Whenever action  is  increased in an  organ, it must either
  perish, or the larger  nerve must send  the  branches more
  energy ; for the branches themselves cannot form it, their ex-
  tremities being only intended for expending it;  from  which
  it follows, that in pregnancy there must be more energy  sent
  to the uterus, and less to some other part.
   This is the case with all organs whose action is increased,
  other parts being deprived in proportion as they are supplied,
  except when irritation raises general action above the natural
  degree ;  the  consequence of which is, that the  power is not
  sufficient for  the  action, which  becomes irregular, and the
  system is exhausted, as we see in febrile conditions.
   There being increased action of the uterus in gestation, re-
 quiring an increased quantity of energy to support it, we find
 that the system is put pro tempore into an artificial state, and
 obliged either to form  more energy, which cannot be so easily
 done, or to spend less  in some  other part. Thus the function
 of nutrition, or the action by which organic matter is deposit-
 ed, in room of that which is absorbed, often yields,  or  is les-
 sened, and the person becomes  emaciated, or the  stomach has
 its action  diminished, or the bowels, producing costiveness
 and inflation.  If no part give way, and no more energy than
 usual be formed, gestation cannot go on, or goes on imper-
 fectly.  Hence some women have  abortion* induced  by being
 too vigorous: that is to say,  all  the organs persist in keeping
 up their action in perfection and complete degree.
   A tendency to abortion also results from a contrary cause,
 from organs yielding too readily,  allowing the uterus to act
 too easily.   In this state it  is  as liable to go  wrong, as  the
 general system is when it is at the highest degree of action,
 compatible with health; the  most  trifling cause  deranges it.
Thus, sometimes, the intestines yield too readily, and become
almost torpid,  so that a stool can with difficulty be procured.
Here costiveness is not a cause  of abortion, though it may be
blamed. In like manner, the muscular system may yield and
become enfeebled; and  in this instance debility is accused as 
227
the cause of abortion although it be, indeed, only an effect of
too much energy being destined for the uterus.  In this case,
the woman is always weaker during menstruation and gesta-
tion than at other times.
  If the neighbouring parts do not accommodate themselves
to the changes in the direction of energy, and act in concert
with the uterus,  their action becomes irregular, and  conse-
quently painful.   In this case, the uterus may have its just
degree of power and action ; but other parts may not he able
to act so well under the change of circumstances.  This is
chiefly the case in early gestation, for, by time, the parts come
to act better. It often gives rise to unnecessary alarm, being
mistaken for a tendency to abortion;  but the symptoms are
different.  The pain is felt chiefly at  night, a time at which
weakened parts always suffer most; it returns pretty regular-
ly for several week, but the uterus continues to enlarge, the
breasts to distend, and all things are as they ought to be, if
we  except the presence of the pain.  This  may be alleviated
by bleeding,  and  sometimes by anodynes; but can only be
cured by time, and avoiding, by means of rest and care, any
additional injury to parts already irregular and ticklish in the
performance of their actions.  If this be neglected, they will
re-act on the uterus at last, and impede its  function.  It is
therefore highly necessary, especially in those disposed to
abortion, to pay attention to pains about the back, loins, or
pubis; and to insist upon rest, open  bowels, and detracting
blood, if the  state of the vascular system indicate evacuation.
  Even although the different organs, both near and remote,
may have accommodated themselves  to the changes in the
uterine action, in the commencement of gestation, the  proper
balance may yet be lost at a subsequent period; and  this is
most apt to take place about the end of the third, or begin-
ning of the fourth month, before the  uterus rises out of the
pelvis: and hence a greater number of abortions take place
at that time than at any other stage of pregnancy.  There is
from  that time, to  the period of quickening, a greater sus-
ceptibility in the uterus to  have its action interrupted, than
either before or afterwards: which points out the necessity of 
228
redoubling our vigilance in watching against the  operation
of any of the causes giving rise to abortion from the tenth to
the sixteenth week.
  If the action of gestation go on under restraint, as, for in-
stance, by a change of position  in the uterus, or by its pro-
lapsing too low in the vagina, it is very apt to be accompanied
by uneasy feelings, for, whenever any action is constrained,
sensation is produced. The woman feels irregular, and pretty
sharp pains in the region of the uterus, and from sympathetic
irritation both the bladder and rectum may he affected, and
occasionally a difficulty is felt  in making water, by which a
suspicion is raised that retroversion is taking place.  Some-
times the cervical vessels in these circumstances yield a little
blood, as if abortion were going to happen; hut by keeping
the patient at rest, and attending to the state of the rectum
and bladder, no  harm is done; and  when the uterus rises out
of the pelvis, no farther  uneasiness  is felt.  Occasionally a
pretty considerable discharge may take place under these cir-
cumstances, if the vascular system be full, or the vessels about
the cervix large. But, by care, gestation will go on; for dis-
charge alone does not indicate that abortion must necessarily
happen.  It, indeed, often causes abortion, and is almost al-
ways an attendant upon it;  but we  form our judgment, not
from this symptom alone, but  also from the state of the mus-
cular fibres, and the vitality of the child.
   Retroversion  of the uterus  likewise constrains very  much
its action,  and may give rise to abortion, though in a greater
number of instances, by care,  gestation will  go on, and the
uterus gradually ascend.  The bowels are to be kept  open,
and the urine gradually evacuated.
   Sometimes in irritable or hysterical habits, the process  of
gestation produces a considerable  degree of disturbance  in
the  actions of  the abdominal viscera, particularly the sto-
mach ; exciting frequent and distressing retching or vomiting,
which may continue for a week or two, and sometimes is  so
violent, as to invert the peristaltic  motion of the intestines
near the  stomach, in which  case  feculent  matter, and,  in
some instances,  lumbrici are vomited. 
22a
  This affection is often accompanied by an unsettled state of
mind, which adds greatly to the distress.   We sometimes, in
these circumstances, have painful attempts made by the mus-
cles to force the uterus downward, and these are occasionally
attended by a very slight discharge of blood.  We have,
however, no regular uterine pain; and, if we are  careful of
our patient, abortion is rarely produced.
  The best practice is to take away a little blood at first, to
keep the bowels open, to lessen the tendency to vomit, by ap-
plying leeches, or an  opium plaster, or a small blister, to the
region of the stomach, and to allay pain by doses of hyoscy-
amiis or  opium,  conjoined  with carminatives.   When  the
mind is much affected, or  the head painful,  it is proper to
shave the head, and wash it frequently with cold vinegar, or
apply leeches to the temples;  at the same time we keep the
patient very quiet, and have recourse to a soothing manage-
ment.
   The uterus being a large vascular organ, is obedient to the
laws of vascular action, whilst the ovum is more influenced by
those regulating new-formed parts; with this  difference, how-
ever, that new-formed parts or tumours  are  united firmly to
the part from which they grow by all kind of vessels, and ge-
nerally by fibrous or cellular substance, whilst the ovum is
connected to the uterus only by  very tender and fragile arte-
ries and veins.   If, therefore, more blood be sent to the ma-
ternal part of the ovum, than it can easily receive and circu-
late and act under, rupture of the vessels will take place, and
an extravasation and consequent separation be produced; or,
even when no rupture is occasioned, the action of the ovum
may be so oppressed  and disordered, as to unfit it for conti-
 nuing the process of gestation.   There must, therefore, be a
 perfect correspondence betwixt the uterus and the ovum, not
 only in growth  and  vascularity, but in every other circum-
 stance  connected with their functions.
   Even when they do correspond, if the uterus be plethoric,
 the ovum must also be full of blood, and rupture  is very apt
 to take place.  This is a frequent cause of abortion, more
 especially in those who  menstruate copiously. On the other 
23U
hand, when the uterus is deficient in vascularity, which often
happens in those who menstruate sparingly or painfully, or
who have  the menses pretty abundant, but  watery, the child
generally  dies  before the seventh month,  and is expelled.
The process is prematurely and imperfectly finished.
  The existence of plethora is to be considered as a very fre-
quent cause of abortion, and requires  most  particular atten-
tion.   It more especially obtains in the young and vigorous,
or in those who live luxuriously, and sleep in soft warm beds.
It renders the uterus too easily supplied with blood : the in-
crease is  not made in the regular degree, corresponding to
the gradual increase of action, and augmentation of size;  but
it is, if I may use the expression, forced on  the uterus, which
is thus made for a time to act strongly and rapidly. This  ac-
tion is sometimes so great, that the person feels weight in the
region of  the uterus, and shooting pains  about the pelvis;
but, in other instances, the vessels suddenly give way, with-
out previous  warning, and the blood  bursts forth at the os
uteri. This cause is especially apt to operate in those who  are
newly married, and who are of a salacious disposition, as  the
action of the uterus is thus much increased, and the existence
of plethora rendered doubly dangerous. In these cases, when-
ever the menses have become obstructed, all causes  tending
to increase the circulation must be avoided, and often a tem-
porary separation from the husband is indispensable.   Often
do we find that  slight exertion, within a fortnight after the
menses stop, will  produce  a speedy and violent eruption of
blood,  which  continues until the vessels  are fully unloaded,
and until all that part of the process  of forming an  ovum
which has been effected, be undone.
  Abortion necessarily implies separation of the ovum, which
may be produced mechanically, or by spontaneous  rupture of
the vessels, or by an affection of the muscular fibres.   It un-
avoidably requires,  for its  accomplishment,  contraction of
those fibres which formerly  were in a dormant state.   A
natural and necessary effect of this contraction is to developc
the cervix uteri.   This, when gestation goes  on  regularly,
i<? accomplished gradually and slowly by  the extension  and 
231
formation of fibres.  In abortion, no fibres are formed ; but
muscular action does all, except in those instances where the
action  of gestation  goes on  irregularly and  too  fast; in
which  case,  the cervix  distends,  sometimes by the  third
month, by the same process which distends the fundus.   But
much more frequently  the cervix only relaxes  during  abor-
tion, as the os uteri does in natural labour, and yields to the
muscular action of the fundus, or distended part.
  The existence and growth of the foetus depend on the foetal
portion of the ovum.   The means of nourishment, and the
accommodation  of the foetus in respect of lodgment, depend
on the  uterus;  and these circumstances requiring both  foetal
and maternal  action, are intimately connected.  The condi-
tion of the uterus qualifying it to enlarge, to continue the ex-
istence and operation of the  maternal portion of the placenta
or ovum, and to transmit blood to the ovum, exactly in the
degree  correspondent  to its want,  constitutes the action of
gestation.  When the action of gestation ceases universally
in the uterus, another action, namely, muscular contraction,
begins,  and then all hope of retaining the ovum any longer
is at an end.  I know that we have been told of instances
where contraction, after beginning, stopped for several wTeeks.
The os uteri may be prematurely developed ; it may be open
for some weeks, even without pain;  but no man will say that,
in this case, labour or uterine contraction has  begun.   We
may even have partial muscular action, in a few cases,  about
the os uteri, which has less to do with the action of gestation
than any other part of the uterus; and this action is often at-
tended with considerable pain or uneasiness.   Sometimes it
is connected  with convulsive agitation  of several of the ex-
ternal  muscles of the body.  Even in  this  case, expulsion
does not always immediately  take  place; for  by bleeding,
and rest, and opiates, the motion may sometimes be checked ;
but regular and universal action of the muscular fibres  never
yet has been stopped.  It may, like other muscular actions,
be suspended by  anodynes or  artificial treatment; but  it
never has, and never can be stopped,  otherwise than by the
expulsion of the ovum, when  a new train of actions  com- 
232
mence.  Whenever, then,  at  any period  of pregnancy, wo
have  paroxysms of pain in the back,* and region of the
uterus, more especially if these be attended with  feeling of
weight in that region, tenesmus, micturition, descent of the
uterus in the pelvis, and opening of  the os uteri, we may be
sure that expulsion, though retarded, will soon take place.
This  fact is  not always attended to in abortion,  for many
think that if by anodynes they can abate the pain, they shall
make the woman go to the full time.—This  is true, with re-
gard  to  many  painful sensations,  which may  attend a
threatened abortion,  or which  may be  present,  although
there be no appearance of abortion ;  but it does not hold with
regard to  those regular pains proceeding  from universal ac-
tion of the uterine fibres ;  and we may save both ourselves
and our  patients some  trouble,  by  keeping this in remem-
brance.
   Seeing, then,  that  contraction is  brought on by stopping
the action of gestation, and that  when it is brought on it can-
not be checked, nor the action of gestation restored, we must
next inquire how this  action may be  stopped.  I have already
mentioned several circumstances affecting  the uterus, and
likely to injure its actions; and these I shall not repeat, but
go on to notice some  others, which  are often more percepti-
ble :  and first I shall  mention violence, such as falls, blows,
and much fatigue, which  may  injure the child, and  detach
part of the ovum.  If part of the ovum  be detached, we have
not  only a discharge of blood, but also the uterus, at that

  * It may not be improper  to mention, that in some febrile affections we
have pain in the back and loins, occasionally remitting, or disappearing alto-
gether for a short space, and then returning.  Sometimes along with this we
have, owing to the affection of the circulation, and in some instances to pre-
vious exertion, a slight discharge from the vessels about the os uteri.  This
state is distinguished from  uterine contraction, by our finding that the cervix
is unaffected, that the pains are increased by motion  or  pressure, and are
more irregidar than those  attending labour.  This  state may be prevented
from inducing abortion, by rest,  by keeping the bowels open, by anodynes
preceded by venesection,  if the  pulse indicate it.  Frictions, with campho-
rated spirits of wine or laudanum, give relief.  Any exertion, during tlio re-
maining period of gestation, will renew the pain in the back. 
233
part, suffers in its action, and may influence the whole organ,
so as to stop the action universally.  But the time required to
do  this is various, and opportunity is often given to prevent
the  mischief from spreading, and to stop any farther effu-
sion—perhaps to accomplish a re-union.
  Violent exercise, as dancing, for instance, or much walk-
ing, or the fatiguing dissipations of fashionable life, more es-
pecially in the earlier  months, by affecting the circulation,
may vary the distribution of blood in the uterus, so much as
to produce rupture of the vessels, or otherwise to destroy the
ovum.  There is also another way  in  which  fatigue acts,
namely, by subducting action and energy from the uterus :
for the more energy that is expended on the muscles of the
inferior extremities, the less can  be afforded or  directed to
the uterus; and hence abortion may  be  induced at an early
stage of gestation.*  Even at  a  more advanced period, in-
convenience will be  produced  upon  the principle  formerly
mentioned ; for the nerves of the loins conveying less energy,
in  many instances, though  not always, to the  muscles, they
are really weaker than formerly, and are sooner  wearied,
producing pain, and  prolonged feeling of  fatigue for many
days, after an exertion which may  be  considered  as  mo-
derate.  This  feeling must not be  confounded  with  a ten-
dency to abortion, though it may sometimes be combined with
it, for generally by rest the sensation goes  off.  Neither must
we suppose that the child  is dead,  from  its  being  usually
quiet during that period, for as soon as the  uterus, which has
been a little  impaired in its action, recovers, it moves as
strongly as ever.
   In the next place, I mention the death of the child, which
may be produced by syphilis, or by diseases perhaps peculiar
to itself, or by that state which produces too much liquor am-
nii, or by injury of the functions of the placenta, which may
arise from an improper structure of the gland itself,  or aneu-

  * The same effect is observable in the stomach and other organs. If a de-
licate person, after a hearty meal, use exercise to the extent of fatigue, he
feels that the food is not digested, the stomach having been weakened or in-
jured in its actions.
   VOL. I.                        Hfl 
234
rism, or other diseases of the cord.  But in whatever way it
is produced, the effect  is the  same in checking the  action of
gestation, unless there be  twins, in  which  case  it  has been
known, that the uterus sometimes did not suffer  universally,
but  the action  went  on, and the one child was  born of the
full  size, the other small and injured.*  The length of  time
required for producing abortion from this  cause is various;
sometimes it is brought on in a few hours ; at other times not
for a fortnight,  or even longer.(c) In these and similar cases,
when the  muscular  action is commencing, the discharge is
trifling, like  menstruation,  until the contraction  becomes
greater, and more of the  ovum be separated.   When symp-
toms of abortion proceed from this cause, it is  not possible
to prevent its completion; and it would be hurtful even if it
were possible.   When, therefore, after great fatigue, profuse
evacuations in delicate habits, violent colic, or other causes,
the  motion of the child ceases, the breasts become flaccid,
and the signs of gestation disappear, we  need not attempt to
retard  expulsion, but should  direct our principal  attention to
conduct the woman  safely through the process.

  * It has even been known, that, in consequence of the death of one child,
the uterus has suffered partially, and expulsion taken place ; but the other
child continuing to hve, lias preserved the action of gestation in that part of
the uterus, which, properly speaking, belonged to it, and  pregnancy has
still gone on. This, however, is an extremely rare  occurrence ; for in al-
most every  instance, the death of one  chdd produces an affection of the ac-
tion of gestation in the whole uterus, and the consequent expulsion of both
children.
  (c) In one instance that fell under my notice, a lady who had suffered se-
veral previous abortions, but who had also borne two healthy  living children,
was overturned in a carriage before the completion of the third month of ges-
tation.  She was extremely bruised, and was, in consequence,  confined to
her bed for several days; yet upon getting about again, she fancied, after the
period of quickening, that she felt the motion of the child, with all the other
symptoms of favourable and healthy pregnancy.  She thus went on to the
full period of utero-gestation; and on the very day she calculated, was  deli-
vered of a foetus that certainly had lost the principle of vitality for several
months, not appearing larger than an embryo of five months.   The placenta
was also almost exangueous, and appeared as if it might have been detached
from  the uterine parietes for some time.  Indeed, the whole appeared like a
preparation  that had been preserved in sp. vini, or sp. terebinth.  The lady
had a speedy recovery, and at no distant period bore a healthy living child. 
233
   Another cause  is, any strong passion of  the mind.   The
 influence  of fear, joy, and other emotions on  the muscular
 system, is well known;  and the uterus is not exempted from
 their power;  any sudden shock, even of the body, has much
 effect on  this organ.  The pulling of a tooth,  for  instance,
 sometimes suddenly produces abortion.
   Emmenagogues,  or acrid  substances, such as savine and
 other irritating  drugs,  more especially those which tend to
 excite a considerable degree of vascular action, may produce
 abortion.
   Such medicines, likewise, as exert a violent action on the
 stomach or bowels, will, upon the  principle formerly men-
 tioned, frequently excite abortion;  and very often are taken
 designedly for that purpose in such quantity as to produce
 fatal effects ;* hence emetics, strong purgatives, diuretics, or
 a full course of mercury, must be avoided during pregnancy.
   If any part with which the  uterus sympathizes  have its
 action greatly increased during pregnancy, the uterus  may
 come to suffer, and abortion be produced.   Hence the acces-
 sion  of morbid action  or inflammation in any important or-
 gan, or on a large extent of cuticular surface, may bring on
 miscarriage, which is one cause why small-pox often excites

  * It is an old observation, that those purgatives, which produce  much
 tenesmus, will excite  abortion ; and this is certainly true, if their operation
 be carried to a considerable extent, and continue long violent  Hence dy-
 sentery is also apt to bring on a miscarriage.  Those strong purges which are
 sometimes taken to promote premature expulsion,  not only act by exciting
tenesmus, but likewise by inflaming the stomach and bowels, and thus affect
the uterus in two ways  It cannot be too generaUy known, that when these
medicines do produce  abortion, the mother can seldom survive their effect.
It is a'mistaken notion, that abortion  can be  most readily excited by drastic
purges, frequent and copious bleeding, &c. immediately after the woman
discovers herself to be pregnant; on the contrary, the action of the uterus
is then more independent of that of other organs, and therefore not easily
injury by changes in their condition.  I have already shown, that abortion
 more frequently happens when the pregnancy is farther advanced, because
 then not only the uterus is more easily affected, but the foetus seems to suffer
 more readily. It is apt, either from diseases directly affecting itself, or from
changes in the uterine action, to die about the middle of the third month,
 in which rase expulsion follows within a fortnight. 
236
abortion, whilst the same  degree of fever, unaccompanied
with eruption, would  not  have had that effect.  Hence also
increased secretory action in the vagina, if to a great degree,
though it may have even  originally been excited in conse-
quence of sympathy with  the uterus,  may come to incapa-
citate the uterus for going  on with its actions, and therefore
it ought to be moderated by means of  an astringent  injec-
tion.
  Mechanical irritation of the os uteri, or attempts to dilate
it prematurely, will also be apt to bring on muscular contrac-
tion.  At the same time,  it is worthy of remark, that the
effect of  such irritation is generally at first confined to the
spot on which it acts, a partial affection of the fibres in the
immediate vicinity of the os uteri being all that is, for some
time, produced; and therefore slight uneasiness at the lower
part of the belly, with or without a tendency in the  os uteri
to move or dilate,  whether brought  on by irritation at the
upper part of the vagina  or os uteri, or  by affection  of the
neck of the bladder, &c. may be often prevented from extend-
ing  farther,  by rest, anodynes, and having  immediate re-
course to such means as the nature of the irritation may re-
quire for its  removal.*
  The irritation of a prolapsus ani, or of inflamed piles, with
or without much sanguineous discharge, may excite the uterus
to contract;  and if the bleeding from the anus have been pro-
fuse, and the woman weakly, it may destroy the child.  The
piles ©light, therefore never to be neglected.
   Tapping  the ovum,  by which the uterus collapses and its
fibres receive a stimulus to action, is another cause by which
abortion fcay be produced; and this is sometimes, with great
propriety, done at a particular period,  in order to avoid a
greater evil.   It is now the general opinion, that contraction
will unavoidably follow the evacuation of the waters. But we
can suppose the action of gestation  to be in some cases so

  * Chronic inflammation of the heart is generally attended with pain at the
bottom of the abdomen, which is sometimes mistaken for symptoms  of  cal-
culus. In one case abortion seemed to proceed from this disease  of the
heart. 
237
strong as not, at least for a very considerable time, to stop
in consequence of this violence, and, if it do not stop, con-
traction will not take place. I do not, however, mean to say,
that all discharges of watery fluid from the uterus, not fol-
lowed by abortion, are discharges of the liquor amnii.  On
the contrary, I know, that most of these are the consequence
of morbid action about the os  uteri, the glands  yielding a
serous, instead of a gelatinous fluid, and this action may con-
tinue for many months.
   In all these cases, the woman must be confined to bed, and
have an anodyne every night at bed-time, for some time, pre-
mising venesection if the  pulse indicate it, and conjoining
gentle laxatives. There is just so much probability of gesta-
tion going on, as to encourage  us to use endeavours to con-
tinue it. In those instances where the discharge is small, and
the oozing pretty constant, we conclude  that it  is  yielded
chiefly by the glands about the os uteri, and may derive ad-
vantage from injecting three or four times a-day a strong in-
fusion of galls, or solution of alum.  The woman ought to use
no exertion, as the membranes are apt to give way.    _  '
   It is sometimes necessary to lay down rules for the manage-
ment of pregnant women, even  although  they  may not have
been liable to abortion.  These  are to be drawn from the re-
marks already delivered, and it is only requisite to add, that
in all cases it is proper to attend to the effects of utero-gesta-
tion, or the diseases of pregnancy, which are to be mitigated
when  severe by suitable remedies.
   The danger of abortion is to  be  estimated by considering
the previous state of the health, by attending to the violence
of the  discharge, and the difficulty of checking it; to its dura-
tion, and the disposition to expulsion which accompanies it;
to the effects  which it has produced in weakening the system,
and to its combination with hysterical or spasmodic affections.
In general, we say that abortion is not dangerous, yet in some
cases   it  does prove  fatal very speedily,  cither from loss of
blood, or spasm of the stomach, or convulsions. It is satisfac-
tory,  however, to know, that this  termination  is rare, that
these  dangerous attendants arc seldom  present, and that a
.> 
238
 great hemorrhage may be sustained,  and yet the strength
 soon recover. But if there be any disposition in a particular
 organ to disease, abortion may make it active, and thus, at a
 remote period, carry off  the patient.   Miscarriages, if fre-
 quently repeated, are also very apt to injure the  health, and
 break up the constitution.
   When abortion  is threatened, the process is very apt to go
 on to completion;  and it is only by interposing, before the ex-
 pulsive efforts are begun, that we can be successful in prevent-
 ing it; for whenever the muscular contraction is  universally
 established, marked  by regular pains, and attempts to distend
 the cervix and os uteri, nothing, I believe, can check the pro-
 cess.  As this is often the case before we are called, or, as in
 many instances  abortion depends on the action of gestation
 being stopped by causes, whose action could not be ascertain-
 ed until the effect be produced,  we shall frequently fail in
 preventing expulsion.
   This is greatly owing to our not being called until  abor-
 tion,  that is to say, the expulsive process has begun; where-
 as, had we  been applied to upon the first unusual feeling, it
 might have been prevented.  What I wish then particularly
 to inculcate is, that no time be lost  in  giving  notice of any
 ground of alarm, and that the most prompt measures be had
 recourse to in the very beginning; for, when universal uterine
 contraction has commenced, then all that we can do is to con-
 duct  the patient safely through  a  confinement,  which the
power of medicine cannot  prevent.
   The case  of threatened  abortion, in which  we  most fre-
quently succeed, is that arising from slipping of the foot,  or
 from  causes exciting a temporary over-action of the vessels
producing a slight separation; because here the hemorrhage
 immediately gives alarm, and we are called before the action
 of gestation be much  affected.   Could we impress upon our
patients the necessity of equal attention to other preceding
 symptoms  and  circumstances, we might succeed in many
 cases where we fail from a delay, occasioned by their not un-
 derstanding that an expulsion can only  be prevented, by in-
 terfering before  that  process begins : for when sensible sign^ 
239
of contraction appear, the mischief has proceeded too far to
be checked.  Prompt and decided means used upon the first
approach of symptoms  indicating a hazardous state of the
uterus, or on the earliest appearance of hemorrhage may, pro-
vided the child be still alive, be attended with success.
  In considering the treatment, I shall first of all notice the
most likely method of preventing abortion in those who are
subject to it;  next, the best means of checking it, when it is
immediately threatened; and,  lastly, the proper method of
conducting the woman through it, when it cannot be avoided.
  The means to be followed in preventing what may be cal-
led habitual miscarriage, must depend on the cause supposed
to give rise to it.  It will,  therefore, be necessaiy  to  attend
to the history of former abortions; to the usual habitudes and
constitution of the woman ; and to her condition when she be-
comes pregnant.
  In  many instances a plethoric disposition, indicated by a
pretty full  habit, and copious menstruation, will be found to
give rise to it.   In these cases, we shall find it of advantage
to restrict the patient almost entirely to a vegetable diet, and,
at the same time, make her use considerable and regular ex-
ercise.
  The sleep should  be abridged in quantity, and taken, not
on a bed of down, but on a firm mattress, at  the same time
that we prevent the accumulation of too much  heat about the
body.  The bowels ought to  be kept open,  or rather loose,
which may be effected  by drinking  Cheltenham water, or
taking some other laxative.  We must not, however, carry
this plan too far, nor make a  sudden revolution in the con-
stitution, as this may be productive of permanent mischief,
and occasion the diseases which proceed from a broken habit.
Whenever the strength is diminished, the  appetite impaired,
or any other bad effect is produced, we have gone  too great
length.
  There is, in plethoric habits, a weakness  of many,  if not
all of the functions; but this is not to be cured by tonics, but
by continued and very gradually increased exercise, laxatives,
and light diet,  consisting chiefly of vegetables.  This plan, 
J240
however, must not  be carried to an imprudent length, nor
established too suddenly; but regard is to be had to the pre-
vious habits.  It is a general rule,  that exercise should not
be carried the length of fatigue, and that it should be taken,
if possible, in the country;  whilst late hours,  and many of
the modes of fashionable life, must be  departed from.   We
may also derive such considerable advantage from  conjoining
with  this plan, the shower bath or sea-bathing, that they
ought not to  be  omitted.   There is,  I believe, no  remedy
more powerful in preventing abortion than the  cold  bath,
and the best time for using  it is in the morning.  By means
of this, conjoined with attention to the vascular system, and
prudent  conduct on the part of the patient, I  suppose that
nine-tenths  of those who are subject to abortion, may  go on
to the full time.  If the shower-bath be employed, we must
begin with a small quantity  of water; and, in some instances,
may  at first add  so much warm water as shall make it just
feel cold, hut not to give too great a shock.  If the cold bath
cause head-ache, this may often be prevented by premising one
or two doses of physic.
  After conception, the exercise must  be taken with  circum-
spection  : hut the diet must still be  sparing,  and the  use of
the cold  bath continued.  If the pulse be  at any  time full,
or inclined to throb, or if the patient be of a vigorous  habit,
a little blood should be taken away at a very early period.
In some  cases where the action is  great, we must bleed al-
most immediately after the  suppression of the menses.  It is
not necessary to  bleed copiously ; it is much better to take
away only a few ounces, and repeat the evacuation when re-
quired, and  we should manage  so as to avoid fainting.  The
cold bath should  be conjoined, and we may  derive advantage
by  using the  digitalis,* so as  slightly to  affect  the pulse,
keeping  it at or below its natural frequency, and to diminish

 * The acetite of lead has been recommended'by the ingenious and justly
celebrated Dr.  Rush of Philadelphia, in doses of from one to  three  grains,
given three times a-day.  Of this practice I cannot speak from my own ex-
perience :  but  Dr. Rush informs me, that in his hands it has been attended
with great success. 
241
 its throbbing.  But it is not requisite to be given to the de-
 gree employed in some other complaints; and, if it be pushed
 to an imprudent length, the child may suffer.   Half a grain
 may be given, twice or thrice  a-day.  It may be continued
 for two days, and then omitted for a day; and in this  way it
 may be continued  till the danger  is past.  In those cases
 where the digitalis produces feebleness, it  is  evidently  im-
 proper to continue it  regularly.   Indeed,  when this effect
 takes place, its farther exhibition is unnecessary.  It  is also
 improper where it ads powerfully  on the kidneys.  By at-
 tending to these cautions, it may, in some cases requiring it,
 be continued with occasional omissions of a day or two, even
 for some weeks, but it is very seldom necessary to persist in
 it above a fortnight at most.
   Injecting cold water into the vagina, twice or thrice  a day,
 has  often a  good effect, at the  same time that we continue
 the shower-bath every morning.  When there is much  aching
 pain in the back, it is of service to apply cl<fchs to it,  dipped
 in cold water, or gently to dash cold water on  it; or employ
 a partial shower-bath, by means of a small watering can.
   In this, and all other cases of habitual abortion, we must
 advise, that impregnation shall  not  take place  until we have
 corrected the system; and after the woman has conceived, it
 is requisite that she live absque marito,  at least until gesta-
 tion  be far  advanced.  I need  hardly add,, that when con-
 sulted  respecting habitual abortion, the strictest prudence is
required  on our part, and that the  situation of the patient,
and many of our advices, should be concealed from the most
intimate friends of the patient.
  In other cases, we find that the cause  of  abortion is con-
nected with sparing menstruation.   This  is often the case
with women whose appearance  indicates good  health,  and
who have a robust look.  This is not often to be rectified by
medicine, but  it may by regimen, &c.  Here,  as  in the for-
mer  case, we find it useful to make the greatest part  of the
 diet consist of vegetables ; but it is  not necessary to restrict
the quantity.
  When, on the other hand, the patient has a weakly deli-
  roi. i.                        11 
242
cate appearance, it will  be proper to give a greater propor-
tion of animal food, and two or three glasses of wine, in tiie
afternoon, with some bitter laxative, twice a day, so as to
strengthen  the  stomach, and  at the same time  keep the
bowels open.
  We also derive in both cases, advantage from the daily
use of the warm bath, made of a pleasant temperature; but
this is to be omitted after conception ; at least for the first
ten or twelve weeks: after which, if there be symptoms of
irritation, or feeling of tension about the belly, or pain about
the groins, or pubis, it  may  be employed, and  is  both safe
and advantageous.  But when the patient is of a phlegmatic
habit, or subject to profuse fluor albus, it is not indicated,
and sometimes  is pernicious.   The internal use of the bath
waters previous to conception is often of service; or where
the circumstances of the patient will not permit this, we may
desire her  to drink, morning  and evening, a pint of  tepid
water, containing half a  dram of sweet spirit of nitre.
Throwing  up into  the  vagina tepid  salt-water  twice  or
thrice a day, seems also to have a good  effect.
  I have already mentioned, that abortion is sometimes the
consequence of too firm action, the different organs refusing
to yield to the uterus, which is thus prevented from enjoying
the due quantity of energy and  action.   These women have
none of the diseases of pregnancy,  or they have  them in  a
slight degree.  They have good health at all times, but they
either  miscarry, or  have labour  in the seventh or eighth
month, the child being dead ; or if they go to the full time,  I
have often  observed the child  to he sickly, and of  a consti-
tution  unfitting it for  living.  Blood-letting is useful  by
making the organs more irritable.  The tepid bath is in ge-
neral of advantage, and may be employed every second even-
ing for some time.
   There is another case in which all the functions are healthy
and firm, except the circulation, which is accelerated by the
uterine irritation.  This  is more  or less  the case in every
pregnancy; but here it is a prominent symptom.   The wo-
man is very restless, and even feverish, and apt to miscarry, 
243
especially if she be of a full habit.  Immediate relief is given
by venesection ; and afterwards we may, for some time, give
every night half a  grain or  a grain of digitalis, with two
grains of the extract of hyoscyamus.
  When, on the  contrary,  abortion  arises  from  too  easy
yielding of some organ, we must keep down  uterine action,
by  avoiding venery,  and injecting cold water often into the
vagina, or pouring cold water every morning from a water-
ing can, upon  the loins and ilia; at  the same time we must
attend to the organ sympathizing with the uterus.
  Sometimes it is  the stomach  which is  irritable, and the
person is often very sick, takes  little food,  and digests ill.
A small blister, or leeches applied to the pit of the stomach,
often relieves this;  a little of the compound tincture of bark,
taken three or four times  a-day, is  serviceable;  or a few
drops of the tincture of muriated iron, in  a tumbler glassful
of aerated water.   At other times, the bowels yield, and the
patient is obstinately costive.   This is cured by aloetic pills,
or manna, with the tartarite of potash.  When the muscular
system  yields, producing a feeling of languor  and general
weakness, the use of the cold bath, with a grain of opium at
bed-time, will be of most  service.
  It is  evident, that it is only by attending  minutely to the
history of former  miscarriages, that we can  detect  these
causes ; and we shall generally find, that  in  each individual
case, it is the same organ in every pregnancy which has yield-
ed or suffered.  Previous to future conception, we may with
propriety, endeavour to render it less easily affected.
  General weakness is another condition giving rise to abor-
tion ; and  upon this I have already made some remarks.   I
have here only to add, that the use of the cold bath, the exhi-
bition of the Peruvian bark, and  wearing  flannel next the
skin, constitute the most successful practice.
   Syphilis is likewise a cause of abortion.  When it occurs
in the mother, it often unfits the uterus for going on with its
actions.  At other times, more especially when the father
labours under  venereal hectic,  or  has not been completely
cured, the child is  evidently affected, and often dies  before 
244
the process of gestation  can be completed.  In these cases,
a course of mercury alone can effect a cure.  But we are not
to suppose that every child, bom  without  the cuticle in an
early stage of pregnancy, has suffered  from this cause;  on
the contrary, as some of these instances depend on causes  al-
ready mentioned, and which cannot be cured by mercury, I
wish to caution the  student against too hastily concluding
that one of the parents has been diseased, because the child
is born dead  or putrid at an early period.  It is not always
easy to form  a  correct judgment; but we may be assisted by
finding that the other causes which I have mentioned are  ab-
sent ; that we have appearances of ulceration  on the child,
and that there are some suspicious circumstances in the for-
mer history and present health of the parents.  A child may
be born dead,  and even putrid, not only in consequence of
syphilis, but  also of some malformation of the foetus itself, or
of its appendage^; or of a general  imperfection of the ovum,
usually combined with an increased quantity of liquor amnii;
or of original debility of constitution, unfitting the  child for
coming to maturity; or of fatal derangement of structure, or
action  taking place in utero,  from causes not very obvious;
or from weakness or imperfect action of the uterus itself, or
such a condition of it as sometimes  produces epilepsy; or it
is in certain  cases occasioned by a convulsion. Most of these
causes are not  under our control;  and  indeed, with the ex-
ception of  the  case of syphilis, we can only propose to pre-
vent the death of the child,  by the  use  of such general
means as invigorate the constitution of the parent, or as  ob-
viate palpable  predisposing causes  of  injury to the  uterine
functions.
   Advancement in life, before marriage, is  another cause of
frequent abortion, the uterus being then somewhat imperfect
in its action.   In general, we cannot do much in  this case,
except avoiding carefully the exciting causes of abortion ; and
by attending minutely to the condition of other organs, dur-
ing menstruation or pregnancy, we may, from the principles
 formerly laid down, do some good.
   It is satisfactory to know, that although we /nay fail once 
245
or twice, yet, by great care, the uterus comes at  last to act
more perfectly, and the woman bears children at the full
time.
  After these observations, it is only necessary to add, that
in every instance of habitual abortion, whatever the condition
may be which gives rise to it, we find it is essential that the
greatest attention be paid to the avoiding of the more evident
and immediate exciting causes of miscarriage, such as fatigue,
dancing, &c.  In some cases, it may even be necessary to
confine the patient to her room, until the period at which she
usually aborts is past.
  When abortion is  threatened, we  come  to consider whe-
ther, and by what means it can be stopped.  I have already
stated  my opinion, that when the action of gestation ceases,
it cannot be renewed, and that general contraction of the ute-j
line fibres is a criterion of this cessation.
   Still, as some of the means which may be supposed useful
in preventing a threatened abortion, are also useful in mode-
rating the symptoms  attending its  progress,  we  may very
properly have recourse to them.  Some causes giving rise to
abortion, do not immediately produce it, but  give warning of
their operation, producing uneasiness in the vicinity of  the
uterus, before the action of that organ be materially affected.
The detraction of a little blood at this time, if  the pulse be in
any measure full or frequent, or, if the patient be not of  a
habit forbidding evacuations, and the subsequent exhibition
of  an  anodyne clyster, or a full dose of opium,* together
with a state of absolute rest in a recumbent posture for some
days, will often be sufficient to prevent farther mischief, and
constitute the most efficacious practice.  The  patient should
be  strictly confined to bed,  sleeping with few bed-clothes,
and without a fire in her apartments.   Indeed, the very first
thing to be done on entering the room, is to order the patient
to bed.  The diet should, in general, be low, consisting of
dry toast, biscuit and fruit;  and much fluid, especially warm
fluid, should be avoided.
  * Opiates are of signal benefit in this situation, and should seldom be omit-
ted after venesection. 
246
  This is the time at which we can interfere with the most
certain prospect of success; and the greatest attention should
be paid to the state of the rest of the system; removing un-
easiness, wherever it is present,  and preventing  any organ
from continuing in a state of  undue action.   It is difficult to
persuade the patient  to comply  with  that strict attention
which is necessary at this period  : but being persuaded that
if this period be allowed to pass over with neglect, and con-
traction begins, nothing can afterwards prevent  abortion,  I
wish particularly to impress  the  mind of the student with  a
due sense of its importance; and I must add, that as after
every appearance of morbid uterine action  is over, the slight-
est cause will renew our alarm, it is necessary great atten-
tion be paid for some time to  the patient.
   Often, instead  of an uneasy feeling about the loins, or
lower belly, we have before  the action of gestation  stops,  a
discharge of blood, generally in  a moderate, sometimes in a
trifling degree.   This is more especially the case when abor-
tion is threatened, owing to  an external cause ;  and, if  im-
mediately checked, we may prevent contraction from begin-
ning.
   Even in those cases  where we do not  expect  to ward off
expulsion,  it is useful to prevent, as far as we can,  the loss
of blood; for as I cannot see that the  hemorrhage is neces-
sary for its accomplishment, although it always attends it,
I conclude that our attempts to prevent bleeding can never
do harm; if they succeed in  checking abortion, we gain our
object; if  they fail, they do not increase, but diminish the
danger.
   It should be carefully remembered,  that the more we can
save blood, the more do we serve our patient.  As the means
for checking the discharge will be immediately pointed out,
it is unnecessary here to enter into any detail.
   Sometimes the vessels  about the cervix and os uteri yield,
post coitum,  a little blood; and this may occur  either  in
those who have the uterus in a high state of activity, or more
frequently where it is feeble  in its functions.  The same dis-
charge may sometimes  appear  in rather greater quantity af- 
247
ter impregnation, passing perhaps for the menses, and mak-
ing the woman  uncertain as to her situation; but it is gene-
rally, though not always, irregular in its  appearance, and
seldom  returns  above once or twice.  In some  instances,
however, it becomes greater and more frequent in proportion
as the  vessels  increase in size.  It is now apt to pass for
menorrhagia.   If it be allowed to continue,  it tends to injure
the action of the uterus, and produces expulsion, which some-
times is the first thing which shows the woman her situation.
The discharge is best managed by rest, and the frequent in-
jection  of  saturated  solution of the sulphate of  alumine,  or
decoction of oak bark.
   When a slight discharge takes place, in  consequence of a
slip of the foot, or some other external  cause, we may also
derive advantage from the use of the injection; but if the dis-
charge be considerable, it will often fail.  It is better, in such
a case, to trust to the formation of a coagulum.
   When in  a plethoric habit abortion is threatened, from a
fright, or mental agitation, we  have  often  palpitation, rapi-
dity of the pulse, head-ache, flushed face, and pain about the
back or pubis; blood-letting  relieves immediately the  un-
easiness in the head, and often the pain in  the  back; after-
wards, the patient is to he kept cool and quiet, and an anodyne
administered.
   In those cases, where regular uterine pain precedes or ac-
companies the  discharge, expulsion  cannot be  prevented ;
but when the discharge precedes the pain, it sometimes may ;
nay, if the child be still alive, it frequently  may.  Rest is ab-
solutely necessary, if we wish the person  to go  to  the full
time :  and it is occasionally necessary to confine her to bed
for several weeks, prescribe the prudent and occasional use
of digitalis*, and give an anodyne at bed-time, taking care
   * I have in a preceding note, advised some caution in the use of digitalis
in uterine floodings. I would here, also, recommend the  same  degree of
circumspection.  When given in sufficient quantity  to make any very sen-
sible impression on the system generaUy, it seems, in a very pecuhar man-
ner, to relax and debilitate the vessels of the uterus,  disposing them, there-
by, to passive hemorrhage. When, however, it is administered with proper
 restrictions, I have no doubt it may prove both a safe  and a useful  medicine.
But still, I would greatly prefer to bleed in the above cases.  C 
248
 also to keep the bowels in a proper state by gentle medicine.
 Blood ought also, unless the pulse and habit  of the patient
 forbid it, to be detracted. Styptic injections into the vagina,
 two or three times a-day are of great benefit.
   This is a very critical situation : much depends on the vi-
 gour and promptitude of our practice ; and much, very much,
 upon the prudence of the patient.  It is teazing to find, that
 sometimes, after all our care and exertions, one rash act de-
 stroys in a single day the effect of the whole.
   When we cannot prevent abortion,  the next  thing is to
 conduct the patient safely through the process, by lessening
 the effects of separation  or  detachment  of the  ovum, and ac-
 celerating the contraction.  The first point which naturally
 claims our attention is the hemorrhage.  Many practitioners,
 upon a general principle, bleed, in order to check this, and
 prevent miscarriage; but miscarriage cannot be prevented, if
 the uterine contraction have universally  commenced ; and the
 discharge cannot be prudently moderated by venesection, un-
 less there be undue or  strong action in  the vessels, or much
 blood in the  system ;  and if so,  a vein  may be opened with
 advantage. This is not always the case,  and therefore, unless
 the vessels be at or above the natural force or strength of ac-
 tion, the lancet is not at this stage necessary.   The fulness
 and strength of the pulse are lost much  sooner in  abortion
 than can be explained, by the mere loss of blood.  This de-
 pends on an affection of the  stomach, which has much  influ-
 ence on the pulse ; and the proper time for bleeding is before
 this has taken place.  When  abortion has made so much pro-
 gress before we are called,  as  to have  rendered the  pulse
 small and feeble; or when this is the case  from the first, bleed-
 ing evidently can do no good.  Instead of this, we may rather
 use the digitalis, but in ordinary  cases,  where  the contrac-
 tion is brisk, and the process quick, it is  not at this stage ab-
solutely necessary; and I  shall afterwards mention  that,
when the stomachic affection is urgent, and the pulse much
 affected by it, the use of  this medicine is improper.   When,
however, the case  is  tedious, and the discharge long con-
 tinued, at the same time that the  sickness is not  considera-
 ble, the digitalis will be  of  essential service, and it may be 
249
very properly combined with the sulphuric acid. Nauseating
doses of emetic medicines act in the same way with the digi-
talis, but are much  less effectual, and more disagreeable, as
well as uncertain in their  operation.  Internal astringents
have been proposed, but they have no effect, unless they ex-
cite sickness, winch is a different operation from that which
is expected from them.
  The application of cloths dipped in cold water to the back
and external parts will have a much better effect than inter-
nal astringents, and ought always to be had recourse to.   If
the digitalis have been exhibited, it assists that medicine in
moderating the circulation.   Even when trusted to  alone, it
lessens the action of the sanguiferous system, particularly of
the uterine vessels.  The introduction  of a small  piece of
smooth ice into the vagina has  been recommended, and has
often a very speedy effect in retarding the hemorrhage, whilst
it never, if properly managed, does any harm. A small snow-
ball, wrapped in a  bit of linen, will have the same effect; but
neither of these must be continued so long as to produce pain,
or much and prolonged shivering. The heat of the surface is
 also to he moderated, by having few bed-clothes, and a free
 circulation of cool  air.
   But the most effectual  local method  of  stopping the he-
 morrhage is by plugging the vagina.  This is best done by
 taking a pretty large piece of soft cloth, and dipping it in oil,
 and then wringing it gently.  It is to be introduced with the
 finger, portion after  portion, until trie lower part of the va-
 gina be  well  filled.   The remainder is then to be pressed
 firmly on the orifice.   This acts by giving the effused blood
 time to coagulate.  It gives no pain; it produces no irrita-
 tion ; and those who condemn it, surely must either not have
 tried it, or have misapplied  it.  If we believe that abortion
  requires for its completion a continued flow of blood, we ought
  not, in those cases where the process must go on, to have re-
  course  to  cold, or other means of restraining hemorrhage.
  If we do  not believe this, then surely  the most  effectual
  method of moderating it is the  best.  Plugging can never re-
  tard the process, nor prevent the expulsion  of the ovum;  for
    vol. i.                          K K 
250
 when the uterus contracts, it sends it down into the clotted
 blood in the upper part of the vagina, and  the flooding
 ceases.
   Faintness  operates also in  many cases, by allowing co-
 agula to form, in consequence of the blood flowing more slow-
 ly ; and when the faintness goes off, the coagula still restrain
 the hemorrhage in the same way as when the plug has been
 used.  This naturally points out the advantage of using the
 plug, together with the digitalis, as we thus produce coagula-
 tion at the mouths of the vessels, and also diminish the vas-
 cular action.  It will likewise show the impropriety of using
 injections at this time; for, by washing out the coagula, we
 do more harm than can be compensated by any astringent
 effect produced on the vessels.
   The principal means, then, which we employ for restrain-
 ing the hemorrhage, are bleeding, if the  pulse  be full and
 sharp; if not, we trust to the digitalis, combined with sulphu-
 ric acid, except in those cases already specified, as forbid-
 ding its use :  to stuffing the vagina: to the application of cold
to the external parts, keeping the heat of the body in general
 at a low temperature; and enforcing a state of absolute rest,
 which must be continued during the whole process, however
long it may, in some cases, be.   The drink should be cold,
 and  the  food, if the patient desire any, light, and taken in
 small portions.
   Opiates have been advised, in order to abate the discharge,
 and  are, by  many, used in every case of  abortion, and  in
 every stage.  But as we  cannot finish the process without
 muscular contraction, and as they tend to suspend that, 1 do
 not see that their constant exhibition can be defended on ra-
tional principles.   If given in small quantity, they do no
 good  in the present  point of view; if in larger doses, they
 only postpone the evil, for they cannot check abortion after
 contraction has begun.  But I will not argue against the use
of opiates from their abuse.  They are very useful in cases of
threatened abortion, more especially in accidental separation
 of the membranes and consequent discharge.   They do not
 directly preserve the action of gestation, but they prevent the 
251
tendency to muscular  contraction,  and thus do good.   In
weakly or emaciated habits, opiates alone, if given upon the
first appearance of mischief, are often sufficient to prevent
abortion ; and, in opposite conditions, when preceded by ve-
nesection, they are of  great service.  Opiates are  likewise
useful for allaying those sympathetic pains about the bowels,
and many of the nervous affections which precede or accom-
pany abortion. They arc also of much benefit in cases where
we have considerable and protracted discharge, with trifling
pains, as the uterus is not contracting sufficiently to expel the
ovum,  but merely to separate  vessels,  and excite hemorr-
hagia.   By suspending for a time its action, it returns after-
wards with more vigour and perfection,  and finishes the pro-
cess.  But  when the process is going on regularly, opiates
will only tend to interfere with it, and prolong the complaint.
   It was, at one time, a very frequent practice to endeavour,
with the  finger or  small  forceps,  to extract the foetus and
placenta, in order to stop the dischai'ge.  Puzos strongly
opposed this practice, and  it is now very properly given up
as a general rule. I do not wish, however, to be understood
as altogether forbidding manual assistance ;  but I am much
inclined to consider it  a useful precept,  not to be hasty in at-
tempting to extract the ovum.  If the discharge be protract-
ed, and the membranes entire, we may, if the situation of the
patient require it, sometimes accelerate expulsion, by evacuat-
ing the liquor amnii.  But if the pregnancy be not advanced
beyond the fourth month,  it will be better to trust to smart
clysters, and restrain the hemorrhage by means of the plug.
We thus have a greater likelihood of getting all the ovum oft'
at once, and may excite the action by gently dilating the os
uteri, and moving the finger round  it.  If the membranes
have given way, and the foetus be still retained, we may, by
 insinuating a finger within the uterus cautiously, hook it out;
 or, in many cases, it  will  be found partly expelled through
 the os uteri, and may  easily be helped  away.  But the most
 tedious  and troublesome case generally is that in which the
 foetus has been expelled, but the secundines are still retained.
 Now, we never can consider the patient as secure from he- 
252
morrhage until these be thrown off, and therefore she must
be carefully watched, especially when gestation is  consider-
bly advanced.  In a great majority of instances, the uterus,
within a few  hours, contracts and expels them.  But in some
cases, the hemorrhage does become profuse, and there is little
disposition to separate them.  By stuffing the vagina,  we
shall often find that the discharge is safely stopped, and  the
womb excited to act in a short time.  But if  we be disap-
pointed, or the symptoms  urgent, the finger must be intro-
troduced within the uterus,* and the remains  of  the  ovum
slowly detached by very gentle motion;  and we must be very
careful not to  endeavour to pull away the secundines until
they be fully  loosened, for we thus leave part behind,  which
sometimes gives a great deal of trouble ;  and farther, if we
rashly endeavour to extract,  we irritate the uterus, and  are
apt to excite inflammation, or a train of hysterical, and some-
times fatal symptoms.  It is these two circumstances which
make me cautious in  advising manual assistance; and, for-
tunately, the  proportion of cases requiring it is not great in
abortion at an early period.
  When part of the ovum is left, or the whole of the secun-
dines are retained, then we have  another danger besides he-
morrhage ; for, within a few days, putrefaction comes  on,
and much iri'itation is given to  the system, until the foetid
substance be expelled.   Sometimes, if gestation  have  not
been far advanced, or the piece  which is left is not very large,
it continues to come away in small  bits for many months;
and during the whole  time, the woman is languid, hysterical,
and subject to  irregularities of the  menstrua, very often to
obstruction.  But more frequently the  symptoms  are very
acute,  we have loss  of appetite, prostration  of strength,
tumid or tender belly, frequent, small,  and sharp pulse,  hot
and parched state of the skin of the hands  and feet, nocturnal
sweats, and  various hysterical symptoms.   The  discharge
from the vagina is abominably foetid, and  hemorrhage some-

 *  In some instances, the half of the secundines will be found in the vagina,
and the other half still  in the uterus.  In this case, all that is necessary is
gently to bring them out. 
253
times occurs to a violent degree.  The treatment of this will
hereafter be pointed out.
  From these observations we may see, upon the one hand,
the impropriety of allowing the  secundines to remain  too
long in  the uterus; and, on the other, the danger of making
rash or  unnecessary attempts to extract, by which we irritate
the uterus, and tear the placenta, which is almost always pro-
ductive  of troublesome consequences.  I now return to the
consideration of the usual progress of abortion. The stomach
very soon suffers, and becomes debilitated, producing a gene-
ral languor and feebleness, with a disposition to faint, which
seems in  abortion, to depend more  upon this cause  than
directly upon loss  of blood.   Indeed, the hemorrhage pro-
duces both slighter and less permanent effects in  abortion
than at  the full time, although less blood may have been lost
in the latter, than in the former case, for the vessels are smaller
and the discharge  is not so  sudden.   There is still another
cause for this; namely, that the action of the uterus is less in
the early than in the late months.  Now, we know that the
effect of hemorrhage from  any organ is, cceteris paribus, in
proportion to its degree of  action.  Hence the discharge is
less dangerous than at the full time, and still less in menorr-
hagia than in abortion.
   The effect of abortion on the stomach seems to be in  pro-
portion  to the period at which  it takes place, being greater
when it occurs before the  fourth  month than after it.   The
effect, though distressing, and often productive of alarm, is
nevertheless beneficial, lessening the action of the vessels in
the same way with digitalis, the  use  of  which is  improper
when this condition is present.  The strength of the pulse is
much abated ; sometimes it becomes slower; but in general it
remains much as  formerly in point  of frequency; we are
therefore  not  to be too anxious  in removing this condition,
which restrains hemorrhage ; yet as it may go beyond due
bounds, and produce dangerous syncope, we must check it in
time.   We must likewise be very attentive to the state of the
discharge when this affection is considerable, for if, notwith-
standing this, the  hemorrhage should continue, it will pro- 
254
 duce greater and more immediately hurtful effects than if this
 were absent.
   The best method of abating this sinking and feebleness, is
 to keep the body perfectly at rest, and the head low. If neces-
 sary, we give small quantities of stomachic cordials, such  as
 a little tincture of cinnamon, or  a few drops of ether in a
 glass of aerated water; or we  may  give a little peppermint
 water, with fifteen  drops  of  tincture of  opium.  In urgent
 cases, Madeira wine or undiluted brandy may be given; but
 these are not to be frequently repeated, and are very rarely
 necessary.  Large doses of opium are also useful.
   Sometimes, instead  of  a feeling of sinking and faintness,
 the  fibres  of the stomach are thrown into  a spasmodic con-
 traction, producing sudden and violent pain.  This is a most
 alarming symptom, and may kill the patient very unexpect-
 edly. It is to be instantly attacked by a mixture of sulphuric
 ether and tincture of opium, in a full  dose, whilst a sinapism
 is applied to the epigastric region ; but if, when this pain oc-
 curs, there be symptoms of approaching convulsions, then bleed-
 ing should precede the anodyne, and no ether should be given.
   Spasms  about the intestines are more frequent, and much
 less  dangerous.  They  are very  readily relieved by thirty
 drops of tincture of opium, in a desert-spoonful of aromatic
 tincture, or forty drops of the tincture of hyoscyamus in two
 tea-spoonfuls of the compound tincture of lavender.
  These disagreeable symptoms which I  have described, for-
 tunately do not often attend abortion; but  the  process goes
 on safely,  and without disturbance.   In  this  case, after it is
 over, we only find it necessary to confine the person to bed
 for a few days, as getting up too soon is apt  to produce debili-
 tating discharge.   We must  also, by proper treatment, re-
 move any morbid symptoms which may be present, but which,
 depending  on the  peculiarities of individuals, or their pre-
vious state of health,  cannot here be specified.  When the
patient continues weakly, the use of the cold bath, and some-
times of Hie bark, will be of  much service  in restoring  the
 strength"; a'ntr, in future pregnancies, great care must he ta-
ken that abortion may not happen again at the same period. 
255
               § 36. UTERINE HEMORRHAGE.

  Of all the incidents  to  which a  pregnant woman is exr
posed, none is more alarming or troublesome than uterine
hemorrhage, when it occurs in the advanced stages of gesta-
tion, or after the delivery of the child.  This, from its ex-
tent and impetuosity, has aptly been  called a flooding; and
from the frequency of its occurrence,  it must be extremely in-
teresting to every  practitioner.
  The ovum  is connected to  the uterus by means of a vast
multitude of delicate vessels, which pass almost at every point
from the one to the other.  These  vessels are  large where
the placenta is attached ; smaller where they pass into the de-
cidua.
  As the ovum corresponds exactly to the inner surface of
the uterus, and is  in close  and intimate contact  with it, we
find, that as long as this union subsists, the vessels, notwith-
standing their delicacy,  are  enabled to transmit blood  with-
out effusion.  But whenever a separation of the one from the
other takes place, then these  vessels  are  either directly
torn ; or, even  supposing them to extend a little, they must
be ruptured by their own action, or by the force of the blood
which they receive and  circulate.  When  this happens, an
extravasation or discharge must be  the consequence, which
will be greater or smaller in proportion to the number and
magnitude of the  vessels  which have given way, and the
strength of the action, wliich exists in  the sanguiferous
system.
  The  membranes are  never so full of water as to  be put
upon the stretch, and therefore they  cannot forcibly distend
the  womb, and make pressure on  its inner surface.  The
womb again, during gestation,  does not embrace the  mem-
branes tightly, so as to compress them.  Hence it is evident,
that when  rupture first  takes  place, no resistance  can, by
the  action of the one upon the other, be afforded to ffre flow
of   the blood.   The consequence  of uterine.. htmomiiageV ^
when considerable, is,  that  the force of the'circulation  is
diminished;  faintness,  or  absolute syncope  being induced-;. 
256
 The blood in this state  flows  more feebly; coagulation  is
 allowed to take place, and the paroxysm is  for the present
 ended.  This  coagulation, in slight cases, may take place
 even without the intervention of faintness.   Re-union, how-
 ever, when the separation is extensive,  and the coagulum
 considerable,  cannot be expected to take place ; and there-
 fore, when the clot loosens, a return of the hemorrhage is in
 general to be looked for.
   One or more copious discharges of blood  must injure the
 functions of the uterus, and ultimately destroy altogether the
 action of gestation.  This tends to excite the muscular action
 of the uterine fibres; and by their contraction two effects
 will be produced.   The uterine vessels will be diminished in
 their diameter  or capacity, and  the  whole  surface of the
 womb pressing more strongly upon the ovum, a greater re-
 sistance will be given  to the flow of the blood.
   Thus it appears, that nature attempts to save the patient
 in two ways.   First, by the induction of a state of faintness,
 or sometimes  of complete syncope,  which tends  to check the
 present attack.   Secondly, when the hemorrhage is so great
 or obstinate as to prevent  any possibility of the woman going
 safely to the full time, such  effects  are produced as tend to
 establish muscular contraction, and  accelerate  expulsion.
 This double process ought, in  all our reasonings, to be held
 in viewr.
   Uterine contraction is of two kinds, which may be called
 permanent and temporary.   The permanent is that continued
 action of the individual fibres by which the uterus is rendered
 tense, so that  it feels  hard if the hand be introduced into its
 cavity.  The  temporary is that greater contraction which  is
 excited at intervals for the expulsion of the foetus, producing
 what are called the pains  of labour.
   In those cases where nature effects a cure by expulsion, or
 the production of labour, it is chiefly to the permanent or to-
 nic contraction  that we are indebted for the stoppage of he-
 morrhage ;  because this contraction lessens  the size of the
'vessels,- and keeps up  a firm pressure of the uterine surface
 up'bn the ovum, until the pains have accomplished the expul- 
257
sion or delivery of the child.  The pains alone could not do
this good; for coming only at intervals, their effect would
be fugacious.  On the other hand, the permanent contrac-
tion would  not  be adequate  to the purpose, without  the
pains, for these temporary paroxysms excite this action  to a
stronger degree, and, by ultimately forcing down the child,
accomplish delivery before the powers of the uterus be worn
out.
   Such are the steps by which the patient is naturally saved.
But we are not to expect that these, shall, in every instance,
or in a majority of instances, take place at the proper time,
or in the due degree.  The debility and syncope may go too
far;  or the clots  may not form in  proper  time, or  may
come away too soon,  or too easily.  The  action of gestation
may continue, notwithstanding the violence of the hemorrhage,
thus preventing the accession of  muscular contraction ; or be-
 fore this contraction be  established and  the  child expelled,
 the discharge may have been so  great  and constant as to ren-
 der the efforts of^he  womb  weak and inefficient, and by still
 continuing, may destroy them altogether.
   These circumstances  being considered, it will be evident,
 that  although when the  injury is small, and the discharge
 trifling, nature may permanently check it; or, in more seri-
 ous  cases, may  preserve the woman by the expulsion of the
 child; yet we cannot, with prudence, place  our whole reli-
 ance on her unassisted operations.
    There is also another circumstance relating to a particu-
 lar species of flooding, which renders the accomidishment of
 a natural cure  or escape still  more doubtful. This is, that
 the placenta is sometimes attached to the os uteri, which ne-
 cessarily must produce a hemorrhage whenever the cervix
 comes to be fully developed, and the mouth to open.
    The  vessels going  to the  placenta are much larger than
  those which enter the decidua ; and therefore, if part  of the
  placenta be detached, the quantity and  velocity of the dis-
  charge must be greater, and the effects more to be dreaded,
  than when a part of the decidua alone is separated.   If the-
  placenta be fixed near the cervix uteri, and a part of it be<le- 
25S
  tached, then the blood which is effused will separate the mem-
  branes down to the  os uteri, and a profuse hemorrhage will
  appear.  But sometimes, if it be fixed to the fundus uteri, the
  blood may be confined, especially if the separation have been
  trifling, and a coagulum will be formed exterior to the mem-
  branes, the lower part of which  will still adhere to the ute-
  rus ; or if the central  portion of the placenta have been de-
  tached, a collection  of blood  may be formed behind it, but
  may not  extend beyond its circular margin.   But  if the pla-
  centa he  placed over the os uteri, then the case is different,
  profuse discharge will take place, sinking the whole system,
  and very much  enfeebling the uterus itself, so that when ute-
  rine contraction does come on, it will be weak, and incapa-
  ple of  speedily effecting expulsion;  even although the con-
  traction  should be brisk  and  powerful, it cannot, owing to
  the structure of the  placenta, do the same  good as in other
  cases of flooding;  and therefore, in every  instance, much
  blood will be lost, and in many, in very many, the patient,
  if  we trust to this contraction alone, will nerish.  Contrac-
  tion can  only be expected in this case to do good, when it is
  powerful, and the pains come  on so briskly  as speedily to
  empty  the uterus, at the  same time  that coagula shut the
  mouths of the placental vessels at the unsupported part.
    It has been  a common  opinion, that flooding proceeded
  always from the detachment  of  a part of the placenta; but
  this point is not established.*   In several cases of uterine he-
  morrhage, the placenta will be found attached to the fundus
  uteri;  and we cannot suppose that in all of these, the whole
  extent  of the membranes, from the placenta to the os uteri,
  has been  separated: yet this  must happen before the dis-
  charge can in these circumstances appear. We can often ac-

   •  Long ago, Andrea Pasta questioned the opinion,  that flooding was
 always produced by separation of the placenta.  Vide Discorso del flusso di
 sangue, &c.  We 'are  not, however,  to suppose, that hemorrhage does not
 proceed from detachment of the placenta in any instance when it is placed
*high up,  but only that it is' a rare occurrence. When  the stream is rapid
 and profuse, we have every reason to suppose that part of the placenta is se-
 parate^;  but if we have occasion to deliver, it will generally be found, that
 it is  placed close  by the cervix uteri, or at least not very fr.r from it. 
259
count for the hemorrhage, by supposing a portion of the de-
cidua to be detached; and  we  know that the vessels about
the cervix are sufficiently able to throw out a considerable
quantity of blood, if their mouths be open. But  in most cases
of profuse hemorrhage, we shall find,  that the placenta is at-
tached near the os uteri, and more or less of it separated.
  It is possible for blood to  be effused in consequence of de-
tachment of part of the ovum, and yet it may not  be discharged
by  the os  uteri.*   This detachment may  be  produced by
fatigue, falls, blows, &c. and the effusion  is accompanied with
dull internal pain at the spot where it takes place.  This pain
is something like  colic, or like pain  attending the approach
of the menses.  The part of the womb where the extravasa-
tion takes  place, swells gradually, and  the uterus in  a short
time feels larger.  If the quantity be considerable, the size in-
creases, the uterus  is firmer and tenser, as well as larger, the
strength diminishes, and even faintings  may come on.  In
course of time, weak slow pains are felt, but if  the injury be
great, these decline as the weakness increases.  They may or
may not be attended with the discharge of coagula from the
os uteri.   In such  a case, it is evident, that nothing  but de-
livery can  save the mother.  But if no bad effect is produced,
and the separation  is not extensive, the accident may not be
discerned or suspected, at least till  after the  child is born,
when often a great quantity of blood is evacuated without af-
fecting the pulse or strength, which it would do,  did  it come
recently from the vessels of the uterus.
  Let us next consider the causes giving rise to hemorrhage
in various degrees; and the first I shall mention is external
violence, producing a separation of part of the ovum.  As the
ovum and  uterus correspond exactly to  each other, and are,
in  the advanced  stages  of gestation,  composed of pretty
pliable materials, falls or blows do not produce laceration so
frequently  as might be supposed. In a majority of instances,
the effect is produced chiefly by the operation on the  vessels,
their action being violently and suddenly excited, and  rupture

  *  Vide Albinus Acad. Annot. lib. I. p. 58. Rccucil Periodique,  torn, ii. p.
15, and torn. Hi. p. I. 
260
 of their coats thus produced. When the ovum is mechanical-
 ly detached, the injury must have been considerable, and in
 general the foetus is destroyed.
   Fatigue, or much exertion may injure the action  of the
 uterus, and give rise  to premature expulsion, which in this
 case is generally attended with considerable discharge.  Such
 exertions are likewise apt, by their effect on  the circulation,
 to operate on the vessels  passing  to the ovum, and produce
 in them a greater degree of activity than they are capable of
 sustaining without rupture.  It is, therefore, very properly
 laid down as a rule of practice, to forbid pregnant women to
 undergo much fatigue, or exert any great  muscular action :
 and wherever this rule has been departed from, especially by
 a patient of an irritable or of a plethoric  habit, it behoves the
 practitioner to attend carefully to the first appearance of in-
jury, or to the first symptoms of decay in the uterine action*
 Rest, and an opiate will upon general principles be indicated,
 and when the circulation is  affected, or  we apprehend in-
 creased action about the uterine vessels,  venesection must be
premised, and the patient  kept cool and tranquil.
  Violent straining at stool, or strong exertions of the abdo-
 minal muscles, made in lifting  heavy  bodies, or in stretch-
 ing to a height, or frequent and  continued stooping, may all,
by compressing the womb, cause separation. For the greatest
effect will be produced where the resistance is least, or the
support smallest, which is at the under  part of the  uterus,
and there rupture will  be apt to take place.
  A preternatural degree of action in  the  a essels going to
the placenta or decidua, must be dangerous, and likely to pro-
duce rupture and extravasation.  This may either be connect-
ed  with  a general state  of the vascular system,  marked by
plethora, or by arterial irritation; or it may be more imme-
diately dependent on the state of the uterus itself.
  When the woman is plethoric, or when the action  of the
vascular system is -increased, it is natural to suppose, that the
effect will be greatest on those parts of the womb which are
in the highest state of activity.   These are chiefly two; the
part to which the placenta is attached, for there the vessels 
261
are large and numerous; and the cervix and os uteri, because
there the greatest  changes are going forward.  At one or
other of these two places, rupture is most likely to take place,
and it will happen still more readily if the placenta be attach-
ed at or near to the cervix.  It may be excited either by too
much blood  circulating permanently in the system, or by  a
temporary increase of the strength and velocity of the circu-
lation produced by  passion,  agitation, stimulants, &c. A ple-
thoric state is a frequent cause of hemorrhage  in the young,
the vigorous, and the active ; the decidua is separated, and a
considerable quantity of blood flows; perhaps the placenta  is
detached, and the hemorrhage is  more alarming.  In  some
cases the rupture is preceded  by  spitting of  blood, or  bleed-
ing  at the nose, and in these cases the lancet may be of much
 service.
   We sometimes find that extravasation is produced by an in-
 creased action of the uterine vessels  themselv es existing  as
 a local d iseasc.  In th is case, the patient fur some time before
 the  attack, feels a  weight and uneasy sensation about the hy-
 pogastric region, with slight  darting pains about the belly or
 back.  These precursors have generally been ascribed to a
 different cause; namely,  rigidity of the ligaments of the womb
 or of the fibres of the uterus itself.
   Spasmodic action about the os uteri, must produce a sepa-
 ration of the connecting vessels.  The causes giving rise to
 this in the advanced period of gestation, are not always ob-
 vious, neither can we readily determine the precise cases in
 which this action  excites flooding.  We should expect that
 the discharge ought always to be preceded by pain, but we
 know  that motion may take  place in some instances about
 the os uteri without much sensation; and, on the other hand,
  many cases of flooding, not dependent on motion of the ute-
  rine fibres, are attended with uneasiness or  irregular pain
  about the abdomen. This spasmodic action i» not unfrequent-
  ly produced by hanging pregnant animals.
     Whatever stops prematurely the  action of gestation, may ^
  give rise to a greater or less degree of hemorrhage.   For in
  Ihis case, the developement of the cervix takes place quickly, 
262
 and the ovum must be separated.  The quantity of the dis-
 charge* will depend upon the state of the circulation—the
 magnitude of the vessels which are torn—the contraction of
 the  uterus—and the care which  is  taken  of the  patient.
 Hence it follows as a rule in  every premature labour, more
 especially in its first stage, that we prevent all exertion, re-
 frain from the use of stimulants, and confine the patent to a
 recumbent posture.
   It sometimes happens, that  effective  contraction does not
 take place speedily after the action of gestation ceases, but a
 discharge appears.  This may stop by the induction of syn-
 cope, or the formation of clots.  The blood which is retained
 about the cervix and os  uteri putrefying, produces a very of-
 fensive smell.  Milk is secreted as if delivery had taken place,
 and sometimes fever is excited. In this state the patient may
 remain for some days, when the hemorrhage is renewed, and
 the patient may be lost if we do not interfere.
   Some undue state of action about the os uteri, removing, or
 ceasing  to  form that jelly which  naturally ought to be se-
 creted there, is another  cause.
   This is generally productive of a discharge of watery fluid,
 tinged with  blood;  and if the patient be not careful, pure
 blood may be thrown out in considerable quantity.   It may
 even happen, that  the   hemorrhage, under certain  circum-
 stances, may prove fatal; and yet, upon dissection, no separa-
 tion of the  ovum be discovered, the discharge taking place
 from the vessels about the os uteri itself.f
   In some instances, where a portion of the placenta has been
 detached, I have observed, that near the separated part, the
 structure of the placenta was morbid, being hard and gristly.
 In these cases, I could not detect any other cause of separa-

  * In those cases where the  contraction becomes universal and effective,
we have httle discharge, and the patient is merely said to have a premature
labour; but if the contraction be partial, and do  not soon become effective,
then  we  have considerable discharge, and the  patient is said to have a
flooding.
  t; Vide a case in point, by M. Heinigke, in the first volume of Brewer's
 Biblioth. Germ. 
263
 tion, and suppose that by the accidental pressure of the child
 upon the indurated part, the uterus may have been irritated.
   The insertion of the placenta over the os uteri,* may give
 rise to flooding in different ways.
   The uterus and  placenta may remain in contact until the
 term of natural  labour, the one adapting itself  to the other;
 but whenever the os uteri begins to dilate, separation and con-
 sequent hemorrhage  must take place.   It is rare, however,
 for the accident to be postponed so long.  In general, at an
 earlier period,  in  the eighth or by the middle of the ninth
 month, wre find that either the uterus and placenta no longer
 grow equally, in consequence of which, the fibres about the
 os uteri are irritated to act; or so much blood as must neces-
 sarily, in this situation,  circulate about the cervix uteri, in-
 terferes with its regular actions, and induces premature con-
 traction  of its fibres, with  a consequent  separation of the
 connecting vessels.
   In  order to ascertain whether the hemorrhage  proceed
 from this  cause, we ought  in every case to which we are
 called, carefully to examine our patient.   The introduction
 of the finger is  sometimes  sufficient  for this  purpose, but
 frequently  it may be necessary to carry the whole hand into
 the vagina.
   If the placenta present, we shall feel the lower part of the
 uterus  thicker than usual, and the child  cannot be so dis-
 tinctly perceived to rest upon it.   This  is  ascertained  by
 pressing with the  finger on  the fore part  of the cervix, be-
 twixt the os uteri and bladder, and  also a little  to either
 side.f

  * So far as I have observed, uterine hemorrhage, when profuse, is pro-
duced most frequently by this cause ; at least two-thirds of those cases re-
quiring dehvery, proceed, I think, from the presentation  of the placenta;
and in the majority of the  remaining third, it will be found attached near to
the cervix.  Most of those hemorrhages, which are cured without delivery,
proceed from  the detachment of the decidua alone, or of a very small portion
of the placenta, which has been separated under circumstances favourable
for firm coagulation.
  ■f When a large coagulum occupies the lower part of the uterus, we may
be deceived if we trust to external feeling alone, without introducing the 
264
  If the os uteri be a little open, then by insinuating the fin-
ger, and carrying it through the small clots, we may readily
ascertain whether the placenta or membranes present, by at-
tending to the difference which exists betwixt them.   But in
this examination, we must recollect, that only a small portion
of the edge of  the  placenta may present and  this may not
readily be felt at first.
  To conclude  this part of the subject,  I remark in general,
that hemorrhage from the uterus is not merely arterial, but
also veinous, and the orifices of these latter vessels are ex-
tremely  large.   Almost immediately after conception, the
veins enlarge and dilate, contributing greatly to give to the
uterus the doughy feel which it possesses. In the end of gesta-
tion the  sinuses  are of immense size, and their extremities
so large that in many places they will admit the point of the
finger.   Now,  as all the veins communicate more freely than
the arteries, and as they have in the uterus no valves, we
can easily  conceive the  rapidity with which  discharge will
take place,  and  the necessity of encouraging coagulation,
which checks veinous still more readily than arterial hemorr-
hage.
  In whatever wray flooding is produced, it has a tendency
to injure or  disturb gestation,  and to excite expulsion ; but
these effects may be very slowly accomplished,  and in a great
many instances may not take place in time to save the patient
or her child. Having already noticed those changes produced
on the womb itself by hemorrhage, and the danger of trusting
to them.for the recovery of the patient, I will  not recapitu-
late, but proceed very shortly to mention the effects produced
on  the system at large.
   During the continuance of the hemorrhage, or by the re-
petition of the  paroxysms,  if this be allowed  to take place,
certain alterations  highly important are taking place.  There
is much less blood circulating than formerly;  and this blood,
when the hemorrhage has been frequently renewed,  is less

finger within the os uteri.  If the uterus have its usual feel, and the child
be felt distinctly throught it, then we are sure that, however near the pla-
centa may be to the os uteri, it is not fixed exactly over it. 
265
stimulating in its properties, and less  capable of affording
energy to the brain and nerves.  The consequence of this is,
that all the actions of the system must be performed  more
languidly,  and with less strength.  The body is much more
irritable than formerly,  and  slight  impressions produce
greater effects.   This  gives  rise to many hysterical, and
sometimes  even to convulsive  affections.  The stomach can-
not so readily digest the food—the intestines become  more
sluggish—the heart beats more feebly—the arteries act with
little  force—the muscular fibres contract weakly—the  whole
system descends in the scale of action, and must, if the  ex-
pression be allow able, move in an inferior sphere.  In this
state, very slight additional injury will sink  the  system ir-
reparably—very trifling causes w ill unhinge its actions, and
render them  irregular.  If the debility be carried to  a  de-
gree  farther, no care can recruit the system—no means can
renew  the vigour of the uterus.  We may  stop the hemorr-
hage, but recovery will not take place.   We may deliver the
child, hut the womb will not contract   If when the system
is debilitated by hemorrhage, some irritation be conjoined,
then  the vascular action becomes more or less irregular, and
 an approximation is made to a state of fever.  The pulse  is
 feeble, but sharp ; the skin  rather warm; and  the tongue
 more or less parched.  This state is dangerous, both as it
 exhausts still more a  system already very  feeble, and also
 as it tends to renew the hemorrhage.   It will often be found
 to depend upon slight uterine irritation, upon accumulation
 in the bowels, upon pulmonic affections, upon muscular pain,
 or upon the  injudicious application of stimuli.
    Such organs as have been previously disposed to disease,
 or have been directly or  indirectly injured during the  con-
 tinuance of protracted flooding, may come to excite  irrita-
 tion, and give considerable trouble.
    An acute attack of hemorrhage generally leaves the pa-
 tient in a state of simple weakness;  but if the discharge  be
 allowed to be frequently conjoined, and the case thus  pro-
 tracted, some irritation often comes to  be produced, which
    VOL. I.                      M M           < 
266
adds to the danger, and excites, if the patient be not delivered,
more speedy returns.
   A woman seldom suffers much in a first attack of hemorr-
hage.  If she be stout  and plethoric, she may lose a great
quantity of blood and yet to appearance not be greatly in-
jured.  The hemorrhage may come  on in every different
situation; in  bed she may awake suddenly from a dream,
and feel herself swimming in blood; or it  may attack her
when walking; or may  be preceded by a desire to make
water, and she is surprised to find the chamber-pot half filled
with blood.   She recovers from her consternation ; perhaps
in spite of every injunction, she walks about as usual, and
finds  no bad effect from  motion; the  feeling of heaviness
which may have preceded the accident is gone, she is lighter
and better than she was before it, and hopes all is well; but
in a few days the hemorrhage is repeated, and  again stops;
at last, after one or two attacks, for the  time  is  uncertain,
the os uteri becomes soft, and opens a  little, perhaps without
pain,  or she feels dull slight pains, which, however, give her
very little uneasiness. This state may take place early, and
Without dangerous debility ; it may take place in the second
or third attack; or possibly the hemorrhage may never have
entirely ceased, continuing  for a day or two like a flow of
the menses, and then  being suddenly increased, or flowing
in a torrent.   But although this state may take place with-
out alarming  debility, it may also, and that very suddenly,
be attended with the utmost danger, or may be accompanied
with so much hemorrhage as to prove  absolutely fatal.  The
patient is found without a drop of blood in her  face, the ex-
tremities  cold, the pulse almost gone,  the stomach unable to
retain drink.  She is  in the last stage of weakness, but it is
not the weakness produced by fever or disease, for we find
her voice  good and generally the intellect clear.  The he-
morrhage has stopped, and a young man  would suppose it
still possible for her to recover.  But  although not a drop of
blood is afterwards lost, the debility  increases, the pulse is
quite gone, she breathes with difficulty, and gives long sighs,
wavers in her speech, and in a short time expires. 
267
    We may lay  it down as a general observation, that few
 cases of profuse hemorrhage, occurring in an advanced stage
 of gestation, can  be cured without delivery or the expulsion
 of the child. For when the discharge is copious or obstinate,
 the placenta is generally separated, sometimes to a very con-
 siderable extent,  and a re-union, without  wliich the woman
 can never be secure against another attack, can rarely be ex-
 pected.   If  the placenta present, the hemorrhage, although
 suspended, will yet to a certainty return,  and few  shall sur-
 vive if the child be not delivered.
   But in those cases where only a portion of the decidua, or
 a little bit of the margin of the placenta* has been  detached,
 and the  communicating vessels opened, either by a state of
 over-action in the vascular system, or by too much blood in
 the vessels, or by some mechanical exertion, if proper care be
 taken, the hemorrhage may be completely and permanently
 checked; or if it should return, it may he kept so  much un-
 der, or may consist so much of the watery discharge from the
 glands about the os uteri, as neither to interfere with gesta-
 tion, nor injure the constitution;  yet it is to  be recollected,
 that even these cases of flooding may sometimes proceed to a
 dangerous degree, requiring very active and decided means
 to be used;  and in no case can the patient be considered as
 safe,  unless the utmost  care and attention be paid to her con-
 duct.
  It would thus appear, that  some hemorrhagies almost in-
 evitably end  either in the delivery of the child, or the death
 of  the parent; whilst others may be checked or moderated
 without an operation.  A precise diagnostic line, liable to no
 exceptions, cannot be drawn betwixt these cases ; and there-
 fore,  whilst we believe that rapid and profuse hemorrhagies,
 which indicate the rupture of large  vessels, can seldom be
 permanently checked, we still,  prov ided the placenta do not
 present, are not altogether without hopes of that termination,

  * In this case, after labour is over, we may discover the separated por-
tion by the difference of colour; it is generally browner and softer than the
rest. 
268
which  is  more desirable  for the mother, and safer  for the
child, than premature delivery.   In slighter cases, our hope
is joined with some degree of confidence.
  A second attack, especially if it follow soon after the first,
and  from  a  slight  cause, or  without any apparent  cause,
greatly diminishes the chance of  carrying the woman to a
happy  conclusion without manual interference.
  In forming our opinion respecting the immediate danger
of the  patient, we must consider her habit of body, and the
previous state of her constitution.   We must attend to the
state of the pulse, connecting that in our mind with the quan-
tity and  rapidity of  the discharge.   A feeble pulse, with a
hemorrhage,, moderate  in regard  to quantity and velocity,
will, if the patient have been previously in good health, gene-
rally be found to depend on some cause, the continuance of
which  is  only temporary.   But when  the weakness of  the
pulse proceeds from profuse or repeated  hemorrhage, then
although  it may  sometimes be rendered still more feeble by
oppression, or feeling of sinking at the stomach;  yet, when
this is relieved, it does not become firm. It is easily com-
pressed, and easily affected  by motion;  or, sometimes, even
by raising the  head.
  If the paroxysm is to prove fatal, the debility increases—
the pulse flutters—the whole body becomes cold  and clam-
my—the breathing  is  performed with a sigh—and syncope
closes the scene.
   If irritation be conjoined with hemorrhage, then the pulse
is sharper, and, although death be near, it is felt more dis-
tinctly than when irritation  is absent.
   The termination  in  this  case is often more sudden than a
person, unacquainted with the effect of pain and irritation on
 the pulse, would suppose.   For when the pulsation  is dis-
 tinct, and even apparently  somewhat firm, a slight increase
 of the discharge, or  sometimes an exertion without discharge,
 speedily stops it, the heat departs, and the patient never gets
 the better of the attack.
   We must likewise remember, that a discharge, which takes
 place gradually, can be better sustained than a smaller quan- 
269
tity, which flows more rapidly.  For the vessels in the former
case come to be accustomed to the change, and are able more
easily to accommodate themselves to the decreased quantity.
But when blood is lost rapidly, then very speedy and univer-
sal contraction is required in the  vascular system, in order
that it may adjust itself to its contents, and  this is always a
debilitating process.   The difference too betwixt the former
and the present condition of the body, is rapidly produced,
and has the same bad effect as if we w ere instantly to put a
free-liver upon a very  low and abstemious diet.
   In  all cases of flooding, we find, that during the paroxysm,
the pulse  flags, and the person  becomes faint.   Complete
syncope may even take place, but this in many.cases is more
dependent on  sickness or oppression at the stomach, than on
direct loss of blood.  In delicate and irritable habits, the
number of fainting fits may be great, but unless  the patient
be much exhausted, we generally find that the pulse returns,
and the strength recruits.  The prognosis here must depend
greatly on the quantity and velocity of the discharge ; for  it
may happen, that the first attack of hemorrhage may produce
a syncope, from which the patient is never to recover.
    When we  are  called to a patient recently attacked with
 flooding, our most obvious duty is immediately to restrain the
 violence of the discharge; after which we can take such  mea-
 sures as the nature of the case may demand, either for pre-
 serving gestation, or for hastening the expulsion of the child.
    A state of absolute rest, in a horizontal posture, is to be en-
 forced with great perseverance, as the first rule of  practice.
 By rest alone,  without any other assistance, some hemorr-
 hages may be cured;  but, without it, no woman can be safe.
 Even after the immediate alarm of the attack is over, the
 woman must  still recollect her danger.   She should be  con-
 fined to  bed, upon a  firm  mattress for several days, and
 ought not to leave her apartment  for a much longer period.
    In general, the patient has gone to bed before we are call-
 ed ; and, perhaps, by the time that we  arrive, the bleeding
 has  in  a great measure  ceased.  The partial unloading  of
 the vessels, produced by the rupture, the induction of a state 
270
approaching to syncope in consequence of the discharge, the
fear of the  patient, and a horizontal posture, may all  have
conspired to stop the hemorrhage.
  The immediate alarm from the flooding having subsided,
the patient often expresses herself as more apprehensive of a
premature labour, than of the hemorrhage, which she  con-
siders as over.  If the attack have been accompanied  with
slight abdominal pain, her fears are confirmed.  But we are
not to enter  into these views of the case;  we are to consider
the discharge as the prominent symptom, as the chief source
of danger.   We are to look upon the present abatement as an
uncertain calm ; and whatever advice we may give, whatever
remedies we may  employ, we are not to leave our patient un-
til we  have  strongly enforced on  her attendants the  danger
of negligence, and the necessity of giving early intimation
should the hemorrhage be renewed.  There is no disease to
which the practitioner can be called, in which he has  greater
responsibility than in uterine hemorrhage.  The most prompt
and decided  means must be used; the most patient attention
must be  bestowed ; and, whenever he  undertakes the man-
agement of a case of this kind, whatever  be the situation of
the patient,  he  must watch  her with constancy, and forget
all consideration  of gain and of  trouble.   His  own  reputa-
tion, his peace of mind, the life  of his patient, and that of
her child, are all  at stake.   I am doing the student the  most
essential service,  when I earnestly press upon his attention
these considerations.  And  when I intreat, implore him to
weigh well the proper practice to be pursued, the  necessary
care to be bestowed, I am pleading for the existence of his
patient, and for his own honour and happiness.  Procrasti-
nation, irresolution, or timidity,  have  hurried  innumerable
victims to the grave ; whilst the rash precipitation of unfeel-
ing men has only  been less fatal, because negligence is more
common than activity.
  I shall endeavour to point out  the proper treatment in the
commencement of uterine hemorrhage, and the  best  method
of terminating the case  when the patient cannot be conduct-
ed with safety to  the full time.   After  the patient is laid in 
271
bed, it is next to be considered how the hemorrhage is to be
directly restrained, and whether we may be  able to prevent
a return.   It is  at all times proper to ascertain exactly the
situation of the  patient by examination,  as we thus learn
the state of the  cervix and os uteri,  and  whether there
be any tendency to labour;  whether the discharge be stopped
by a coagulum in the mouths of the vessels,* or by a large
clot in the  upper part of the vagina; whether the  placenta
be attached to the os  uteri, or whether the membranes  pre-
sent.   We likewise endeavour to ascertain the quantity of
blood which has been lost—the rapidity with which it flowed—
the effect which it has produced upon the mother or child—
and the cause which appeared to excite the hemorrhage.
  The first remedy which,  upon a general principle, offers
itself to our attention, is blood-letting.  In those cases, where
the attack  has been produced by over-action of the vessels, or
a plethoric condition; or where it seems  to be kept up by
these causes, this remedy employed early, and followed by
other means, may be  effectual not only in  checking the pre-
sent paroxysm, but also in preventing a return.  By the time-
ly and decided use of the lancet much distress may be avoid-
ed, and  both the mother and the child  may be saved from
danger.  But we are  not to  apply the remedy for one state to
every condition; we must have regard to the  cause, and con-
sider how far the hemorrhage is kept up by plenitude or mor-
bid activity of the vessels. In those  cases where the attack is
not excited by, or connected with plethora, or  undue action
in the vascular  system, venesection is  not indicated.  We
have in these cases,  which are, I  believe, by far the most .
numerous,  other means of safely, and powerfully moderating
vascular action, without the detraction of blood, which in this
disease it ought to be a leading principle to save as  much as •
possible. Whatever lessens materially or suddenly the quan- ,

  * We may conjecture that this is the case, if we  find no clot in the vagina,
plugging the  os uteri.  We are not warranted to  thrust the finger forcibly
within the os  uteri, in this  examination ; or to rub away the small coagula
wliich may be formed within it, and which may be restraining the heoaarr-
hage. 
                           272

 tity of blood, must directly enfeeble, and call for a new sup-
 ply, otherwise  the system suffers for a long time.
   We shall find, that except under those particular circum-
 stances which I have specified, and where we have ground to
 believe, that the  rupture of vessels  has been dependent on
 their plenitude or over-action, the circulation may be speedily
 moderated by other means, and especially by the application
 of cold.   This is to be made  not  only by applying  cloths
 dipped in cold water to the back and vulva, but also by spong-
 ing over  the legs, arms, and even the trunk, with any cold
 fluid ; covering  the patient only  very lightly with clothes,
 and promoting a free circulation of  cold air, until the effect
 upon the vessels be produced.  After this we shall find no
 advantage, but rather harm from the further application of
 cold.  All  that  is now necessary, is strictly and constantly
 to watch against the application of  heat, that is,  raising
 the temperature  above the natural standard.
   The extent to which this cooling pain is to be carried, must
 de'pend upon circumstances.  In a first attack, it is in general
 to be used in all  its vigour; but where the discharge, either
 towards the end of this attack, or in a subsequent paroxysm,
 has gone so far as to reduce the heat much below the natural
 standard, the vigorous application of cold might sink the sys-
 tem too much.  In  some urgent cases it may even be neces-
 sary to depart from our general rule, and apply warm cloths
 to the hands, feet, and stomach. This is the case where the
 discharge has been excessive, and been suffered to  continue
 profuse or for  a  long time, and where we are afraid that the
 system is sinking fast, and  the  powers of life giving way.
 There are cases  in which  some nicety is required in deter-
 mining this point, and in these circumstances we must never
 leave our patient, but must watch the effects of our practice.
 This is a general rule in all hemorrhagies, whatever their
' case may have been, or from  whatever vessels the blood  may
 come.  A cold skin and a feeble pulse never can require the
 positive and vigorous application  of cold;  but, on the other
 hand, they do  not indicate the application of heat, unless they
 be increasing, and the strength declining.  Then we cau- 
273
tiously use heat to preserve what remains,  not rashly and
speedily to increase action beyond the present state.of power.
   Wheii an  artery is divided, it is now the practice to trust
for a cure  of the  hemorrhage to compression, applied by a
ligature.  We cannot, however, apply pressure directly and
mechanically to the uterine vessels, but  we  can promote
coagulation, which has the same immediate effect.  Rest and
cold are favourable to this process,  but ought only in slight
cases to be trusted to  alone.  In this country it  has been the
practice to depend very much upon the application to the
back or vulva, of cloths dipped in a  cold  fluid,  generally
water, or vinegar and water; but these are not always effec-
tual, and sometimes,  from the  state  of the patient, are not
admissible.
   Plugging the v agin a with a soft  handkerchief,* answers
every purpose which can be expected from them; and when-
ever a discharge takes place to sucli  a degree as to be called
a  flooding, or lasts beyond a  very short time, this ought to
be resorted to.  The advantage is so great and speedy, that
I am surprised that it ever should be  neglected.   I grant that
some women may, from delicacy or  other motives, be averse
from it; but every consideration must yield to that of safe-
ty : and it should be impressed deeply on the  mind of the pa-
tient, as well as of the practitioner, that blood is  most pre-
cious, and not a drop should be spilled which can be preserved.
Unless the flooding shall in the first attack  be permanently
checked, which, when the separated  vessels are large or nu-
merous, is rarely accomplished,  we may expect one or more
returns before expulsion can  be accomplished.  The more
blood, then, that we allow to be lost at first, the less able shall
the patient he to support the course  of the disease, and the

  *  The insertion of a small piece of ice in the first fold of the napkin, is at-
tended with great advantage, and has often a very powerful effect. Dr.
Hoffman employed the introduction of lint, dipped in solution of vitriol, but
this was rather as an astringent than a plug, and he does not propose it as a
general practice.  He considers, that he was obliged to have recourse ad
anceps et extremum  auxilium.—Vide Opera Omnia,  T. iv.  Leroux em-
ployed the plug more freely.—Vide Observations sur les l'ertes, 1776.
   VOL.  I.                          N N 
274
more unfavourable shall delivery, when it comes to be per-
formed, prove to her and to the child.   It is of consequence
to shorten the paroxysm as much as possible ; and, therefore,
when circumstances will permit, we should  make it a rule to
have from the first a careful nurse, who may he instructed in
our absence to use the napkin without delay, should the he-
morrhage return.
   But whilst I so highly commend, and so strongly urge the
use of the plug, I do not wish to recommend it to the neglect
of other means,  or in every situation.   In  the early attacks
of hemorrhage, when the os uteri is firm, and manual inter-
ference is improper, I know of no method more safe  or more
effectual  for restraining the hemorrhage and preserving the
patient.  But when the hemorrhage has been profuse, or fre-
quently repeated, and the  circumstances of the patient de-
mand more active practice, and point out the necessity of de-
livery, then the use of the plug cannot be proper.  If trusted
to, it may be attended with fatal and deceitful effects. We can
indeed restrain  the hemorrhage from  appearing outward-
ly ; but there have been instances, and  these instances ought
to be constantly remembered, where the blood  has  collected
Within the uterus, which, having lost all power, has become
relaxed, and been slowly enlarged with  coagula; the strength
has decreased—the bowels become inflated—the belly swelled
beyond its size in the ninth month, although the patient may
not have been near that period; and in these circumstances,
whilst an inattentive practitioner has perhaps concluded that
all was well with regard to the hemorrhage, the patient has
expired, or only lived long enough  to permit the child to be
extracted.  All practical  writers  warn us against internal
flooding; nay, so far do some carry their apprehension, that
they advise us to  raise the head of the child, and observe
whether  blood  or liquor  amnii he discharged*; an advice,
however, to which 1 cannot subscribe, because in those cases
where the membranes have given way, or been opened, the
head cannot be thus moveable,  nor these trials made, unless

  • Vide Dr. Johnson's System of Midwifery, p. 157, and Dr. Leake's Diseases
of Women, vol. ii. p. 280. 
275
we have waited until a dangerous relaxation has taken place
in the uterine fibres ; and if, on the other hand, we have de-
livery in contemplation, it is our object to confine the liquor
amnii as much as possible, until we turn the child.
   Besides using these means, it will also, especially  in a first
attack, and  where we have it not in contemplation to deliver
the woman, be proper to exhibit an opiate,(d) in order to
allay irritation ; and this is often attended with a very hap-
py effect.
   Such are  the most effectual methods  of speedily or imme-
diately stopping the  violence of the hemorrhage.  The next
points for consideration are, whether we can expect to carry
the patient  safely to the full time, and by what means we are
to prevent a renewal of the discharge.
   It may, I  believe, be laid down  as a general rule, that when
a considerable portion  of the decidua  has  in the seventh
month, or later, been separated, the hemorrhage, although it
may  be checked, is  apt to return.  When a part of the pla-
centa has  been detached, and more especially if that  organ
be fixed over the os uteri, gestation  cannot continue  long;
for either such injury  is  done to the uterus as produces ex-
pulsion and a natural cure, or the  woman bleeds to  death,
or we must deliver, in order to prevent that dreadful termi-
nation.
   If the discharge be in small quantity,  and have not flowed
with  much rapidity—if it stop soon or easily—if no large clots
are formed  in the vagina—if the under part of the uterus has
its usual feel, showing that the placenta is not attached there,
and that  no large coagula are  retained within the os uteri—
if the child  be still alive—if there be no indication of the ac-
cession of labour—and if the slight discharge  which is still
coining  away  be chiefly  watery, we may  in these circum-
stances conclude that the vessels  which have given way are

  (d) In the exhibition of opiates in uterine hemorrhages generally, we
would  advise their combination with ipecacuanha, in the proportion of half
a grain of the latter to about two grains of opium ; to be repeated more or
less frequently, according to the circumstances of the case.  Vide Barton's
Edit, of Cullen's Mat. Med. Vol. ii. p. 334, and Chapman's Edit, of Burns. 
276
 not very large, and have some reason to expect, that by care
 and prudent conduct,  the full period of gestation may be ac-
 complished.  It is difficult to say, whether in this event the
 uterus forms new vessels to supply the place of  those which
 have been torn, and whether re-union he effected by the incor-
 poration of these with corresponding vessels from the chorion.
 In the early months we know that re-union may take place;
 but when, in the advanced period  of pregnancy, the decidua
 has become very thin, soft, and almost  gelatinous, it is not
 established that the circulation may be renewed. At all events,
 we know that the power of recovery or reparation is very
 limited, and can only be exerted  when the  injury is  not ex-
 tensive.  The means  for promoting re-union of the uterus
 and decidua, are the same with those  which we  employ for
 preventing a return of the hemorrhage ;  and these we advise,
 even when we have little hope of effecting re-union, and mak-
 ing the patient go to the full time, because it  is our object
 to prevent as much as  possible the loss of blood.
   When the  placenta is partly separated, all  the  facts of
 which  we are in possession are against  the opinion that re-
 union can take place.   If the spot be Very trifling, and the
 vessels not large, we may have  no return of the bleeding;  a
 small  coagulum may permanently restrain it;  but if the sepa-
ration be greater,  and the  placenta attached low down,  or
 over the os uteri, the patient cannot go to  the full time, un-
 less that be very near  its completion.  We judge of the case
 by the profusion and violence of the discharge; for all great
 hemorrhagies  proceed from the separation  of the placenta:
 and by the feel of the lower part of the uterus,—by the quan-
 tity of clots, and the obstinacy of the discharge, which  may
 perhaps require  even  actual syncope to stop the paroxysm ;
 a circumstance indicating great danger.
   The best way by which we can prevent a return,  is to mo-
 derate the circulation,  and keep down the actions of the sys-
 tem to a proper level with the power.  The propriety of at-
 tending to this rule will appear, if we consider, among other
 circumstances, that when a patient has had an attack of flood-
 ing, a surprise, or any agitation which can give a temporary 
277
acceleration to the circulation, will often renew the discharge.
The action of the arteries depends very  much upon that of
the heart;  and the action of this organ again is dependent on
the blood.  When much blood is lost, the heart is feebly ex-
cited to contraction, and in some cases it beats with no more
force than is barely sufficient to empty itself. This evidently
lessens the  risk of a renewal of the bleeding;  and in several
cases, as, for example, in hemoptysis, we, by suddenly detract-
ing a quantity of blood, speedily excite this state of the heart.
Whatever tends to rouse the action of the heart, tends to re-
new hemorrhage; and if the proposition be established, that
the rapidity with which the strength and action of the vessels
are diminished is much influenced by the rapidity with which
a stimulus is withdrawn, the converse  is also true, and we
should find,  were it practicable to restore the quantity of
blood as quickly as it has been taken away, that the same ef-
fect would be produced on the action of the heart,  as if a per-
son had taken a liberal dose of wine.   It  has been the prac-
tice to give nourishing diet to restore the quantity of blood;
but until the ruptured  vessels be closed,  or the tendency to
hemorrhage stopped, this must be hurtful.   It is our anxious
wish to prevent the loss of blood; but it does not thence follow,
that, when it is  lost,  we  should  wish rapidly to restore it.
This is against every principle of sound pathology;  but it is
supported by the prejudices of those who do not reflect, or
who are ignorant of the matter.  When a person is reduced
by flooding, even to a slight degree, taking much food into the
stomach gives considerable irritation;  and if much blood be
made, vascular action must be increased.   What is it which
stops the flow of blood, or prevents for a time its repetition ?
Is it not diminished force of the circulation which cannot
overcome the resistance given by the coagula ? Does not mo-
tion displace these coagula, and renew  the bleeding ?  Does
not wine increase for a time the force of the circulation, and
again excite hemorrhage ?  Is it not conformable to every just
reasoning,  and to the experience of ages, that  full diet is
dangerous  when vessels  are  opened ?  Do  we not prohibit
nourishing food and much speaking in hemorrhage  from the
V 
                             278

 lungs?  and can nourishing diet and motion be proper in he-
 morrhage from the uterus ? If  it were possible to restore in
 one hour the blood  which has been lost in  a paroxysm of
 flooding, it  is evident, that unless the local condition of the
 parts were altered, the flooding would at the end of that hour
 be renewed.
   The diet  should be light, mild,  given  in small quantity at
 a time, so as  to  produce  little irritation,* and much fluid,
 which would soon fill  the  vessels, should be  avoided.   We
 shall do more good by avoiding every thing which can stimu-
 late and raise action,f than by replenishing the system rapid-
 ly, and throwing rich nutriment into the stomach.
   It is, however, by  no means  my intention to say, that we
 must, during the whole remaining course of gestation, (pro-
 vided that that go on, the attack having been permanently
 cured) keep down the  quantity  of blood.   I only mean that
 we are not rapidly to increase it.   Even where the strength
 has been much impaired by the profusion of the discharge, or
 the previous state of the system, it is rather by giving food so
 as to prevent farther sinking, than by cramming the patient,
 that we promote recovery; and I  beg it to  be remembered,
 that although I talk of the management of those who are much
 reduced, yet I am not to be understood as in any degree en-
  * Such as animal jellies, sago, toasted bread, hard biscuit, &c.  These ar-
ticles given at proper intervals, are sufficient to support the system without
raising the action too much.
  f The system, with its power of action, may, for illustration, be compared
to «a man with his income.  He who had formerly two hundred pounds per
annum, but has  now only one, must, in order to avoid bankruptcy, spend only
one half of what he did before; and if  he  do so,  although he has been ob-
liged to hve lower, yet his accounts will be square at the end of the year.—
The same applies to the system. When its power is reduced, the degree of its
action must also be reduced; and, by carefully proportioning the one to the
other, we may often conduct a patient through a very great and continued
degree of feebleness.  At the same time, it must be observed, that as there
is an income so small as not to be sufficient to procure the necessaries of life,
so also may the vital energy be so much reduced as to be inadequate to the
performance of those actions which are essential to our existence, and death
is the result. But surely be who should attempt to prevent this by stimulat-
ing the system, would only hasten the fatal termination. Does not heat
 overpower and destroy those parts which  have been frost-bit.; 
279
couraging the practice of delay, and allowing the patient to
come into this situation of debility ; but when we find her al-
ready in this state, it is not by pouring cordials and  nutri-
ment profusely into the stomach, that we are to save her;  it
is by giving mild food, so as gradually to restore the  quan-
tity  of blood and the  strength; it is by avoiding the stimu-
lating plan on the one hand, and the starving system on the
other, that we are to carry her safely through the danger.
   Some medicines possess a great power over the blood ves-
sels, and enable us in hemorrhage to cure our patient with
less  expense of  blood  than we could otherwise  do.   The di-
gitalis is of this class, and may  often be given with much ad-
vantage in flooding, where the pulse indicates increased vas-
cular action, and when we do not mean to proceed directly to
delivery.  But when the discharge has been trifling, and the
pulse is  slow, and perhaps feeble, the digitalis is unnecessary
even from the first; and if, in  the  progress of the  disease,
the stomach have become affected, and the patient is sick, in-
clined to vomit, or faintish, or the pulse feeble and small, it  is
likewise improper.
   In those  cases which demand it,  when the pulse is sharp,
and  throbbing, and frequent, it may be  given either  in the
form of powder or of tincture; half a grain of the dried
leaves may be given every two hours, until the pulse be af-
fected, and afterwards at longer intervals, so as to keep the
circulation  moderate.   The tincture may also be employed
with  the same  advantage.  Two drams may be added to  a
four-ounce  mixture, and a table-spoonful  given  every two
hours, watching the effect, and  diminishing  the dose  when
necessary.  The addition of a  little well-prepared hepatised
ammonia sometimes makes the  effect  be more speedily pro-
duced, but not more than five drops should be added to each
dose.(e)

  (e)  Our author has here  omitted to  mention, the powerful effects of the
acetate of lead in restraining uterine hemorrhage.
  The dose must depend upon the circumstances of the case, and the judg-
ment  of the practitioner. In a general way we may say, that two or three
grains may be given at a time, and repeated more or less frequently,  accord- 
280
   At the same time that we  thus endeavour to diminish the
 action of the vascular system, we must also be  careful to re-
 move as far as we can, every irritation.  I have already said all
 that is necessary with regard to  heat,  motion,  and diet.
 The intestinal canal must also be  attended to,  and accumu-
 lation within it should  be carefully  prevented by the regular
 exhibition of laxatives.  A costive  state is generally attend-
 ed  with a slow circulation in the veins belonging  to  the
 hepatic system, and of these the uterine sinuses form a part.
 If the arterial system  be not proportionally  checked, this
 sluggish motion is apt  by  retarding the free  transmission
 along the meseraic veins, to excite the hemorrhage again.
   Uneasiness about the bladder or rectum, or  even in more
 distant parts, should be immediately checked ;  for, in many
 cases, hemorrhage is renewed by these irritations.  In those
 cases, or where the patient is troubled with cough or affected
 with palpitation, or an hysterical state, much advantage may
 be derived from the exhibition of opiates.  In many instances
 where  an attack of flooding is brought on by some irritation
 affecting the lower part of the uterus in particular, or the sys-
 tem in general, or where the bowels are pained,  and the pulse

ing to the urgency of the symptoms.   It should be combined with a portion
of opium.
  Professor Barton, who has called the attention of American practitioners
to this powerful article of the materia medica, in restraining internal hemorr-
hage, recommends the combining  with it a portion of ipecacuanha.  For his
opinion on this subject, we must refer the student to the Professor's edition
of Cullen's Materia Medica, vol. ii. p. 20, 21, and 334.  Other practitioners,
among whom is Dr. Chapman, in these cases place  considerable confidence
in a combination of opium-and ipecacuanha, in the proportion of two grains
of the former to half a grain of the latter, to be repeated every two hours.
  From my own experience, I should be induced to decide in favour of the
acetate of lead, when combined as above directed.
  Dr. Kuhn informs me that the late Dr. Glentworth of this city, placed the
greatest reliance  on yarrow-tea, or a  strong decoction  of  yarrow (Achillea
Millefolium L.) in  uterine hemorrhage, and  said that he  never was disap-
pointed in his expectations of a cure after the proper use of this article of
the materia medica.  Instances of  its good effects in hemorrhages are
mentioned by several of the -German pliysicians, particularly by Stahl and
Hoffman. 
                            881

 not full  nor strong, rest, cool air, and an  adequate dose of
 tincture of opium will terminate the paroxysm, and perhaps
 prevent  a return.  This  is especially the case, if oidy a part
 of the decidua have been separated, and the discharge have
 not been profuse.  When the vascular  system is full,  vene-
 section is necessary before the anodyne be administered, and
 the digitalis may either succeed the opiate, or be omitted,  ac-
 cording to the state of the pulse and of the stomach.
   But although anodynes be in many instances, and especial-
 ly  in first  attacks, of great benefit, yet they are not to be in-
 discriminately employed nor  exhibited when the circum-
 stances of the patient require delivery, unless the strength be
 much impaired; and then, a full dose is to be given as a cor-
 dial,  previous to delivery.
   It may happen that we have not been  called early in a
 first  attack, and that some  urgent symptom  has appeared.
 The most  frequent of these, is a feeling of faintness or com-
 plete syncope.   This feeling often arises rather from an af-
 fection of the stomach than  from absolute loss of blood ; and
 in this case it  is less alarming than when  it follows copious
 hemorrhage.   In either  case, however, we must not be  too
 hasty in exhibiting cordials.  When the faintishness depends
 chiefly upon sickness at the stomach, or feeling of failure,
 circumstances  which may accompany even a small discharge,
 it will be sufficient to give a few drops of hartshorn  in cold
 water and sprinkle  the face with  cold  water.  When it is
 more dependent on absolute loss of blood, we may find it  ne-
 cessary to give small quantities of wine warmed with aro-
 matics;  but our cordials  even in this case must not be given
 with  a  liberal hand, nor too  frequently  repeated.*  It is
 scarcely necessary for me to add, that we are also to take

  * As syncope and loss of blood have both the effect of relaxing the muscular
fibre, as is  well known to surgeons, it may be supposed that they should in-
crease the flooding by diminishing the contraction of the uterus, if that have
already taken  place. But the contrary is the case, for by allowing coagula
to form, syncope restrains hemorrhage, and therefore ought not to  be too
rapidly removed.
  VOL. L,                         0 0 
288
immediate steps by the use of the plug, &c. for restraining
the discharge.   This I may observe once for all.(/)
   Complete syncope is extremely alarming to the bye-stand-
ers; and, if there have been a great loss of blood, it is indeed
a most dangerous symptom.  It must at all times be relieved,
for although faintness be a natural mean of checking hemorr-
hage,  yet absolute and  prolonged  syncope is hazardous.
But we are not to exhibit  large doses of cordials for its re-
moval.   We must keep the patient at perfect rest, in  a hori-
zontal posture, with the head low, open the windows, sprinkle
the face smartly with cold vinegar, apply volatile salts to the
nostrils, and  give some  hartshorn, or a spoonful of warm
wine internally.
   Universal  coldness is  also  a symptom which must not be
allowed to go beyond a certain degree, and this degree  must
be greatly determined by the strength of the patient, and the
quantity and rapidity  of the discharge.  When the strength
is  not previously much reduced, a  moderate degree of  cold-
ness, is, if the hemorrhage threaten to continue, of service; but
when there has been a great loss of blood, then universal  cold-
ness, with pale lips, sunk eyes, and approaching  dcliquium,
may too often be considered as a forerunner of death.  When
we judge  it necessary to interfere, we should apply warm
cloths  to the hands and feet,  a bladder half filled with  tepid
water to the stomach, and give some hot wine and water in-
wardly.
   Vomiting  is another symptom which sometimes appears.
It proceeds very generally from the attendants having given
more nourishment or fluid than the  stomach  can  bear, or
from a gush of  blood taking place soon after the patient has

  (/) In restraining uterine hemorrhage, we should not forget that injec-
tions thrown up the vagina, and if possible into the uterus, may have a con-
siderable effect in repressing the discharge.   In this way I have known solu-
tions of the acetate of lead, of the sulphate of alumine, and a strong decoction
or infusion of galls, produce salutary effects.  A solution of the acetate  of
lead in  cold water combined with  laudanum may be also tlirown up by
enema, as recommended by Dr. Dewees. 
283
had a drink.  It in  this case is commonly preceded by sick-
ness and oppression, which are most distressing, and threaten
syncope, until relief is obtained by vomiting.   Sometimes it
is rather connected with an hysterical state, or with uterine
iri'itation.   If frequently repeated, it is a debilitating opera-
tion, and by displacing clots may renew hemorrhage; but
sometimes  it  seems fortunately to excite the  contraction of
the uterus, and  gives  it a  disposition to empty itself.   For
abating vomiting, we may apply a cloth dipped in laudanum,
and camphorated spirits of wine, to the whole epigastric re-
gion ; or give two grains of solid  opium, or even more, if the
weakness be great.   Sometimes a little infusion of  capsicum
is of service.  It should just be gently pungent.   In flooding
it is of importance to pay much attention to the state of the
stomach, and prevent it from being loaded;  on  the  other
hand,  we  must not let it  remain too  empty, nor allow its
action  to  sink.   Small quantities of pleasant nourishment
should be given frequently.  We  thus  prevent it  from los-
ing its tone, without oppressing it, or  filling the system too
fast.
  Hysterical affections often accompany protracted  floodings,
such as globus, pain in the head, feeling of suffocation, pal-
pitation,* retching, in which nothing but wind is got up, &c.
These are best relieved by some  foetid or carminative sub-
stance conjoined with  opium.   The retching sometimes re-
quires an anodyne clyster, or the  application of a camphorat-
ed  plaster,f to the region of the stomach.
   After having made these observations on the management
of flooding, and the best means  of moderating its violence,
of  preventing  a return,  and  of relieving those dangerous
symptoms  which  sometimes  attend  it; 1 next proceed to

  * The quantity of blood lost is sometimes so great as to do irreparable in-
jury to the heart, and ever after to impede its action. One well marked in-
stance  of this is related by Van  Swieten, in his commentary on Aph. 1304,
where, for twelve years the woman after a severe flooding, could not sit up in
 bed without violent palpitation and anxiety.
  f This may be made by melting a little adhesive plaster, and then  adding
 to it a  large proportion of camphor, previously made into a thick liniment by
 rubbing it with olive oil. 
                          $84

speak of the method of delivering  the patient  when that is
necessary.   I have separated the detail of the medical treat-
ment of a paroxysm from the consideration of the manual
assistance,  which  may be required; because,  however inti-
mately connected the different parts of our plan may be  in
actual practice, it is  useful in  a  work of this kind, in order
to avoid confusion, that I lay them down apart.
  As some peculiarities of practice  arise from  the implanta-
tion  of the placenta, over the os uteri, I shall confine may
present remarks to those cases in which the membranes are
found at the mouth of the womb, desiring it to be remem-
bered,  however, that this  circumstance does not necessarily
indicate that the hemorrhage does not proceed from separa-
tion of the placenta, which may be fixed very near the cervix,
although it cannot he felt.
  The operation of delivering the child is not difficult to de-
scribe  or to perform.  The hand,  previously lubricated,  is
to be slow ly and gently introduced completely into the vagina.
The finger is to be introduced into the os uteri, and cautious-
ly moved so as to dilate it; or if it has already dilated a little
more, two fingers may be  inserted, and very slow and  gentle
attempts made at short intervals to  distend it; and the prac-
titioner will do well  to remember,  that he will succeed best
when he rather acts  so as to stimulate the uterus, and make
it dilate its mouth, than directly to  distend it.   On the  part
of the  operator,  is  demanded  much tenderness, caution,
firmness, and composure; on the part of the patient is to  be
desired patience and resolution.  The operator is to keep  in
mind, that painful dilation is dangerous, it irritates and  in-
flames  the parts, and that the woman should complain rather
of the uterine pains which are excited, than of the  fingers of
the practitioner.  More or less time will be required fully to
dilate the os  uteri, according to the state in which the  uterus
was  when the  operation was begun.   If the os uteri  is soft
and  pliable, and has  already by slight pains been in part dis-
tended, a quarter of an hour, or perhaps only a few minutes
will  often be sufficient for  this purpose; but if it has scarce-
ly been affected before by pains, and  is pretty firm, though 
285
not unyielding, then half an hour may he required.  I speak
in general terms, for no rule can  be given applicable to
every case.  Not unfrequently, although the patient have
felt scarcely  any pains, and certainly no regular pains, the
os uteri will he found  as large as a penny-piece, and its mar-
gin soft and thin.  The os uteri being sufficiently dilated, the
membranes are to be ruptured, the hand  introduced, the
child slowly turned and delivered, as in footling cases; en-
deavouring rather to  have the child expeUed by uterine con-
traction than brought  away by the hand. Hasty extraction
is dangerous, for the  uterus will not  contract after it.  And,
therefore, if when we are turning, we do not feel  the uterus
acting, we must move the hand a little, and  not begin to de-
liver until we perceive that  the womb is contracting.  The
delivery must he but  slow until the breech is passing, then
we must be careful that the cord be not too long compressed
before the rest of the child be born.   The child being re-
moved, and the belly  properly supported, and gently pressed
on by an assistant, the hand should again be cautiously  in-
troduced into the womb, and the two knuckles placed on the
surface of the placenta, so as  to press  it a little, and excite
the  uterus to separate it.   The  hand  may  also be gently
moved in  a little time, and the motion repeated at intervals,
so as to excite the uterus to expel its contents; but upon no
account are we to separate the placenta and extract it. This
must be done by the  uterus; for we have no other sign that
the contraction will be sufficient to save the  woman from fu-
ture hemorrhage.  The whole process, from first  to last,
must be slow and deliberate, and  we are never to lose sight
of our object, which is  to excite the expulsive power of the
uterus.  It is not merely to empty the uterus—it is not mere-
ly to deliver the child, that we introduce our hand :  all this
we may do, and leave the woman worse than if we had done
nothing: the fibres must contract and press upon the vessels ;
and as nothing else can save the patient, it is essential that
the  practitioner have clear ideas of his object, and be con-
vinced on what the security of the patient depends.
   But to  teach the method  of delivery, and say nothing of 
286
the circumstances under which it is to be performed, would
be a most dangerous error.  I have in the beginning of this
section, pointed  out the effect  of  hemorrhage, both on  the
constitution and on the uterus;  and I have stated, that  the
action of gestation  is always  impaired  by a certain loss of
blood, and a tendency to expulsion brought on.  But before
the uterine contraction can be fully  excited, or become effec-
tive, the woman may perish, or the uterus be so enfeebled as
to render expulsion impossible.  Whilst  then  we look upon
the one hand to the induction of contraction, we must not on
the other delay  too  long.   We must not witness many and
repeated attacks of hemorrhage; sinking the strength; bleach-
ing the lips and tongue, producing repeated fainting fits, and
bringing life itself into immediate danger. Such delay is most
inexcusable and dangerous; it may end in the sudden loss of
mother and child ; it may enfeeble  the uterus, and render it
unable afterwards to contract; or it may so ruin the constitu-
tion, as to bring the patient, after a long  train of sufferings,
to the grave.
  Are we then uniformly to deliver upon the first attack of
flooding, and forcibly open the os uteri ?  By  no  means;
safety  is not to be found either in rashness or procrastina-
tion.
  The treatment which I have pointed out, will always secure
the patient until the delivery can be safely accomplished.  As
long as the os  uteri is firm and unyielding—as long as there
is no tendency to open, no attempt to establish contraction,
it is perfectly safe to trust to the plug, rest, and cold.   But I
must particularly state to the reader, that the os uteri may
dilate without regular pains ;  and in almost every instance it
does, whether  there be or be not pains, become dilatable. Did
I not know the danger of establishing positive rules, I would
say, that as long as the os uteri is firm, and has no disposi-
tion to open, the patient can be  in little risk if we understand
the use of the plug; we may even plug the os uteri itself, which
will excite contraction.  But if the patient be neglected, then
I grant that long before a tendency to labour or contraction
be introduced, she may perish.  I am not, however, consider- 
88?
ing what may happen  in  the  hands of a negligent practi-
tioner; for, of this, there would be no end, but what ought to
be the  result of diligence and care.
  It is evident, that when the uterus has a disposition to con-
tract, and the os uteri to open, delivery must be much safer
and easier than when it is still inert, and the  os uteri hard.
  We  may  with confidence trust to the plug, until these de-
sirable effects be produced ; and, in some instances, we shall
find, that by the plug alone we may secure the patient: the
contraction  may become brisk, if we  have prevented much
loss  of blood, and expulsion may naturally take place.   Who
Would  in those circumstances, propose to turn the child, and
deliver it ?  Who would not prefer the operation of nature to
that of the accoucheur ? To determine  in any individual case
whether this shall take place, or whether delivery must be re-
sorted to, will  require deliberation on  the part of the prac-
titioner.  If he have used the plug early and effectually, and
the pains have become brisk, he  has good reason to expect
natural expulsion;  and the labour must be conducted on the
general principles of midwifery.  But if the uterus have been
enfeebled by loss of blood—if the pains are indefinite—if they
have done  little more than just  open the os uteri, and have
no disposition to increase, then  he is not justified in expecting
that expulsion shall be naturally and safely accomplished,
and he ought to deliver.   When he dilates the os uteri, he
excites the  uterine action,  and feels the membranes become
tense.   But he must not trust to this, he must finish what he
has  begun.
   Thus it appears, that by the early and effective use  of the
plug, by filling the vagina with  a soft napkin, or  with tow,
we may safely and readily restrain the  hemorrhage,  until
such changes  have taken  place on  the os uteri as to render
delivery easy;  and then we either  interfere or trust to na-
tural  expulsion, according to the briskness and force  of the
contraction, and state of the patient
   By  this treatment, we obtain all the  advantage that can be
derived from the operations of  nature, and, where these fail, 
£88
 are enabled to look with confidence to the aid of artificial de-
 hvery.
   But it may happen that we have not had  an opportunity of
 restraining the hemorrhage early; we may not have seen
 the patient until she has  suffered much from bleeding.*   In
 this case, we shall generally be obliged to  deliver, and must
 upon no account delay too long;  yet, if the os uteri be very
 firm, and without  disposition to open, we shall generally  find
 that  the  sinking  is  temporary: we may still trust for some
 time to the plug.
   Hemorrhage is  naturally restrained by faintness.   A repe-
 tition is checked in the same way ;  and faintness takes place
 sooner than formerly.  In one or two attacks, the uterus  suf-
 fers, and the os  uteri becomes dilatable.  Slight pains come
 on, or are readily  excited by attempts to distend the os uteri.
 Syncope then will,  in general, even when the plug has not
 been used, and the  patient has been neglected, restrain he-
 morrhage, and prevent it from proving fatal until the os uteri
 has relaxed; but a little delay beyond that period will destroy
 the patient; and it is possible, by giving wine, and otherwise
 treating her injudiciously, to make hemorrhage prove fatal,
 even before this takes place.  But although  I have considered
 it as a general rule, that where the os uteri is firm  and un-
 yielding, we may, notwithstanding present  alarm, trust some
 time to the plug,  yet I beg it to be remembered, that there
 may be exceptions to this rule ; for the constitution may be
 so delicate,  and the hemorrhage  so sudden, or so  much in-
 creased by stimulants, as to induce a permanent effect, and
 make it highly desirable that delivery should  be  accom-
 plished  : but such  instances are rare;  and although  I have
 spoken  of the effects of syncope in restraining hemorrhage, I
 hope it  will not be imagined by the student that I wish to
 make him familar with  this symptom.  It is very seldom
 safe, when we have  our  choice, to wait till  syncope  be in-

  * We are not to confine our  attention to the quantity which has been lost,
but to the effect it has produced; and this will ceteris paribus be great in
proportion as the hemorrhage has been sudden. 
289
 duced; and if it have occurred, it is not usually prudent to
 run the risk of a second attack.
   The old practitioners,  not aware of the value of the plug,
 nor acquainted with the sound principles of physiology, had
 no fixed rule relating to delivery, but endeavoured to empty
 the uterus early;  but it was uniformly a remark, that  those
 women died  who had the os uteri firm and hard.*   What is
 this but to declare, that the rash and premature operation is
 fatal ? It is an axiom which should be deeply engraved  on
 the memory  of the accoucheur, and which should constantly
 influence his conduct.   Pain and suffering are the immediate
 consequence of the practice ; whilst a  repetition of the flood-
 ing after delivery, or the accession of inflammation, are the
 messengers of death.
   It was the fatal consequence of this  blind practice that sug-
 gested to M.  Puzos the propriety  of puncturing the mem-
 branes, and thus endeavouring to excite labour.  His reason-
 ing was ingenious;  his proposal was a material improvement
 on the practice V hich then prevailed.  The ease of the ope-
 ration, and its occasional  success, recommend it to our no-
 tice ; but experience has  now determined that it  cannot be
 relied on, and that it may be dispensed with.   If we use it
 early, and on the first attack, we do not know when  the con-
 traction may be established; for, even in a  healthy uterus,
 when we use it on account of  a deformed pelvis, it  is some-
 times several days before labour be produced.  We cannot
 say what may  take  place  in the interval.  The uterus being
 slacker,  the hemorrhage is more apt to return, and we may
 he obliged after all to have recourse to other means, particu-
 larly to the plug.   Now we know that the plug will,  with-
 out any other operation,  safely  restrain hemorrhage,  until
 the os uteri be in a proper state for delivery.!  The propo-

  * Vide the works of Mauriceau, Peu, 8cc.
  f The ingenious M. Aiphonse Le Roy seems much inclined to trust al-
most entirely to the plug, and supposes that the blood will act as a foreign
body, and excite contraction; but this, as a general doctrine, must be greatly
qualified.  Respecting the proposal of M. Puzos, he observes, "Puzos, en
conseillant assez hardiment de perccr  les eax,  n'avoit d'autres vues que U
   vol.  r.                         p r 
290
sal of M. Puzos then is, I  apprehend, inadmissible before
this time.  If after this, there  be occasion to interfere, it is
evident that we must desire  some interference which  can be
depended on,  both with respect  to time and degree.  This
method can be relied on  in neither; for we  know  not how
long it may be of exciting contraction,  nor whether it  may
be able t* excite effective contraction after any lapse of time.
If it fail, we render delivery more painful,  and consequently
more dangerous to the  mother, and  bring the child into
hazard.   It has been  observed, in objection to this, by Dr.
Den man,* that if turning be  difficult, the  flooding will  be
stopped by the contraction of the womb.  But we know that
the uterus, emptied of its water, may embrace the  child so
dosely as to render turning, if not difficult, at least painful,
and yet not  be acting so briskly  as to restrain flooding:
nothing but brisk contraction can save a patient in flooding,
if the vessels be large or numerous.
  The only case then which remains to be considered, is that
in which pains come on, and expulsion is  going forward.
Now, in this case, the flooding is stopped  either by the con-
traction or by the plug, and  the membranes burst in the
natural course  of labour; after  which it  is speedily  con-
cluded.  Here, then, interference is not  required;  but  if,
after going on in a brisk way  for some time, the pains abate
a little, wliich often happens even in a natural labour, it will
be proper to  rupture the membranes, if we have reason to
think that a slight stimulus to the uterus would renew its ac-
tion : and  in determining this, the practitioner must be in-
fluenced by the previous  discharge;  for if the uterus have
been much vtduced by it in its  vigour, it will be less under
the influence of a stimulus ; and if, upon the present diminu-
tion of the pains, the flooding is disposed to return, I should

contraction de la matrice, qui est la suite de cette operation et la cessation de
la perte, et il la conseilla meme dans  les cas des pertes qui arrivent avant
tenne.  Mais un grand nombre de femmes sont peries par I'effect de cette
meme pratique."  Lecons sur les pertes de sang, p. 45.
  * Introduction to the Practice of Midwifery, vol. ii. p. 310, 
291
think that we surely ought to trust rather to the hand, which
can stimulate in the necessary degree, and finish the process
with safety, than to a method which is much more uncertain
and less under our command.*
   The proposal of M. Puzos then will, if this reasoning is
just, be very limited in its utility.   Its simplicity gave me at
first a strong partiality  in its  favour; and if  t fcovv have
changed my opinion, 1 have given my reasons.
   But there still remains a most> important question  to  be
answered.   In those cases where the patient has been allow-
ed to lose a great deal of blood frequently and suddenly,
when  the strength is gone, the pulse scarcely to be felt, the
extremities cold, the lips and  tongue  without blood, and the
eye ghastly, shall  we venture to deliver the  woman ?  Shall
we by plugging, endeavour to  prevent  farther loss, and by
nourishment and  care recruit the strength; or empty the
uterus, and then endeavour to restore the  loss ?   We have
only a choice of two dangers.   The situation of the patient
is most perilous, and I have in practice weighed the argu-
ment with  that  attention  which the awful circumstances of
the case required.   I  think myself justified in  saying, that
we give both mother and child the best chance  of surviving
by a cautious delivery.   For in these cases the  uterus is  al-
most toipid, it possesses no tonic contraction ;f the very con-
tinuance of the ovum within it is more than it can bear, and
on the most favourable supposition,  it  would require many
days before it could be brought into a state  capable of con-
tracting.  The general system is completely exhausted, and

  * In those cases where the placenta presents, few practitioners would
think of trusting to the evacuation of the hquor amnii j they woidd deliver.
If then dehvery be considered as safe and proper in one species of flooding,
it cannot be dangerous in the other; and whenever interference in the  way
of operation is necessary, the security afforded by the introduction of the
hand will much more than compensate for any additional pain.  But  even in
this respect, the two operations are httle different, if properly performed.
  f The use of the plug cannot here certainly prevent the  farther loss of
blood, for the uterus affords no  resistance, the hemorrhage continues,  and
after death large coagula will be found within the womb. 
293
 cannot support its condition long.  I  have never known a
 woman live twenty-four hours in these circumstances.
    On the other hand, I grant, that it is possible the woman
 may die in the act of delivery, or very soon after it;  but if
 she can be supported for  two days, we may have  hopes of
 recovery.  By a very slow  and cautious delivery, and by
 endeavouring |o excite the action of the uterus, so as to pre-
 vent discharge afterwards, we not only remove the irritation
 of the distended  womb, but we likewise take away a recepta-
 cle of blood.  During the contraction of the uterus, the blood
 in its  sinuses will be thrown into the system,  and tend to
 support it.   Part, no doubt, will escape; but by keeping the
 hand in the uterus, by supporting the abdomen with a com-
 press, and exciting the uterine  action by  cold  applications
 to the belly, we may prevent  a great loss.  When  to these
 considerations we add the additional  chance which the child
 has for life, our practice, I apprehend, will, in this very haz-
 ardous case, be decided.  When the  pulse becomes firmer
 and fuller upon  the contraction of the uterus, the risk from
 debility  is diminished.  A full dose of laudanum ought to be
 given previous to delivery.
   The remarks upon the subsequent management of the pa-
 tient, I shall reserve  until I consider the treatment of flood-
 ing, after delivery.
   At one time it was supposed, that the placenta was,  in every
 instance, attached originally to the fundus uteri, and that it
 could only be found presenting in consequence of having been
 loosened and falling down.  This accident was supposed  to
 retard the birth of the child, by stopping up the passage, and
 also was considered as dangerous  on account of the  flood-
 ing which attended it. On this account Deventer endeavour-
 ed to accelerate the delivery by tearing the placenta,  or rup-
 turing the membranes when they could be found. This was a
 dangerous practice, and very few  survived when  it was em-
 ployed.  Mr. Giffard and M. Levret* were among the first

  * Je m'engage a prouver lmo. que le placenta s'implante-quelquefoissiii
la circonference de I'orifice de la matrice; c'est-a-dire, sur celui qui du col 
293
 who established  it as  a rule that the placenta did not fall
 down, but was from the first implanted over the os uteri: and
 the latter gentleman  published a very concise and  accurate
 view of the treatment to be pursued.
   We know, that during the eighth month of gestation, very
 considerable changes take place about the cervix uteri.   It
 is completely  developed and expanded;  and  in the  ninth
 month, very little distance  intervenes  betwixt the ovum and
 the lips of the os uteri.  These changes cannot easily take
 place without a rupture of some of the connecting vessels, for
 either the placenta does not adapt itself to the changes in the
 shape of the cervix; or, which happens more frequently, some
 slight mechanical cause, or action of the fibres  about the  os
 uteri, produces a rupture.
   This rupture may doubtless take place at any period  of
 pregnancy,* but it is much  more frequent in the end of the
 eighth and beginning of the  ninth month, than  at any other
 time.  But whether the separation happens  in the seventh,
 eighth, or ninth month, the consequent hemorrhage is always
 profuse, and the effects most alarming.  The quantity, but
 especially the rapidity of the discharge, very frequently pro-
 duce a tendency  to faint, or  even complete syncope, during
 which the hemorrhage ceases, and the woman may  continue
 for several days  without experiencing a renewal of it.  In
 some instances she is able to  sustain  many and repeated at-
 tacks, which may take place  daily for some weeks.   These,
 however, it is evident, cannot be very severe, and the  strength
 must originally have  been great.  In  other  instances, the
 woman never gets the better  of the first attack.  It indeed

va joindre I'interieur de  ce viscere, &  non sur cehu qui regarde de la
vagin.
  2do. Qu'en ce cas la perte de sang est inevitable dans les dernier tems de
la grossesse.
  Et 3tio. Qu'il n'y a pas de voye plus sure pour remcdier a cet accident
urgent que de fair l'accouchement force"—L'art des Accouchemens, p. 343.
  * In some cases, hemorrhage has taken place so early as the third month.
By proper means this has been stopped, and the patient has continued Well
for some months, when the flooding has returned, and the placenta been dis-
covered to present. 
294
 diminishes, but does not  altogether leave  her, and a slight
 exertion renews  it in its former violence.  But whether the
 patient suffer much or little in the first attack—whether she
 be feeble or robust,  the practice must  be  prompt, and the
 most solemn call is made upon  the practitioner for activity.
 The momenTthat a discharge of blood takes places, he ought
 to ascertain by careful examination the precise nature of the
 case,  and must take instant  steps for checking it, if nature
 have not already accomplished that event.
   If the os uteri be firm and close in  a first attack, we ought
 to use the plug, which will restrain the hemorrhage, and in-
 sure the present safety of  the patient.  If this practice have
 been immediately followed, she shall in general soon recover,
 and the length of time for  which she shall remain free from a
 second attack, will  depend very much  upon the care which
 is taken of her; but sooner or later the attack must and will
 return.   If the uterus have been injured in its action by the
 first attack, this will generally be attended with very slight
 dull pains, and we shall feel the os uteri more open and Iaxer
 than usual; but if the first and second discharges  have  been
 promptly checked, it may  be later before these effects be per-
 ceived ; hut the moment that they are produced, we ought to
 deliver,  and it should even be a rule, that where they are not
 likdy soon to take place, and the discharge has been profuse
 and rapid; and'produced those effects on the system which I
 have already pointed out,  as  the  consequence of dangerous
 hemorrhage, we must not  delay until pains begin to open the
 os uteri.   Fortunately, we are not often obliged to interfere
 thus early; for by careful management, and the use of the
 plug,  we can secure our patient.
   Although I have said that we may wait safely until the os
uteri  begins to open, and  asserted, that no woman can die
 from  mere hemorrhage, before the state of the os uteri admit
 of delivery, I must yet add, on this  important  subject, that
 this state  docs not consist merely in  dilatation, for it may be
 very little dilated, but in dilatibility;(g)  we may safely deli-

   Qr) TR"«gt>y, a respectable surgeon of Norwich in England, is entitled, as
• ve beheve, to the credit  of first promulgating this distinction, which is of 
295
ver whenever the hand can be introduced without much force.
A forcible introduction of the hand on the first attack of he-
morrhage,  wrould,  in many cases,  be attended  with  the
greatest danger, and in almost  every case is improper and
unnecessary.  I have never yet seen an instance, where deli-
very was required during the first paroxysm, if the proper
treatment was followed.   Whether it may  be required in a
second or third attack, or even  later, must depend upon  the
quantity and  rapidity of the discharge,  its effects and  the
strength of  the woman.   But whenever we find the os uteri
soften, and in any degree more open  than in its usual state,
and it admits the finger to be introduced easily within it, we
may deliver safely; and if the  hemorrhage  be continuing,
ought  not to delay.  This state will generally be found  ac-
companied with obscure pains; but we attend less to the state
of pains, than of discharge, in determining on delivery. The
pains gradually increase  for  a  certain period,  and then go
off.  During their continuance, the os uteri dilates more; but
if the hemorrhage have been, or continues to be considerable,
we must not wait until the  os  uteri be much dilated, as we
thus reduce the woman to  great danger,  and diminish the
chance of her  recovery.   A prudent practitioner will not, on
the one  hand, violently open  up the os uteri at an early pe-
riod, but will use the plug, until the os uteri becomes soft and
dilatable;  and if the hemorrhage^be not considerable, he will
even, if  the state of the patient allow him, wait until slight
pains  have  appeared, or the  os uteri begun sensibly to open

great importance to be attended to in practice; his words are, "We should
be as much influenced (as respects the period of introducing the harid) by
the os uteri being in a state capable of dilatation without violence, as by its
being really open; when this is the case, therefore, if the woman's situation
demand speedy assistance, we sliould not hesitate to attempt delivery." His
Essay on this subject, was published in the year 1777, and is in every respect
a valuable work, rendered more so by tiie number of interesting cases ap-
pended to it.  It has been republished in this city,  and is highly worthy of
the perusal of every Student and Practitioner of Midwifery.  Its title is " An
Essay on the Uterine Hemorrhage, which precedes the delivery of the full
grown Foetus: illustrated with cases by Edward Uigby, member of the  Cor*
poration of Surgeons in London." 
296
  without them;  for he will recollect, that the more violence
  that is done to the os uteri, the  greater is  the risk  of bad
  symptoms supervening.  It is an error into which some have
  fallen, who  look upon debility from discharge, as the only
  barrier to recovery.   Violent delivery may produce inflam-
  mation, or a very troublesome  fever,  On the other hand, he
  will  not allow his* patient to lose much blood or have many
  att^dts; he will deliver her immediately, for he knows that
  whenever this is necessai'y it is easy, the os uteri yielding to
  his cautious endeavours.
    But v ery  frequently we are not called until the patient has
  had  one or two attacks, and  been reduced to great danger.
  We  find her  with feeble pulse,  ghastly countenance,  fre-
  quently vomiting, and occasionally complaining of slight grind-
  ing pains.  On examination, the vagina is so filled with clot-
  ted blood which adheres so firmly by the lymph to the uterus,
  that at first we find some difficulty in discovering the os uteri.
  We cannot here hesitate a moment what course to follow. If
  the patient is to be saved, it  is  by delivery. The os uteri  will
  be in part dilated; it will easily be fully  opened.  We per-
  haps find an edge of the placenta projecting into the vagina,
  perhaps the centre of  the placenta presenting or protruding
  like a cup into the vagina; but in those cases, the rule is the
  same.  We  pass by the placenta  to the membranes, rupture
  them,* and turn the child, delivering according to the direc-
  tions which I have already given.
    It  may be supposed, that as the treatment is so nearly the
  same, it is not material that we distinguish whether the pla-
  centa or membranes present.  But it is convenient to make a
  distinction, because in those cases  where the placenta does not
  present, it is possible, in certain circumstances, to  cure  the
  flooding, and carry the patient  to the full time; and in those
,  cases, which are indeed the most numerous, where this cannot
  be done, we always look to uterine contraction as a very great
*  assistance, and expect  that where that is greatest, the dan-

   * This is much safer for the child than pushing the hand through the pla-
  centa: and it is equally  advantageous for the  mother, and easy  to the
  operator. 
297
ger will be least. But when the placenta presents, we have no
hope of conducting the woman safely to the  full time.   We
have  no ground to look to contraction or labour pains as  a
mean of safety ; for, on the contrary, every effort to dilate the
os uteri separates still more the placenta, and increases the he-
morrhage.* The very circumstance which in some other cases
would  save the patient,  will here in general, increase  the
danger.  I say in general, for there are  doubtless  examples
where the patient has by labour, been safely and without as-
sistance delivered of the child, when part of the placenta  has
presented.  Nay, there have been instances  where  the pla-
centa has been expelled first, and the child after it.f  These
examples are to be met with in collections of cases by practi-
cal writers ;  and some solitary instances are likewise to be
found in different journals.  It would be much to be lament-
ed if these should ever  appear without  having  at  the same
time a most solemn warning sent along with them to the ac-
coucheur, to pay no attention to them in  his practice.:}: I am
convinced that they may do inexpressible mischief by afford-
ing argument for  delay, and  excusing the practitioner to
himself for procrastination.  There is scarcely any malady
so very dreadful  as not to afford some examples of a cure
effected by the powers of nature alone; but ought  we thence
to tamper with the safety of those whose lives are committed
to our charge ?   Ought we to neglect the early and vigorous
use of an approved remedy, because  the  patient has  not in
every instance perished from the negligence of the attendant ?
It is highly proper to publish the case of a patient who, from
hernia, has had an anus formed at his groin, because it adds
to our stock  of knowledge.   But what should we  think  of a

  * The greatest number of profuse or alarming hemorrhagies proceed from
the presentation of the placenta, or the implantation of its margin over the os
uteri; and consequently, the greatest number of cases requiring dehvery are
of this kind.
  f Even in those cases where the placenta is expelled first, the flooding
may recur, and the woman die, if she be not assisted. Vide La Motte. Obs.
ccxxxviii, and cexxxix.
  * Most of those who have met with such cases, do not seem to count much
upon them.
   vol. i.                         q,ci 
298
surgeon who should put such a case into the hands of a young
man, without, at the same time, saying, " Sir, if such a case
ever happen in your practice, either you or your patient will
be  very  much to blame."  I do not mean from this to say,
that we  are to blame, in every  instance, the accoucheur
who has attended a case where the placenta has presented,
and the patient been delivered by nature;  far from it, for by
the use of the plug,  he may have restrained the hemorrhage,
pains may have come  on, /md the child, descending, may
have carried the plug before it: or w hen he was called  to his
patient, he may  have found her  already in labour, and the
process going on so well  and so safely, that all  interference
would have been injudicious. But these instances are not to
be converted into general rules, nor allowed to  furnish any
pretext for procrastination.  They happen very seldom, and
never ought to be related to a young man without an express
intimation that  he  is not to neglect delivery, when it is  re-
quired, upon any pretence whatsoever.

                    § 37. FALSE PAINS.

  Many  women are subject, in the end of  gestation, to pains
about the back or bowels, somewhat resembling those of la-
bour, but which, in reality, are not connected with it. These,
therefore, are called false pains.   They sometimes only pre-
cede labour a few hours; but in many cases, they come on
several days, or even some weeks,  before the end of pregnan-
cy, and may be very frequently repeated, especially during
the night, depriving the woman of sleep. They are often con-
fined altogether to the belly, shifting their place, and  being
very irregular both in their attacks and continuance. In some
cases they affect the side, particularly the right side,  in the
region of the liver, and are exceedingly severe, especially in
the ev ening; they are accompanied with acidity or w ater-
brash, or retching, and generally the child is at that time
very restless. These pains may doubtless occur in any  habit,
but they chiefly harass  those who are addicted to the use of
cordials.   On other occasions, the false pains occupy chiefly 
299
the back or hips or upper part of the thighs. They even some-
times resemble still more nearly parturient pains, in being at-
tended with an involuntary effort on the part of the abdominal
muscles, to press down, so as to make the woman suppose that
she is about to be delivered; and this is occasionally accom-
panied with tenesmus, or with protrusion of the bladder from
the vagina, very like the membranes of the ovum.  In other
cases, they are attended with a discharge of watery fluid from
the vagina. False pains may be occasioned by many causes: the
most frequent are flatulence ;  a spasmodic state of the bowels,
resembling slight colic; or irritation,  connected with cos-
tiveness or diarrhoea; or  nephritic affections, often accom-
panied with strangury.  A sudden motion of the back, or un-
usual degree of fatigue,  may cause a  remitting pain  in the
back and loins : or getting suddenly out of bed when warm,
and placing  the  feet on the cold floor, may have the same
effect.  A slight  degree of lumbago may also resemble the
parturient pains.  Agitation  of mind, or a febrile  state of
the  body, or some irritation in the neighbourhood of the ute-
rus, or some unusual motion  of the child, may  produce  an
uneasy sensation  in the uterus; and  sometimes this  is ac-
 companied by a discharge of watery fluid from the vagina.
   False pains may often be distinguished by their situation;
 as for instance, when they affect the bowels or kidneys ;  by
 their shifting their situation ; by their duration; by their  ir-
 regularities ; and by the symptoms with which they are  at-
 tended.  But  the best criterion is, that they seldom affect
 the os  uteri, that part not being dilated during their con-
 tinuance.   It is  necessary however to observe, that a dilated
 state of the os  uteri does not always prove that the pains
 are those of labour ; for it may be found prematurely dilated,
 to a slight degree, before the proper term of labour, without
 any pain.   In this case, if the pains proceed from  affections
 of the  bowels, no effect is produced during the pain, in ren-
 dering the os uteri tense, or making it larger.  On the other
 hand,  it sometimes happens, that the fibres about the os uteri
 are prematurely irritated ; and this state may be accompanied
 with  pain,  and with a  perceptible  change in the  os uteri 
J  p                       300
v   \  during a pain.  This is a very ambiguous case; but we may
\ J  be assisted in our judgment, by discovering, that the term
 (\j   of utero-gestation is not completed, that the os uteri is hard
     or thick, and the pains irregular.  In all such cases, it is
     best to proceed on the supposition, that the woman is not ac-
     tually in labour; for by letting her alone, she most likely will
     have a continuance of pain, terminating, it is true, in labour,
     but the process  will be  tedious  and fatiguing; whereas, by
     suspending the action by an opiate, and if necessary by vene-
     section, the  woman may go on for some time longer, and
     shall at all events have an easier delivery.
       When the  false pains are accompanied with a febrile state,
     or are very distressing during the night, it will be proper to
     detract blood, and afterwards give an anodyne.  In all other
     cases, it is generally sufficient to keep the woman in a state
     of rest, open the bowels by means of a clyster, if there  be
     no diarrhoea, and afterwards give an opiate to be succeeded
     by a laxative.   Rubbing with anodyne balsam is also useful.
       Shivering  and tremor occur in some cases,  in  the end of
     pregnancy;  and as they also occasionally precede labour,
     they often give rise to an unfounded expectation, that delivery
     is approaching. They  appear to be connected sometimes
     with the state of the stomach, or alimentary canal;  in other
     instances with some change in the os uteri itself, which, even
     without pain, may be so far opened  or relaxed as to allow
     the finger very easily to touch  the child's head through the
     membranes.   It is  usually in the evening, or through the
     night, that the shivering is felt; and it is occasionally pretty
     severe, and  may be several times repeated.  Nothing, how-
     ever, is required, except a little warm gruel, or a moderate
     dose of laudanum, which is always effectual. 
NOTES.
                            BOOK I.

                            CHAP. II.

  NOTE 1, Page 12.—Dr. Denman mentions  an  instance,  where the pa.
tient, in three  succeeding  pregnancies, was  progressively worse, and did
not, until the lapse of eight years, recover from the lameness produced by
the third dehvery.   Introd. Vol. I. p. 16.
  NOTE 2, p. 13.—In one case, where the symphysis was divided, the pa-
tient was able  to walk on the 15th day.—In Dr. Smollet's case, although in
the 8th month of gestation, the bones were found to rise above each other,
yet the woman  recovered in  two months after dehvery.  Smellie, Vol. II.
coll. 1, n. i. c. 2.
  NOTE 3, p. 13.—As an illustration of tliis disease, I shall relate the out-
lines of a case mentioned by Louis, in the Memoirs of the Royal Academy
of Surgery.  A  woman in the 2d month of her pregnancy, after pressing in
a drawer with her foot, felt a considerable pain at the lower part of the bel-
ly» greatly increased by every change of posture; and along with this she
complained  of  strangury. She was bled, and purged, and kept at rest, by
which means, especially by the last, she grew better.   But in the two latter
months of pregnancy, the symptoms were renewed,  so that presently she
could neither walk, nor even turn in bed, without great pain; but her greatest
suffering was caused by  raising the legs to pull on her stockings, as then
the bones were more powerfully acted on.  A  slight  degree of hectic fever
now appeared.   Her dehvery was accomplished easily;  but on the evening
of the 3rd day,  when straining at stool, after having received a clyster, the
pain, which had troubled her httle since her labour, returned with as much
severity as ever. On the 5th day the pulse was very weak and frequent, she
sweated profusely, and had a wildness in her  countenance,  with symptoms
of approaching  delirium.  In the afternoon the pulse  became full and tense,
with vertigo and throbbing  of the arteries of the head.   The pain at the
symphysis was excruciating, and although she was fomented and bled seven
times, she obtained no relief.  On the 8th day the pain abated, but diffused
itself over the rest of the pelvis, particularly affecting the  left hip and the
sacrum.  On the 11th day she died.  On opening the  body, there was found
a separation of the bones at the pubis, but the capsule was entire, and much
distended.  It contained about an ounce and a  half of matter.  Whether the
timeous evacuation of this matter might  have saved the patient, is a question 
302
worth our consideration.  I am disposed to answer it in the affirmative, from
observing, that wherever the patient has recovered in such circumstances, it
has uniformly happened, that a discharge of matter has taken place.
  NOTE 4, p. 14.—Dr. Laurence shewed Dr. Smellie a pelvis, where all the
bones were separated to the extent of an inch.
  NOTE 5, p. 14.—In  a case related by De la Malle,  the pain did not ap-
pear till the 14th day after dehvery, and was felt first in the groin. The pa-
tient was unable to move the leg, and had acute  fever, which proved fatal.
The sacrum was found separated, three hues from the ilium.
  In the operation of dividing the pubis in a parturient woman, it was found
that one side  yielded more than the other, and consequently that side would
suffer most at the sacrum.  Baudelocque L'Art, &c. section 2063.
  NOTE 6, p 14.—Dr. Smellie  relates an  instance, where,  during  labour,
the woman felt violent pain at the right sacro-iliac symphysis.  On the 5th
day this pain  was extremely severe, and attended with acute fever; but the
symptoms were abated by blood-letting, and a clyster,  and fomentations,
which produced a copious perspiration.  She was not able to walk for five or
six months without crutches, but was restored to the  use of the limb, by
means of the cold bath.  Coll. 1.  n. i. c. 1.

                                CHAP. VI.

  NOTE 1, p. 30.—It is not necessary to give examples of every degree of
deformity; but it will be useful to select  some specimens of the different
kinds.  The  slighter degrees do not require to  be particularized.-  I shall
first of all give the dimensions of a dried pelvis, so contracted, as to prevent
a child at the full time from passing without assistance.  From the pubis to
the sacrum, it measures three inches; from the acetabulum  to  the sacrum,
on the right side, two and a half inches; on the left, two inches and seven-
eighths ; from the brim above the  foramen thyroideum, to the  opposite sa-
croiliac junction, five inches; from the same part of the brim on one side, to
the same on the opposite, three inches and a half; transverse diameter, four
inches and seven-eighths;  from the arch  of the pubis to the hollow of the
sacrum,  five inches; from one tuberosity of the  ischium to the other, four
inches and a half; from one spine to another, four inches and a half; the
arch of the pubis is natural.  The distance from the face of the third lumbar
vertebra, to the spine of the ilium on both sides, is six inches. These  di-
mensions may be compared with those of the well-formed pelvis.  The sym-
physis pubis  has the  cartilage in the inside, projecting like a spine, wliich,
added to the  smallness of the pelvis when recent.   The linea ilio-pectinea
also, on the left side, is for the length of two inches  as sharp  as a knife; and
from these two causes, the cervix uteri and bladder were torn in labour.
  NOTE 2, p. 30.—In a pelvis of this kind, which I shall describe, the ver-
tebrx and sacrum lean much to the left side.  The line from the promontory
of the sacrum to the part of the pubis opposite it, is barely an inch and a half;
but an oblique line drawn to  the symphysis, which is to  the right of the pro-
montory, is near two inches.   From the promontory to the side of the brim 
303
at the ihum on the left side, is two inches and three-tenths; on the right side,
three inches and four-tenths.  On the left side, from the lateral part of the
sacrum to the acetabulum, is nine-tenths of  an inch; on the right side, fully
two inches.  Now in tliis pelvis, when the  soft parts are added, we shall
find that an oval body may pass on the right  side, whose long  diameter is
three inches and a half, and  whose short diameter is barely two inches.
  in a pelvis with a semicircular brim, whose short diameter, at the middle
and each side, is one inch and a half, an oval could  pass when the soft parte
are added, whose long diameter is about two inches and a quarter; and the
short one  about one inch and a quarter.
  NOTE 3, p.  31.—In a well-formed pelvis, a line drawn transversely along
the brim, and  in contact with the sacrum, either touches at its two extremi-
ties, the sacro-Uiac junctions or the hnea  ilio-pectinea, about half an inch
before them;  but in a very deformed pelvis, such a line will touch the brim,
at, or even before the acetabula.  In a well-formed pelvis, a line drawn from
the middle of the linea ilio-pectinea on one side, to the same spot on the op-
postde side, is  about an inch, or an inch and a half distant from the sacrum.
But  in a deformed pelvis,  this hne would either pass through the sacrum, or
altogether behind it.
   NOTE  4, p. 31.—The following are the dimensions of a pelvis of this kind,
which I select as a specimen.  From the spinous process of the ihum on one
side to the other, is eight  inches and three-fourths.   From the lumbar ver-
tebrae to the spinous  process of the ihum on the right side, six inches; on
the left side, one inch and seven-eighths.  From the  spinous process of the
ihum back to its ridge, two inches and a half.  From the symphysis pubis to
the  sacrum, one inch and  three-fourths.  From the right  acetabulum to the
sacrum, six-tenths of an inch; from the left, seven-eighths  of an inch.  From
the  brim  above the foramen thyroideum to the same point on the opposite
side, seven-eighths of an inch.  From the same part of the  brim to the oppo-
site sacro-iliac junction, three inches and a  half on both sides.   From the tu-
berosity of one ischium to that of the other, two inches and a half. From the
tuberosity to the coccyx, three inches.   From the spine of one ischium to
that of the other, three inches and a half.   From the lower part of the sym-
physis pubis to the hollow of the sacrum, four inches;  distance of the rami
of the pubis, five-eighths of an inch.
   This pelvis has a triangular brim; for it will be observed, that the  brim
above the foramen thyroideum measures  nearly an inch  across, and there-
fore there is a considerable space betwixt the two ossa pubis, gradually, how-
ever, becoming narrower toward the junction of the bones; but  little advan-
tage in delivery can be gained from this.  When we examine it with a view
to determine what bulk may be brought through the brim, we find that it is
by its shape  virtually divided into two  cavities, one on the right, and the
other on  the left side, and the short diameter of the one  is six-tenths of an
inch, and that of the other  seven-eighths of an inch;  therefore no art can
 bring a child  at the full time through it.
   In this pelvis, the sacrum  has fallen so forward at the top, that in a stand- 
304
ing posture the face of that bone is almost horizontal, and its under part with
the coccyx is bent forward like a hook.   The vertebra are much distorted.
  NOTE 5, p. 31.—This is the case in a pelvis where the distance from the
part of the brim  above the foramen thyroideum on  one side, across to tiie
same part on the opposite side, is only five-eighths  of an inch.   From the
right acetabulum to the sacrum is an inch and three-eighths.  From the left
is one inch.  This pelvis at the brim is externally triangular,  but it is, from
the near approximation of the bones, virtually semicircular, the space betwixt
the two ossa pubis being so trifling as not to  merit  consideration;  and the
diameter of the brim here is one inch, exclusive of the small slit betwixt the
bones.  The  sacrum in this  pelvis is very  much curved, and the outlet is
small.
  NOTE 6, p. 33.—Dr. Denman mentions a fatal case of this kind, to which
Dr. Hunter was called.  The child was delivered by the crotchet,  but the
patient died on the fourth day.  A firm fatty excrescence, springing from one
side of the sacrum,  was found to have occasioned the difficulty. Vide Introd.
Vol. II. p. 72.—Baudelocque, in the 5th  vol. of  Recueil Periodique, relates
a case, where, in consequence of a scirrhous tumour adhering to the pelvis, the
crotchet was necessary.  In a subsequent labour, the cesarean operation was
performed, and proved fatal to the mother.—Dr. Drew  records an instance
where the tumour adhered to the sacro-sciatic ligament, and was successfully
extirpated during labour.  It was 14 inches in circumference.   Vide Edin.
Journal, Vol. I. p. 23.
  NOTE 7, p. 33.—A  fatal case of this kind occurred to  Dr. Ford, and  is
noticed by Dr. Denman.   Vol. II. p. 75.—Another fatal instance is recorded
by M. Baudelocque, L'Art. section  1964.  See also a case by  Dr. Merriman,
Med. and Cliir. Trans. HI. 47. This ovarium contained a fluid, and probably
might have been  opened during labour with advantage.
  NOTE 8, p. 33.—Several cases of this kind have been met with, and in one
related by M. Brand,  and noticed by Dr. Sandifort in his Obs. Anat. Path.
the woman died undelivered.
  NOTE 9, p. 33.   M. Pclletin  details  several cases of tumours within the
pelvis, some of them fatty or fibrous, and easily turned out, merely by mak-
ing an incision over them, through the vagina; one encysted containing puri-
form matter; and one about an inch long, of a cartilaginous  nature, adher-
ing to the descending branch of the pubis, the vagina being  divided, it was
cut off with scissars. Clinique Chirurgicale, Tom. 1.203, 206, 224, 228, 250.
Mr. Park likewise relates several cases, chiefly of tumours containing liquid,
or soft contents, and which  were pierced  from the vagina  during labour.
Med. Chir. Trans. II. 293.

                              CHAP. VII.

   NOTE 1, p. 36.—The following are the dimensions of a very krge pelvis
 which I possess.  The conjugate diameter is four inches and three fourth ;
 the lateral, five inches and five-eighths; the diagonal, five inches and a half 
305
From the symphysis pubis to the sacro-iliac junction, five inches. From the
top of the arch of the pubis to the sacrum, is five inches and three-eighths.
From one tuberosity of the ischium to the other, is five inches and a half-;
and the arch is very wide.  Depth of the pelvis at the sacrum without the
coccyx, five inches.  Breadth of the sacrum at the top, four inches and seven-
eighths.  Depth of the pelvis  at the sides, four inches.

                              CHAP. IX.

  NOTE 1, p. 46.—In birds, we find that the ovaria contain a great number
of yolks of different sizes.  Those wliich are nearest the wide canal called
the oviduct which leads to the cloaca, are largest, whilst those remote from
it are  very minute.  The full grown yolk is detached from  the ovarium,
and in its passage down is furnished both with  the albumen and the neces-
sary membranes and shell.  In viviparous fishes, as the skate, ray, &c. the
same structure obtains.   These animals have two ovaria, containing eggs of
different sizes; the smaller are white,  the larger yellowish, and they pass
down to an oviduct, which contains a glandular body that furnishes the cover-
ing of the egg.  Each ovary has a separate oviduct,  which forms a vast sac,
that terminates in the  sides of the cloaca, by  orifices that have a duplicature
like a  valve.   The cloaca itself forms an ample reservoir, that seems more
like a  continuation of the oviduct than the termination of the rectum.  In
oviparous fishes, the ovaria are  known under the name of roes, and all the
visible eggs are of the same size, and so numerous, that some contain above
200,000.   They are enveloped  in a fine  transparent membrane ; and septa
from this envelope, divide the internal parts, and furnish points of attach-
ment to the ova, which  are expelled previous to fecundation.  These  are
called oviparous fishes, and have, properly speaking, no oviduct. The ovaria
of frogs resemble those of fishes,  and the ova are, previous to expulsion,
enveloped in a glary fluid.  In  the slug we find both testicles and ovaria.
The ovarium is a grape-like tissue, containing numerous small grains, or ova,
attached by pedicles,  which are canals that lead into the oviduct.  This is a
serpentine canal, that after having adhered to the testicle,  opens in  the
common cavity of generation, in which also the penis or duct from the tes-
ticle opens, and during copulation, the two individuals mutually impregnate
each other.  The ovaria of the  adder are like strings of beads.
   In many quadrupeds, the ovaria contain ova almost  as distinct as some of
those  animals I have just  noticed.  The hedgehog has an  ovarium like a
bunch of grapes; and the  ovarium  of the civet has a knotted surface, and
resembles a packet of httle spheres : the ovarium  of the  didelphis is also
vesicular.  The common sow has also an ovarium somewhat resembling,  ex-
ternally, that of oviparous animals.  Most other quadrupeds have an ovarium
 more  smooth and somewhat oblong in shape, and in  general the tube and
 ovarium  are unconnected, as in the human female;  but in  the otter, my
 brother observed, that both were contained in  a kind of capsule formed by
    VOL. I.                             R» 
300
the peritoneum, so that ventral extra-uterine pregnancy cannot take place in
this animal.  -

                             CHAP. X.

  NOTE 1. p. 54.—The females amongst the Bosjesmans have the nymphae
sometimes five inches long. Their colour is a livid blue, like the excrescence
of a turkey.  Vide Barrow's Travels in Africa, Vol. I. p. 279.
  NOTE 2, p. 54.—On the shores of the Persian gulph, among the Christians
in Abyssinia, and in Egypt among the Arabs and Copts, girls are circumcised.
Niebuhr says, that at Kahira, the women who perform this operation  are as
well known as  midwives.  Travels, Vol. II. p. 250.—Dr. Winterbothom, in
his account of Sierra Leone, Vol. II. p. 239, says it is practised among the
Mandingo, Foola, and Soosoo women.
  NOTE 3, p. 54.—M. Causaubon has inserted a memoir on this subject, in
the 1st Vol. of Recueil Periodique, which contains several useful cases.  In
one of these, the tumour was produced in the seventh month by a kick, and
terminated fatally by hemorrhage.—In another given by Sedillot, the labia
became prodigiously distended during labour, and the head of the child could
not be touched.  The labia were torn by the attendant.  Afterward the child
was delivered with the lever.—In cases related by Baudelocque, Brasdor,
&c. the tumours were  opened, and the vagina plugged whilst the wound was
stuffed with lint dipped in solution of alum, to prevent hemorrhage.
  NOTE 4, p. 54.—In a case related by Mr. Reeve, the tumour which I sus-
pect proceeded from  the rupture of the nympha,  was perceived first in
perineo, but soon occupied all the left labium, which was enormously distend-
ed.  The pain at first was so great as to cause syncope.  The parts sloughed,
and discharged pus and clotted blood.  Bark was  given, and she got well.
Lond. Med. Journ. Vol. IX. p. 119.
  NOTE 5, p. 54.—Vide case by Dr. Maitland, in Med. Comment. Vol. VI.
p. 95.—Dr. Perfect relates a case, where it burst itself before the child was
born, and discharged much blood, Vol. II. p. 63.—In another,  which  ended
fatally, the tumour burst after dehvery, and discharged five pounds of blood.
Vide Plenk Elementa, p. 111.—Case by M. Sedillot, in Recueil Period. Tom.
I. p. 260.
  NOTE 6, p. 54.—Vide cases by Dr.  Macbride in Med. Obs. and Inq. Vol.
V. p. 89.
  NOTE 7, p. 55.—In Mr. Blagden's case, related by Dr. Bailhe, the woman
soon after dehvery had violent bearing-down pains, as if another child were
to be born.  A monstrous swelling appeared in the right labium, extending
to the perinxum.  A large incision was made, which did not heal till the 2lst
day.  Med. and Physical Journal, Vol. II. p. 42.
  NOTE 8, p. 55.—Vide Fichet de Flechy, Observ. p. 375.  The patient was
cured by introducing a compress into the vagina, and dressing the sore with
digestive ointment. 
807
  NOTE 9, p. 55.—Le Dran relates a case, where above 20 ounces of blood
were evacuated by incision.  Consultations, p. 413.
  NOTE 10, p. 55.—-Mr. Simmons cut off a clitoris, which formed a tumour
nine inches in length, and fourteen  in circumference at the largest end.
The circumference of the stem was five inches.  Med.  and Phys. Journal,
Vol. V. p. 1.
  NOTE 11, p. 55.—Schmucker's Miscel. Surg. Essays, art XXIII.
  NOTE 12, p. 56.—Upon this subject, see Arnaud on Hermaphrodites.
  In a child aged three years, I found the mons veneris prominent, and, as
well as the labia, covered with a considerable quantity of red hair. The labia
were large and thick, hke those of a grown woman, but shorter.  Their in-
ner surface was white and rugous, until near the orifice of the vagina, where
the skin was red. At the top the labia divaricated, and showed a large clitoris,
which hung down like the penis; it was upwards of an inch long, and about
half an inch in diameter, and furnished with  a thick wrinkled prepuce.  It
had a distinct glans, at the end of which was observed something hke a per-
foration ; but on raising it up, this  was seen to be only the  extremity of a
deep  sulcus, which extended all  the way to the urethra, or orifice of the
vagina.   It resembled the  male urethra  slit up.   The sides of this were
formed by the nymphae.  A httle before  the orifice of the  urethra, there
was a longitudinal eminence, hke the veru montanum. The vagina was
shut up by the  hymen.  The uterus was large, hke that  of a girl of
fourteen years  of age, and was  shaped  hke hers.   The ovaria  were of
corresponding size; one of them lay on the psoas muscle, the other was
loose in the pelvis.  The tubes were fimbriated  at their extremity, but in
their course were knotted and serpentine, hke the commencement of the
vas deferens.  The uterus was very vascular, and had an inflamed appear-
ance.  Its mouth was apparently impervious.
   In a male child that I lately saw, the external parts resemble those of the
female.  The scrotum is cleft like the vulva, the penis consists only of cor-
pora cavernosa, and the urethra  opens between  the  labia formed by the
scrotum.
   NOTE 13, p. 56.—The same effect may be produced, by a continuation
of the skin being extended over the parts.   It  must be cut up.   See a case
by M. Larrey, in Rapport General de la Societe Philomatique, Tom. II. p. 86.
   NOTE 14, p. 56.—Vide case of a patient of Dr. Chamberlain's,  in Cow-
per's Anatomy.—Case by Mr. Fryer,  in  Med. Facts  and Obs. Vol.  VIII.
p. 132.
   NOTE 15, p. 56.—Case by Mr. Sherwin, in Med. Records, &c. p. 379.
   NOTE 16, p. 56.—Case by Mr. Kaeymer, in  Med.  Annals,  VoL VI. p.
 347.  By Mr. Eason, in Med. Comment. Vol. II. p. 187, and a variety of
 other cases.  This, in every instance I have known, has been the greatest
 complaint.
    NOTE 17, p. 56.—Dr. Smellie candidly acknowledges, that in one instance
 he took the protrusion of the hymen, for the  membranes of the ovum, forced 
308
down by lahour pains.  These pains were accompanied with suppression of
urine.  He let out about two quarts of blood.   Col. I. n. i. c. 6.
  NOTE 18, p. 56—In a case related by Benevoli, the belly was very much
swelled, and the urine suppressed.   He attempted to pass the catheter, but
without success.  Next day he repeated his endeavour,  and pushing with
more force than prudence, considering his object, he ruptured the hymen,
and immediately a great quantity of dark matter was evacuated, even to the
extent of 33 pints.—See also Mr. Fryer's case.—Mr. Warner relates the case
of a httle girl, where the hymen was continued half way over the orifice of
the urethra.   The effects were at first attributed to stone  in the bladder;
but the nature of the case being made out,  she was cured by dividing the
hymen.  Cases, p. 75.
  NOTE 19, p. 56.—In a case by Mr. Bardy, the patient, who was 15  years
of age, had every month, for some days, pain  in the uterine region.  The
external parts were greatly protruded and  stretched as in labour, and the
nymphs formed merely two lines.   The anus was thrust backward and dis-
tended, and she  passed the  urine  and faeces  with  great pain ; the hymen
from irritation was covered with scab, the health had suffered.  Six pounds
of thick gelatinous matter were evacuated by  incision.   Med. and Chir. Re-
view for September, 1807.
  NOTE 20,  p. 56.—In Mr. Fynney's case, the part to be  divided was very
thick;  and in Dr  M'Cormick's case, the vagina seemed to  be in part imper-
vious.  Med. Comment. Vol. n. p.  1S8.—In general the membrane is thin.
  NOTE 21, p. 56.—Vide Mr. Niven's case, in Med. Comment. Vol. IX. p.
330. The symptoms gradually abated.
  NOTE 22, p. 56.—M. Baudelocque mentions an instance where the hymen
resisted, for half an hour, the strong action of the uterus.  Note to Section
341.
  NOTE 23,  p. 59.—Upon this subject, vide La Motte's Traite ; and cases
and observations by  Noel,  Saucerote, Trainel, and Sedillot, in the fourth and
seventh Vol. of the Recueil Periodique.  Dr. Denman mentions an instance
where the perinaeum was not torn up, but perforated by the head.
  NOTE 24,  p. 59.—In a case where the vagina would not admit the point
of the little finger, the child was  delivered  after eighteen hours labour.
Plenk Elementa, p. 113.  See also Van Swieten.
  NOTE 25,  p. 59.—This  may  produce bad effects, from retention of the
menses.   M.  Magnan relates the case of a girl, aged 22 years, who had been
subject to monthly colics and suppression of  urine.  An  incision was made
through the membrane, and two pounds of blood let out. Hist, de la Societe
de Med. pour. 1776, art. II.
  NOTE  26, p. 59.—In this  case the faeces do not always pass continually.
The patient has been known not to have a  stool once in a fortnight; which
probably depended on the faeces being indurated, and the communication
small.
  NOTE  27, p. 59.—In the 33d VoL of the Phil. Trans, p. 142,  there is  a 
309
case related, where there was a kind of double vagina, separated by a trans-
verse septum or membrane.  The orifices were very small.  During labour,
the pain was so great as  to produce convulsions.  She was delivered, by
laying the two passages into one.  Chapman relates a case of malformation,
where the woman was impregnated, and in labour all the forcing was felt at
the anus.   From this an opening was made through into the vagina, and the
child was born per anum.  Portal mentions a girl, who had only avery small
aperture at the vulva,  for the evacuation of the urine ;  the menses came
from the rectum; nevertheless, she became pregnant.   Before delivery, the
orifice of the  vagina appeared, and she bore the child the usual way.   Precis
de Chirurgie, Tom.  II. p. 745.
  NOTE 28,  p. 59—Richter in Comment. Gotting. Tom. in. art. 2.  relates
a case of a girl aged 20 years, who for three years had been subjects to vio-
lent pains about the sacrum, with tremors and syncope every month.  The
vagina was found to be closed at the upper part, in consequence, it was im-
agined, of a variolous ulcer in infancy. Fluctuation was felt  in the vagina,
when pressure was  made with the  other hand on the abdomen.  The con-
traction was opened, and a quantity of blood let out.
  NOTE 29,  p. 60.—In some parts of Africa, the vagina is made impervious,
in order to prevent coition.  This operation is generally performed betwixt
the age of eleven and twelve years.   Brown's Travels, p. 349.
  NOTE 30,  p. 61.—Burton relates a case, where the  prolapsed vagina was
mistaken for part of the placenta, and rudely pulled away,  by which the
vagina and bladder were torn.  System, p. 170.
  Stollers relates a case, where  this  was  complicated with calculi.  These
being removed, the parts were reduced, and a cure obtained.  Cases, Obs. 2.
   NOTE 31, p. 61.—Mr. Henry Watson, in the Med. Communications, Vol.
I. p. 162, called the  attention of practitioners to this disease.  In a case he
relates, he drew off in the month of June, four gallons of fluid, by tapping
the  vagina;  and immediately after this  she passed the urine freely, which
she coidd not do before.  She required again to be tapped in two  months,
and died in November*  The left ovarium was found to be converted into a
cyst,  about the size of a sow's bladder, but it had not been touched by the
trocar.  In one case, he punctured with a lancet instead of a  trocar, but this
was succeeded by troublesome hemorrhage. The good effects of tapping
are also seen in a case related by Mr. Coley, in Med. and Phys. Journal, Vol.
VII. p. 412.  In this two gallons of water were drawn off* and she continued
well for five months, after which, dropsical symptoms returned, and altHough
diuretics gave her some relief, yet she was  at last cut off.   In the  case of
Mrs. Jarritt, related by Sir W. Bishop, in Med. Commun. Vol. II. p. 360, pain
was felt in the right  side of the belly, after parturition, accompanied with
tumefaction.  In two years the vagina became prolapsed, the tumour being
four inches in diameter.  The tumour was punctured twice; the first  time
46 pints, the second 51, were drawn off.  Diuretics had no effect.   In a case
related by Dr. Denman, the woman was pregnant, and no operation was per- 
310
formed.  On the fourth day after her dehvery, after a few leose stools, she
expired,  Introd. Vol. I. p. 150.
   NOTE 33, p. 71.—In a case of this kind, described by Mr. Patton as a
spasmodic affection of the neck of the bladder, calomel appeared to cure the
complaint.   London Med. Journal, Vol. X. p. 360.  The  use of the  bougie
may be proper.
   NOTE 34, p. 71.—Morgagni relates an important case, where there was a
hard painful tumour in the hypogastric region, accompanied with fluor albus,
uterine hemorrhage, and stillicidium of urine.  After death, the bladder was
found very large and scirrhous, with two large bodies in the cervix, prevent-
ing the urine from being retained.  The uterus  was diseased only  in con-
sequence of its vicinity to tiie bladder.  Epist XXXIX. art. 31.
   NOTE 35, p. 72.—Of this disease I have never seen an  instance ; but Dr.
Bailhe mentions a case, in which the greater part of the bladder was filled
with a polypus.  Morbid Anat. p. 298.
   NOTE 36, p. 72.—The patient to whom I allude, had, I understood, four
years before her death, been dehvered with the forceps, and soon afterwards
had incontinence of urine.  I found a large perforation in the bladder, exact-
ly resembling the fauces without an uvula.  The uterus was a little enlarged
and indurated; and its mouth, which was ulcerated and fungous, lay in this
opening, projecting into the bladder, and closing up the communication be-
twixt tiie bladder and vagina.
   NOTE 37, p. 73.—In a case related by Sandifort, the suppression of urine
was always attended with convulsive cough. Lib. I. cap. 5.  And in a case
related by Dr. J. Hamilton, where prolapsus took place before  parturition,
the muscles of the body were spasmodically agitated.   Cases, he. case 9.
   NOTE 38* p. 74.—Mr. Sharp mentions a case, where they  grew in small
quantity upon the orifice, producing excruciating torment till they were ex-
tirpated. Critical Inq. p. 168.
   NOTE 39, p. 75.—In the instance related by Mr. Warner,  the urine  was
voided in drops with great pain, especially about the menstrual period, and
she sometimes even had convulsions. He  dilated the urethra, by inclining the
catheter to one side and thus saw two excrescences near the upper end. He
divided or laid open the  urethra,  and cut off the excrescences successfully
with scissors.  Cases, p. 309.
  NOTE 40, p. 75.—In the patient of Mr. Hughes, the disease was taken at
first for prolapsus uteri, for there was a substance filling the os externum,
and appearing without the vidva.  It was a spongy excrescence  from  the
whole circumference of the meatus.  It was drawn out with a thread passed
through it, and then cut off.   Strangury,  with pain  above the pubis,  and
fever, took place, on which account the catheter was introduced.  Suppres-
sion of urine repeatedly occurred; and as it was often difficult to introduce
the catheter, the semicupium was employed, and always  with  advantage ;
but once after it, she became faint, and the limbs were convulsed. A stricture
being suspected at the upper part of the urethra, a bougie was introduced, 
811
and kept in the canal, wliich removed the symptoms.  Med. Fact, and Obs.
Vol. m. p. 26.
  NOTE 41, p. 75.—In Mr. Jenner's case, the irritation of the bladder was
great, and the menses were irregular. A fungus was found filling the orifice
of the urethra ; this was cut off, and the bougie used for an hour every day
for a fortnight; a httle before the extirpation, a hemorrhage took place from
the  excrescences.  Vide Lond. Med. Journal, Vol. \'U. p. 160.
  NOTE 42,  p. 75.—M. Sernin relates a case of a girl eleven years of age,
who from her fifth year had been subject to frequent attacks of difficuly in
voiding the urine.  He had an opportunity of examining her after a violent
attack, and found a cylindrical body,  4 inches long, projecting from the vul-
va ; and whenever she attempted to  make water, this projection swelled up.
It was amputated with success.  Recueil Period, torn. XVH p. 304.
  NOTE 43,  p. 75.—In Dr. Chamberlain's patient, who had the hymen im-
perforated, the urethra was so ddated as to admit the finger; and Portal found
it, in an analogous case, dilated so as to form a cul-de-sac, admitting the point
of the thumb.  Cours d'Anat. Medicale, Tom III. p. 476.
  NOTE 44, p. 76.—Morgagni mentions a porter's wife, in whom the uterus
was found not above an inch long, and without any ovaria.  The pudendum
was extremely small, and there was scarcely any appearanc of a clitoris. In the
Phil. Trans, for 1805, there is a case where the uterus of a woman, 29 years
of age, was not larger than in the foetal state, and scarcely any appearance
of ovaria.  She ceased to grow at ten years of age, had no hair on the pubis,
never menstruated, and had an aversion to men.  I have seen the uterus of
the adult not larger than that of a child; the woman never menstruated, and
had very flat  breasts.
  NOTE 45,  p. 76—Columbus dissected a woman who always complained of
great pain in coitu.  The vagina was very short, and had no uterus at its ter-
mination.
  Fromondus relates an instance, where the place of the os externum was
occupied with a cartilaginous substance.
  Morgagni was consulted by a barren woman, whose vagina was only a third
part of the usual  length, and its termination felt firm and fleshy. He advised
dissolution of the  marriage.
  M. Meyer  in Schmucker's Essays, mentions a case where the vagina and
uterus were  wanting, but  the ovaria existed.  The labia and clitoris were
small, and there were no nymphae.   Mr. Ford dissected a child who had no
vagina, uterus, or ovaria.  The urethra and rectum terminated close to each
other.  Med. Facts, Vol. V. p. 92.
  NOTE 46, p.  76.—Vide Hist.de l'Acad.de Sciences, 1705,p.47.—Haller
Opusc. path.  60. AcrelPs cases.—Purcel in Phil. Trans.  LXIV. p. 474.—
Canestrini in Med. Facts, Vol. HI. p. 171.—Valisneri met with a double uterus
and double vulva.  Opera,  Tom. III. p. 338.—Dr. Pole  describes a double
uterus in the 4th Vol. of Mem. of Medical Society, p. 92.
  NOTE 47,  p. 76.—Littre found it almost closed, by a continuation of the 
312
inner sur/ace of the vagina. Mem. de l'Acad. de Sciences, 1704, p. 27;  and
in the seventh month of pregnancy, closed  by a glandular substance, 1705,
p. 2.—Morgagni found it shut with a membrane.  Epist. XLVL  art. 17.—
Boehmer quite shut up.  Obs. Anat. fasc. 2, p. 62.—Ruysch saw it so small as
scarcely to admit a pin; and Sandifort so  well closed, that nothing but air
could be forced through it.   Obs. Anat. Path, lib II. c. ii. p. 67.
  NOTE to Section 26, p. 80.—A peculiar growth is described by Dr. Clark
under the name of cauliflower excrescence, which is probably of tiie nature
of that I speak of, but I never have seen it after death, and therefore cannot
be certain.  It springs from the  os  uteri, the  base is  broad, the  surface
granulated, the substance brittle, and the fragments broken off white ; pres-
sure does  not cause much  pain, but the patient has more or less pain at
times, but not of the lancinating kind.  The discharge is at first  like fluor
albus, but frequently becomes watery and transparent, but stiffens  the linen.
When the excrescence is large, the discharge is so great  as to wet 10 or 12
napkins daily, and  occasion fatal debility.  The progress is variable, some-
times it is so rapid that in 9  months the cavity  of the pelvis is  filled by it.
The only treatment that bids fair to give relief,  is the application of a liga-
ture, but  the  peculiarity is, that when the vessels  are  constricted by  this
during life, or collapse after death, the  sohdity  of the tumour is lost, and it
resembles merely a glary substance. Trans, of a Society, &c. Vol. III. p. 321.
  NOTE 48, p. 81.—Vide  Stalpart Vander Wiel, obs. 87.—Segerus in Mis.
Cur. 1671, obs. 121.  Notwithstanding these cancerous  excrescences about
the os uteri, a woman may conceive.  Dr. Denman relates a case where there
was a large excrescence in the  gravid state, with profuse bleeding.  The
head of the child was lessened, but the woman died undelivered.   Vol. II. p.
65.  When the os uteri has been affected with scirrhus, and the  woman has
conceived, the uterus has sometimes been ruptured, or the woman died un-
delivered. Hildanus, cent. I.  obs. 67. Horstius Opera, Tom. II. lib. 2. obs. 5.
Blancard Anat p. 233.  Hist, de l'Acad. de  Sciences,  1705, p. 52.
  NOTE 49, p. 82.—Le Dran attended a patient who had all the symptoms
of scirrhous uterus, and, by examination, fungous excrescences were found
shooting down into the vagina.  The pain was continual, and could only be
mitigated by the constant  use of opium.  Urine was discharged by the va-
gina, and after death the bladder was found to  be perforated.  The fundus
and body of the uterus were not  much diseased.
  NOTE 50, p. 83.—Absolute abstinence has been recommended by Pou-
teau,  Qiuvres  Post. Tom. p. 105.  He relates a case, which was  cured by
confining the patient to eau de glace.—Mr. Pearson, p. 113, gives  two suc-
cessful cases.  In the first, the uterus was  enlarged and retroverted, but by
very spare diet, was restored to  its natural state.
  NOTE 51, p. 85.—Vide Mem. de l'Acad. de  Chirurg. Lieutaud relates a
case of a woman who had a tumid belly, and complained of great pain. The
womb was not much larger than usual, but it was almost bony.  Hist. Anat
Med. p. 320.—Grandchamp found an osseous tumour, as  large as the  fist, 
313
inclosed  in a sac, betwixt the uterus and bladder.  It produced constant
ischuria, relieved only by lying on the back.  Med. and Phys. Journal, Vol.
HI. p 587.
   NOTE 52, p. 90.—Gaubius relates a case, where it was complicated with
prolapsus uteri.  After a  length of time, severe pains came  on, and in  an
hour a large stone was  expelled; next day a larger stone presented, but
could not be brought away  until the os uteri  was dilated.  From time to
time after this, small stones  were expelled;  but at  last she got completely
well.
   NOTE 53, p. 91.—In a case which  occurred to the late  Mr Hamilton of
this place, the polypus was expelled by labour  pains, but the woman died
exhausted.—In a case related by Vater, it was expelled when the woman was
at stool.   Haller, Disp. Chir. Tom. III. p. 621.  See also a case in the same
work, p. 611, by Schunkius.—In the patient of Vacoussain, the polypus was
expelled after severe pain; its pedicle was felt to pulsate very strongly, but
a ligature being apphed, the tumour wsis cut  off.  Instantly  the ligature dis-
appeared, being drawn up within the pelvis, but on the third day it dropped
off.  Mem. de l'Acad. de Chir. Tom. III. p. 533.
   NOTE 54, p. 91.—Vide case by Vater, in  Haller, Disput. Chir. Tom.  IH.
 p. 621.—In the case furnished by  M. Espagnet, an attempt was made to intro-
 duce the catheter;  but a straight one being employed instead of a curved
 one, or an elastic catheter, it was found necessary previously to make an in-
 cision in the fore part of the polypus, which had protruded.  Mem. de l'Acad.
 de Chir. Tom. IH. p. 531.
   NOTE 55, p. 94—Dr. Denman, Vol. I. p.  94, mentions a young lady who
 had suffered long from uterine hemorrhage. A polypus was found  just to
 have cleared the os uteri ; a ligature was applied, but as she felt severe pain,
 and vomited, it was slackened.   Every attempt to renew the ligature had
 the same effect.  In six weeks she died, and it was  found that the uterus
 was inverted.                                                •
    NOTE 56, p. 94.—M. Herbiniaux, Tom. H. obs. 17, relates a  case. The
 ligature seemed to act on an inverted portion of the womb, producing pain,
 fever, and convulsions; it was slackened, but afterwards, notwithstanding a
 renewal of dreadful suffering, it was, with a perseverance hardly to be com-
 mended, employed so as at least to remove the polypus—Desault found,
 after having applied a ligature round a polypus, and cut the tumour off next
 day, that part of the fundus uteri was attached to the amputated substance;
 the patient did well.  Baudelocque supposes that some cases, related as  ex-
 amples  of  amputation  of inverted uteri,  were merely polypi, accompanied
  with inversion. Recueil Period.  Tom. IV. p. 115.
    NOTE 57, p. 95.—Dr. Denman, Vol. I. p.  95, relates a case of polypus with
  broad stem, which was supposed to be a cancer of the uterus.  The ligature
  was applied,and in eight or nine days it came away;   but when  the polypus
  was removed, another substance, nearly of the same size, was found to hava
  grown into the vagina.   The woman died in a month.  I have seen the com-
  mon polypus combined with an indurated thickening of the uterus, and  fun-
     VOL. I.                             s  S 
314
 gous or flocculent state of the cavity.  In one case of this kind, the uterus
 and rectum freely communicated by  ulceration. See also some cases in
 Trans, of a Society, &c. Vol. HI.
   NOTE 58, p. 96.—Sometimes the mass appears to be putrid, and is  ex-
 pelled with great hemorrhage.  Vide case by Dr. Blackbourn,  Lond. Med.
 Journal, Vol. n. p. 122.—Sometimes it has a kind of osseous covering, as in
 the case by Hankoph, in HaUer, Disp. Med. IV. p. 715.
   NOTE 59, p. 97.—In the Hist, of Acad, of Sciences for 1714, is the case of
 a woman who received a fall in the third month of pregnancy.  The belly,
 however, increased in size till the fifth,  when itbegan to lessen.  In  the sixth
 she was dehvered of a bag, as large as the fist, with the placenta and foetus of
 the size of a kidney bean.  In this case, hydatids were not  formed; but in
 the History for 1715,  is  a  case, where tiie woman,  falling in  the second
 month, had the ovum  converted into hydatids, which were expelled in  the
 tenth month.  As hydatids often succeed to  genuine pregnancy, the symp-
 toms may at first be exactly the same  with  those of pregnane}', nay, even
 motion may be felt, but afterwards the child may die, and hydatids form.—
 Mr. Watson, in the Phil. Trans. Vol. XLI. p. 711, gives a case, where there
 was, for a long time before the  expulsion of hydatids, a quantity of blood
 discharged every  night;  pains at  last came on, and expelled many hydatids.
 In this case, the symptoms of  pregnancy were evident from Nov. to Feb.
 When the  ovum is blighted, the belly ceases to enlarge in the  due propor-
 tion, and the breasts become flaccid.
   Dr. Denman gives an engraving of a diseased ovum: and Mr. Home relates
 a case, where the patient, after being attacked  with flooding, vomiting, and
 spasm in the abdomen,  died.  On opening her, the womb was found filled
 with hydatids, and its mouth  a  little dilated.  Trans, of a Society, &c. Vol.
 II. p. 300.—Such  cases as I have seen have been attended with a consider-
 able discharge; but as a great part of it was watery, it made a greater  ap-i
 pearance than the real quantity of blood would have caused.
   In a case related by Valleriola, p. 91, the woman had at first her usual symp-
 toms of pregnancy, but in the eighth month expelled hydatids.—Pichart in
 Zod. Med. Gall. an. 3, p. 73, relates a similar case, but the hydatids were ex-
 pelled in the fourth month without hemorrhage. Other cases of hydatids are
 to be found in Tulpius, lib.  HI. c. 32. Shenkius, p. 685. Mercatus de Mulier.
 affect, lib. HI. c. 8.  Christ, a Veiga Art Med. lib. III. § 10. c. 13, relates an
 instance of 60 hydatids, as large as chesnuts, being expelled.
   Stalpart Vander Wiel, Tom. I.  p. 301, mentions  a woman,  who in the
 ninth month, after enduring pains for three days, expelled many hydatids, and
 the process was followed by lochia. Lossius, Obs. Med. hb. IV. ob. 16, men-
 tions a widow who for several years had a tumid belly: after death, hydatids
 were found in utero.  See also Mauriceau's Observations, obs. 367.  Ruysch,
jObs. Anat. Chir. p. 25.  Albinus Anat. Acad.  lib. I. p.  69. and tab. HI. fig. 1,
 describes in an abortion,  the  commencement of this change. The vesicles
 are not larger than the heads of pins.   Wrisberg describes a more advanced
 stage in Nov. comment. Gotting. Tom.  IV. p. 73; and Sandifort, in his Obs. 
315
Anat. Path. lib. H. c. 3. tab. VI. fig. 5, has a case extremely distinct.  See also
Haller, Opusc. Path. ob. 48.
  Vigarous, Malad. &c. Tom. I. p. 385, proposes mercury to kill the hydatids.
He knew an instance where the woman discharged hydatids always when she
went a la garde-robe.  Mr. Mills relates  a  case, where the woman betwixt
tiie second and third month, had symptoms of abortion, and afterwards, in the
fifth or sixth, expelled above three pints of hydatids. Vide Med. and Phys.
Journal, Vol. H. p. 447.
  When the mass is expelled, it is found either to consist entirely of small
vesicles, or partly of vesicles, and partly of more solid remains of the ovum,
or coagulum of blood.
  NOTE 60, p. 99.—Hildanus relates a case  of this kind  in his own wife, did-
cissima et charissima conjux mea.  Hydatids may also be combined with preg-
nancy.  The same author tells us of a woman who,  in  the fifth month, was
dehvered of a mola aquosa, or vesicles containing ten pounds of water; she
did not miscarry, but went to the full time.
  NOTE 61, p.  100.—Kirkringius, p.  28, considers dropsy of the uterus as
impossible, and  says, that every case  of collection of water depends on a
large  hydatid.   Dr. Denman seems to be much of the same  opinion.  But we
find instances where water is accumulated and repeatedly discharged, ap-
parently from the removal of  a temporary obstruction.  Fernelius relates a
case,  where the woman always before menstruation  discharged much water.
Path.  lib. VI. c.  15.  And M. Geoffroy describes a case of repeated discharge.
Vide Fourcroy la Med. Eclare, Tom. II. p. 287. A case is related by Turner,
where the external membrane of the uterus  was said to be distended with
water.  The menses were suppressed, and a secretion  of whitish fluid took
place from the  breasts.  Phil. Trans. No. 207.
  NOTE 62, p.  102.—Sometimes the situation of the  abdominal viscera is
very much altered.  In Mr. White's case, the liver was found to descend to
the lower part of the belly, and the diaphragm was lengthened so as to allow
the stomach to reach the umbilical region.   Vide  Med. Obs. and Inq. Vol.
III. p. 1.   In a complicated case, related by Schlincker, the pylorus hung
down to the pubis.  Haller, Disp. Med. IV. 419.
  NOTE 63, p. 102.—This point is very well  considered by Vcrdier, in his
paper on Hernia of the Urinary Bladder, in the first Vol. of Mem. de l'Acad.
de Chir.  See also a paper by M. Tenon, in Mem. de l'lnstitute, Tom. VI p.
614.—Mr. Paget relates  a very interesting  case of prolapsus uteri, in which
the bladder became retroverted, lying above  the uterus.  It could not de-
scend before it, or along with it, being filled  with a calculus,  weighing 27
ounces, and others of a small size.  Some parts of the bladder were an inch
thick; a catheter could not be introduced.   Med. and Phys. Journal, Vol.
VI. p. 391.
   NOTE 64, p. 103.—Ruysch, feeling some  hard bodies in the tumour formeg
by the protruded parts,  cut out 42  calculi from the  bladder.  M. Tolet ex-
tracted fifty, and afterwards  cured the  woman with a pessary.  Duverney
met with large calculus in the bladder, with procidentia uteri; and Mr. Whyte 
316
 relates a similarfact Med. Obs. and lnq. Vol. in. p. 1.  See also Deschamps
 Traite de la T,jjlie, Tom. IV. p. 158.
   NOTE 65, £. 103.—Kirkringius says, nemo vitlit, nemo sensit, decepti oir.nes
 imagine falsa, alios  decipiunt,-  laxitas qu&dam colli qute extra pudendum pro-
 minet hec nobis fecit hidibrio.  Opera, p. 48.   Vide also  Job a Meckren,
 Observ. Chir. c. 51.   Barbette Chirurg. c. 8.  Roonhuyscn, Obs. Chir. part
 I. ob. 2.
   NOTE 66, p. 103.—Dr. Monro  mentions a procidentia uteri, in a very
 young girl.  It was preceded by bloody discharge. Works, p. 535.  Another
 case is related by Saviard, Obs. 15, in which the prolapsed uterus was mis-
 taken for the male penis; and as  Goldsmith's soldier believed they would
 allow him to be born in no parish, so this girl was in danger of being deter-
 mined to have no sex.
   NOTE 67, p. 104.—Morand  relates the case of a  woman  who had foetid
 dischai'ge from the vagina, accompanied  with pain. On examination, fungous
 excrescences were discovered  in the vagina, and amongst  these a hard sub-
 stance, which being extracted, was found to be part of a silver pessary The
 vagina contracted at this spot  and thus, though in a disagreeable  way, pre-
 vented a return of the prolapsus.   Pessaries have also ulcerated through to
 the rectum; and Mr. Blair mentions a woman in the Lock Hospital, who had
 introduced a quadrangular piece of wood into the vagina as a pessary, and
 which ulcerated thus into the rectum, producing great irritation.  Med. and
 Phys. Journal, Vol. X. p. 491.  It is likewise necessary, if the pessary have
 an opening, in it, to observe that the cervix uteri do not get into the open-
 ing, and become strangulated.
   NOTE 68, p. 106.—See Rossuet, Plater, and Platnf r, Inst. Chir. section
 1447.  Wedelius de  Procid.  Uteri, c. 4.  Volkamer,  in Miscel. Cur. an. 2.
 ob. 226.  Another case may be seen in  Journal  de Med. Tom LXVHI. p.
 195. Pare CEuvres, p.  970.—Carpus extirpated it with success.  Vide Longii
 Epist. Med. lib. II. epist. 39.—Slevogtius relates a distinct case, where the
 womb was  found in the  vagina, as  if in  a purse.  Dissert. 12.—Benevenius
 says, he saw a woman whose uterus sloughed off.  De Mirand. Morb. Causis,
 cap. 12.—Dr. Elmer supposes he has met  with a similar case.  Med. Phys.
 Journal, Vol. XVIII. p. 344.—The latest case is related by Laumonier.  The
 patient was long subject to prolapsus uteri, but at last the womb, with the
 vagina, was forced out so violently, that she thought all her bowels  had come
 out.  At the upper part of the tumour there was a strong pulsation.  It was
 extirpated  chiefly by ligature.   The woman died some years after this, and
 the womb was found wanting.   La Med. Eclare', par Fourcroy,  Tom. IV. p.
 33.  M. Baudelocque, however, says, that tiie uterus was  only partially ex-
 tirpated.  Vide Recueil Period. Tom. V. p. 332.
   NOTE 69. p. 106.—Harvey relates a case, where the tumour was as large
' as a man's head, ulcerated, and discharged sanies.  It was proposed to  ex-
 tirpate the prolapsed  uterus, but  the following night a foetus was expebYil,
 spiihama longitudine.   Opera, p. 558.  See  also a ease by Mr. Autrobus, in
 Med. Museum, Vol. I. p. 227. 
317
   NOTE 70, p. 107.—Dr. Burton had a patient, who in the fourth month of
 pregnancy fell, and was thereafter seized with suppression #f urine.  The
 os uteri was found almost at the orifice of the vagina.  He drew off about
 three quarts of urine, raised up the womb, and introduced a pessary.  Sys-
 tem, p. 156.
  NOTE 71, p. 107.—Mr. Dray mentions a case where, in the fourth month
 of pregnancy, the woman was seized with pains, like those indicating abor-
 tion, accompanied with suppression  of urine. The os uteri was very near
 the orifice of the vagina.  This disease proving fatal, the bladder was found
 to be thickened, enlarged, and in part mortified.  Vide Med. and Phys. Jour-
 nal, Vol. III. p. 456.
  NOTE 72, p. 107.—Reink mentions a woman who was  pregnant of twins.
 In the fourth month the womb prolapsed, and caused a fatal suppression of
 urine.  The vagina, at the upper part, was corrugated and inverted. Haller,
 Disp. Chir. Tom. III. p. 585.
  NOTE 73, p. 109.—Sampson, in the Phil.  Trans. No. 140,  describes an
 ovarium filled with hydatids, containing 112 pounds of fluid.—.Willi mentions
 a tailor's wife, whose ovarium weighed above 100 pounds, and contained
 partly hydatids, partly gelatinous fluid. Haller, Disp. Med. Tom. IV. p. 447.
  NOTE 74, p. 109.—In a case detailed by Vater, the patient had symptoms
 of pregnancy, secreted milk, and even thought she felt motion.   The belly
 continued swelled, and she had bad health for three years and a half, when
 she died.  The abdomen contained much water, and the right ovarium was
 found to be as  large as a man's head, containing capsules, filled with purulent
 looking matter.  The uterus was healthy, but prolapsed, and the ureter was
 distended from pressure. Haller, Disp. Med. Tom. IV. p. 401.  This was not
 a case of extra-uterine gestation, for the ovarium  was divided into cells, and
 had no appearance of foetus.
  NOTE 75, p. 109.—In some cases it does not ascend out of the pelvis, or
 if it do, the inferior part of the tumour sinks again into it.  Morgagni relates
 an instance where the ovarium weighed 24 pounds; and the lower part of it
 filled the pelvis so well, that when it was drawn out, it made a noise like a
 cupping glass when pulled away from the skin. Epist 39, art 39.
  NOTE 76, p. 109.—It may be combined with effusion of water in the ab-
 dominal cavity.  Dr. Bosch's patient had  16 pints  of water in the abdomen,
and both ovaria were enlarged so as to weigh 102 pounds. Phis patient com-
plained of great pain and weight in the lower belly, and over the right hip.
She was much emaciated, but the  menses were regular. When she was tap-
ped, not above two.tea-cupfuls of fluid were discharged.  Med. and Phys.
Journal. Vol VIII. p 444—Mr. French met with a case of ascites and drop-
sy of the ovarium.  The ovarium extended from the pubisto the diaphragm.
This patient had  voracious  appetite.   Mem. of Medical Society, Vol. I.
 p. 234.
  NOTE 77, p. 110.—If only one of the ovaria be enlarged, or if both be af-
fected, but only one much increased, the uterus is often not raised, because
the ovarium turns on its axis, and the litems lies below it.  In a  case with 
                               318

wliich I was favoured by Dr. Cleghorn, both ovaria were greatly tumefied, and
could be felt on each side of the navel, whilst immediately beneath that, they
seemed to be united by a flat hard substance; and when tiie urine was long
retained, a fluctuation could be perceived before that part.  Upon dissection,
a firm thick substance was found, extending from the pubis to the navel, be-
twixt the ovaria.  This  was  the  uterus and vagina.  The uterus itself was
lengthened, the cervix was three inches long, and all appearance of os tincx
was destroyed.  Her complaints began after being suddenly terrified; first
she felt severe pain in the right groin, with weakness of the thigh, and soon
afterwards perceived a tumour in the  belly, and presently another appeared
in the left side.  She was tapped 16 times.
  NOTE 78, p. 111.—In a case noticed by Dr. Denman, the labour was ob-
structed until the ovarium was emptied, by piercing it from the vagina.  The
woman died six months afterwards. Introd. Vol. U. p. 74. In Dr. Ford's case,
related by Dr. Denman, the crotchet was employed. See also a case by M.
Baudelocque, 1'Art des Accouch 1964.
  NOTE 79, p 112.—Dr. Denman justly observes, that diuretics have no ef-
fect, Vol. I. p. 122. And Dr. Hunter remarks, that "the dropsy of the ovarium
" is an incurable disease, and that the patient will have the best chance for
" living longest under it, who does the least to get rid of  it.  The trocar is
" almost  the only palliative."   Med. Obs. and Inqu.  Vol. II. p. 41.
  Willi, however, relates a case  of 14 years standing, which was cured by
diuretics; and it was calculated that the tumour contained 100 pounds of fluid.
Haller, Disp. Med. Tom. IV. p. 451.
  NOTE 80, p. 112.—Dr. Denman advises the operation to be deferred as long
as possible, and I beheve he is right; for every operation is followed by re-
accumulation, which is a debilitating process; yet it is astonishing how much
may in the course of time be secreted, without destroying the patient.  Mr.
Ford tapped his patient 49 times, and drew off 2786 pints.  The secretion
was at last so rapid, that three pints  and three  ounces were accumulated
daily.  Med. Commun. Vol. II. p. 123.  Mr. Martineau tapped his patient 80
times, and drewoff 6831 pints, or 13 hogsheads;  at onetime he drew off no
less than 108 pints.   Phil. Trans.  Vol. LXXIV. p. 471.
  [In the London Medico-chirurgical  Transactions, Vol. HI. p. 40. et seq.
may be found the history of a remarkable case of  ovarian dropsy, by Thomas
Chevalier, Esq. P. L. S. &c. The abdomen in  this case measured 63$ inches in
circumference, and 38 inches from the point of the ensiform cartilage to the
top of the pubis.  The navel when she sat was on a line with the knee.   The
quantity of fluid drawn off amounted to 17 gallons.  The patient died.]
   NOTE 81, p. 113.—Le Dran relates two cases  in the Mem. de l'Acad. de
 Chir. Tom. HI. In the first, the cyst was opened, and the woman cured of the
 dropsy, but a fistulous opening remained, p. 431.  In the second, he made a
 pretty large incision, and introduced a canula into the sac.  The operation
 was followed by fever, delirium,  and vomiting; the woman retained nothing
 but a httle Spanish wine for three  weeks.  She discharged daily 8 or 10
 ounces of red fluid.  At length, all of a sudden, 15 ounces  of white pus were 
319
evacuated, and then the  symptoms abated; but a fistula remained for two
years; then it healed, p. 442.
  [Dr. M'Dowell of Danville, Kentucky, relates three cases of extirpation of
diseased ovaria, in Eclectic Repertory, for April, 1817. Vol. VII. p. 242. The
patients recovered.]
  Dr. Houston relates the case of a woman in this neighbourhood, in whom
lie made  an incision 2 inches long into the ovarium, and then with a fir splint
turned out a great quantity of gelatinous matter and  hydatids.  He kept the
wound open with a tent,  and succeeded in curing the patient.  The disease
was attributed to rash extraction of the placenta, and had existed for 13 yearJ.
It was attended with violent pains.  Phil. Trans. XXXIII. p. 5.
  M. Voison relates a case, which was palliated by  tapping, and keeping a
fistula open.  Recueil Periodique, Tom. XVII. p. 381.   And Portal gives an
instance,  where, by keeping the canula in the wound for a short time, a radi-
cal cure was obtained, and the person afterwards had  children. Cours d'Anat.
Tom. V. p. 554.
  NOTE 82, p. 113.—De La Porte tapped a woman who had a large tumour
in the belly, but nothing came through the canula.  He made an incision of
considerable length, and, in the course of two hours and an half, extracted
35 lb. of jelly.  The lips of the wounds were then brought  together. Next
day 15 lb. of jelly were evacuated, but presently vomiting and fever took
place; and she died on the thirtieth day, having discharged altogether 671b.
of fluid.  This disease was of sixteen months standing, and was attributed to
hemorrhage.  Mem. de l'Acad. de Chir. Tom. III. p. 452.
  Dr. Denman notices the case of a patient, who died the sixth day after in-
jecting the ovarium. Vol. I. p. 122.
  NOTE 83, p. 113.—Dr. Monro, in Med.  Essays, Vol. V. p. 773, details the
history of a patient who  had a diseased  ovarium, and in whom the tumour
pointed about four inches below the naveL  It was opened, but nothing but
air came  out, followed next day by faeces; on the fifth day some pus was dis-
charged.   She gradually  improved in health, and the tumour of the belly
subsided; but in two years afterwards the suppuration was renewed, and she
died.  In this case, the colon had probably adhered to the ovarium.
  NOTE 84, p. 113.—Dr. Denman relates the case of a patient, who, having
for some time suffered from pain and tenderness about the  sacrum and ute-
rus, and uterine hemorrhage, was  suddenly seized with vomiting, syncope,
pains in the belly, and costiveness; presently a tumour was felt in the right
side, and this soon occupied the whole  abdomen. This patient was  cured,
after purging a gelatinous fluid.  Med.  and Phys. Jour. Vol. II. p. 20.     ; ..
  NOTE 85, p. 114.—Dr. Monro  relates a case of supposed pregnaney, in
the tenth month of which, the tumour was  removed by an aqueous discharge
from  the vagina.  In a future attack, however, violent  bearing-down pains
were excited, and the woman died exhausted.  The  left ovarium was found
greatly enlarged with vesicles.  Med. Essays, Vol. V. p. 770.
  NOTE 86, p. 114.—See  Dr. Baillie's Morbid Anatomy, chap. 20.  Dr. J.
Cleghorn  mentions  a woman who died ten days after being tapped. The- 
320
 right ovarium was found  greatly enlarged, and had many cells, some con-
 taining hair, cretaceous matter, fragments of bone and  teeth, other gelati-
 nous fluid   Trans, of Royal Irish Acad. Vol. I. p. 80. In Essays Phys. and
 Literary, Vol. II. p. 300, a case is mentioned, in which the one ovarium con-
 tained many vesicles; the  other contained a mass, like brain, with bones
 and teeth.  In the  Museum attached to the hospital  at Vienna, there is a
 large ovarium, the inner surface of which is covered with hair. Horstius met
 with an ovarium, containing hair, purulent-looking and oily matter. Opera, p.
 249.  Schenkius met with fat and hair, p. 556, and  Schacher relates a simi-
 lar case in Haller's Disp. Med. Tom. IV. p. 477.  Ruysch, in his Adversaria,
 says, he met with bones and hair, and Le Rich, in the  Hist, de l'Acad. de
 Sciences, 1743, met  with  hair  and oil, in cells, together  with  bones and
 teeth.   See also Recueil Period. Tome XVB. p. 462.
   NOTE 87, p. 114.—Duverney saw a tumour extirpated from the scrotum,
 containing fleshy matter and bones. CEuvres, Tom. II p. 562. And M. Dupuy-
 tren presented a report to the Medical School at Paris, relating the history of
 a tumour found in the abdomen of a boy, containing a mass of hair, and a foetus
 nearly ossified. It was supposed, that at conception, one germ had got with-
 in  another.  See Edin. Med. Jour.  Vol. I. p. 376.  From the respectable
 evidence of Baudelocque, Le Roy, &c. this cannot be placed  on a footing
 with Halley's case of a greyhound dog, who voided by the anus a  hving
 whelp ! Phil. Trans. Vol. XIX. p. 316.  I beheve that bones, hair, &c. have
 been found in a gelding.
  NOTE 88, p. 114.—Schlencker mentions  a woman, who, soon after deli-
 very, felt obtuse pains in the left side, and presently a swelling appeared in
 the  belly.  She had bad appetite, swelled feet prolapsed uterus, and sup-
 pression of urine and fxces.  The left  ovarium was hard and stony,  and
 weighed 3 ounces. Haller, Disp Med. Tom. IV. p. 419. In this case the tume<
 faction of the belly could not be caused by the  presence of the ovarium, but
 rather by the pressure on the intestines.
  NOTE 89, p. 114—Vide case by  Fontaine, in  Haller, Disp. Med. Tom.
 IV. p. 485.  The patient had tumour of the  abdomen, with lancing pains in
 the left side, extending to the thigh.   The left ovarium weighed 10 pounds,
 the right was as large as the fist, and both consisted of fatty matter.  Portal
 likewise relates a case of this disease, where the right ovarium was as large
 as a man's head, very  hard, and filled with  steatomatous matter, weighing
 altogether 35 pounds.   The uterus and bladder were turned to the left side.
 No water was effused, but the person was cut off" by hectic and diarrhoea.
 Some steatomatous concretions were found in the lungs.  Cours d'Anatomie,
Tom. V. p. 549.

                             CHAP. xn.

  NOTE 1. §. 1. p. 121.—Although hysteria be not a diseased state of men-
 struation, yet as it is a very general attendant upon deviations of that action,
 and a very frequent and distressing complaint  to which women are subject,
 it willbe properto notice it briefly at this time. 
321
   In the well marked hystei'ic paroxysm, a sense of pain or fulness is felt in
 some part of the abdomen, most frequently about the umbilical region, or in
 the left side, betwixt that and the stomach.  This gradually spreads, and the
 sensation of a ball is felt passing along.  It mounts upwards, and by degrees
 reaches the throat, and impedes respiration, so as to give the  feeling of a
 globe  in the  oesophagus, obstructing  the  passage  of the air, and, as Van
 Swieten observes, the throat appears sometimes really to be distended.  The
 patient now falls down convulsed, and apparently much distressed in breath-
 ing, uttering occasionally shrieks, something hke the crowing of a cock, or
 sobbing violently,  or otherwise indicating a spasm of the muscles of respi-
 ration.  She is generally pale, and frequently insensible, at least during part
 of the fit, and seems to be in a faint;  but when  she recovers, she is con-
 scious not  only of having been ill, but of  many things which passed  in a
 state of apparent insensibility.  After remaining for some time in a state of
 considerable agitation of the muscular  organs, the affection abates, and the
 patient remains langiud and feeble, but  gradually recovers, and presently is
 restored to her usual health.  This restoration is accompanied with eructa-
 tion, which indeed often takes place during the paroxysm; and also by the
 discharge of limpid urine, which, by Sydenham, is considered as a pathogno-
 monic  symptom  of hysteria.  Head-ache is also apt to follow a fit.
   Besides producing these regular paroxysms, hysteria still more frequently
 occasions many distressing sensations, which are so various, as not to admit of
 description.  Of this  kind are violent head-ache, affecting only a small part
 of the head, sudden spasms of the bowels, dyspnoea, with  or without an ap-
 pearance of croup, and sometimes attended  with a barking cough, irregular
 chills,  and  sudden  flushings  of  heat, spasmodic pains, palpitation, syncope,
 &c.  These, if  severe, or frequently repeated, are generally attended  with
 a timid or desponding state of mind.
   During an hysteric fit, the patient is  to be laid in an easy posture, a  free
admission of cool air is to be procured,  the face is to be sprinkled with cold
 vinegar or  Hungary water, volatile salts are to be held to the nostrils, and if
she can swallow, 30 drops of tincture of opium are to be administered,  with
the same or a greater quantity of ether,  in some carminative water; or should
there be a tendency to syncope, a drachm of the spiritus ammonix aroma-
ticus may be conjoined.
   A similar combination of opium is the most powerful  remedy in the differ-
ent hysterical affections above enumerated.  But it is  further useful to re-
mark, 1st, that local pain is frequently removed by sinapisms, with or with-
out the internal use of opium; 2d, that severe affections of the organs of re-
spiration sometimes yield  more speedily to emetics than  to antispasmodics,
or may even require the use of the lancet, but this mode of evacuation  is to
be avoided as much as possible, as it increases a disposition to  the disease;
 3d, that irregular action of the heart, besides requiring  powerful antispasmo-
 dics, demands, more  than  any other symptom,  during  the attack, a state of
rest, and the removal of every thing which can agitate the mind; 4th,  con-
tinued insensibility, or coma* is a very  dangerous symptom, as it may end
   VOL. I.                            T T 
3£2
fatally; the lancet ought to be early, but not largely used, the bowels should
be emptied, and the head covered with a blister.
  The prevention of regular hysteric fits, or of individual symptoms, is to be
attempted by a tonic plan, especially by the use of the cold bath, moderate
exercise, preserving a correct state of the bowels, or even giving pretty power-
ful purges, and the administration of preparations of steel; the mind ought
also to be called as much  as possible from brooding over the disease; for in
hysteria, the patient  is frequently desponding, and anticipating many evils.
The menstrual action, if  irregular, must, if possible, be rectified by appro-
priate remedies. The diet should be hght, and rather sparing, and all causes
of debility must be avoided.
  If particular symptoms should be frequently repeated, or the fits occur
often, it may be useful to conjoin along with this plan, the exhibition of some
antispasmodic medicine, such as valerian, assafoetida, or camphor.
  Hysteria may occur during the course  of other diseases, or in the stage of
convalescence from them. In the first case, it may cause some deviation from
the regular progress or train of symptoms of the disease, and, it is to be feared
sometimes calls the attention of the practitioner from more serious parts of
the patient's malady.

                              CHAP. XV.

  NOTE 1, p. 160.—In the  eg'gs of fowls, we observe the following circum-
stances.  1st, Upon removing the porous shell, we find the albumen inclosed
in a membrane, consisting of two layers, and called sacciform  by Levielle.
These are separated from each other at .the large end of the shell, so as to
form a small  sac, called  the folliculus aeris.  The albumen is divided into
three strata;  the first, or  cortical, is most liquid; the second, or middle, is
more abundant, and thicker than the first, but less so than the third or central.
The middle and central strata are  inclosed in a delicate  membrane, called
leucilyme by  Levielle, which separates them from the corticle.   2d, Within
the albumen  we have the vitellus  or yolk, which is inclosed in a vascular
membrane, called chlorilyme, or membrana vitelli, which again is enveloped
by a membrane common  to it and the intestines of the chick, called entro-
chlorilyme.   3d, To  each end of the vitellus, we have connected a portion of
the central albumen, called chalaza; and in each of these a membranous sub-
stance is discovered, attached to the membrane of the vitellus, and a vascular
structure, which can absorb the albumen into the vitellus, to contribute to
the nutrition  of the chick. 4th,  Upon the vitellus, we observe the cicatriculn,
or small sac,  called by Harvey the eye of the egg, and which was  supposed
to contain the foetus, the rudiments  of which are allowed by Malpighi, Haller,
and Spallanzani, to be pre-existent to fecundation.  This cicatricula was con-  „
sidered as analogous to the amnion, and supposed to  contain a transparent
fluid, called by Harvey colliquamentum candidum, or liquor amnii.  More
modern observations ascertain that the embryo  is not formed in the cicatri-
cula, but very near it on the vitelms, and tliat the amnion inclosirtg it, can at 
823
first scarcely be distinguished from the embryo.  The cicatricula soon dis-
appears.   Harvey's account must therefore be transferred to amnion.   5th,
During incubation, the vitellus becomes specifically lighter than the albumen,
and rises toward the folliculus aeris.   Two arteries and two veins go  from
the messeraic and hypogastric vessels of the foetus, to the membrane of the
yolk, and  are supposed to absorb the vitellus,  which therefore is carried
to the vena portx of tiie chick, and nourishes the foetus. There is also a con-
nection betwixt the intestines and vitelline membrane, by means of a liga-
mentous substance, which was supposed by Haller and Vicq. D'azyr to be a
tube, and called vitello-intestinal canal, for it is said that air has  been passed
through it.  It was supposed to absorb the yolk, by many villi on the  inner
surface of the vitelline membrane ; but these are said by Levielle" not to be
vessels, but  soft lamellated plates.  At the end of the second day, red  blood
is observed on the membrana vitelli. A series of dots are formed, which are
converted first into grooves, and then  into vessels, which  go to the foetus.
This appearance has been called figura venosa, and the marginal vessel vena
terminahs.  6th, The vitello-intestinal ligament, and these vessels, form an
umbilical cord.   But besides these, we find, after the  fourth day, a vascular
membrane at the umbilicus, called membrana umbilicalis, which rapidly in-
creases, and comes presently to cover the inner surface of the membrane of
the shell.   It is the chorion, and has numerous  vessels ramifying on it, like
the chorion of the sow, and connected in like manner with the  foetus.   The
blood of the umbilical artery is dark-coloured, that of the vein bright.   7th,
As incubation advances, the amnion enlarges,  and comes in contact  every
where with the chorion. The albumen is all consumed, being taken into the
vitellus, which is in a great measure absorbed;  and what remains is taken,
together with the sac, into the abdomen of the cluck, and the parietes close
over it.  On the 21st day, the chick breaks the shell and escapes.   By in-
creasing or  diminishing the temperature within  a certain extent, the process
may be somewhat accelerated or retarded.  The eggs of large birds require
a longer  time to  be hatched; those of the  ostrich, for example, take six
weeks.
   Hence it appears, that the vitellus and albumen contribute to the increment
of the foetus, whilst the exterior membranes act as lungs, the air being  trans-
mitted through the pores of the shell.
   The eggs of fishes have a general resemblance to those of fowls, and con.
sist of a vitellus and albumen, with their membranes; but in place of being
furnished with a shell, they have a tough, or  sometimes a horny covering,
and some, as those of the  shark, torpedo,  &c.  are quadrangular in shape.
The yolk is connected to the intestines of the foetus, and its membrane is very
vascular.  As in fowls, so in fishes, it is ultimately inclosed within the  abdo-
men of the young.  In the skate, numerous blood vessels are formed in the
albumen,  which supply the place of gills, and are supposed by Dr. Monro,
to be afterwards covered and converted into gills.  The  two functions of a
placenta, then, are still more distinctly fulfilled  here than even  in fowls, for
the apparatus for nutrition and respiration has different or distinct termina- 
SM
   tions; whereas in fowls and quadrupeds, all the vessels enter at one place.
   A similar fact is observed in the ova of frogs, for the umbilical cord in the
4  tadpole goes to the head.
     The egg of the serpent is nearly the same with that of the fish, and is in-
   closed in a flexible membrane.  The foetus is coiled up spirally within it, and
   the chorion is vascular, as in the egg of the fowl.
     The adder is a viviparous animal; its uterus is membranous, and divided, I
   find, into eight or nine cells, each of which, in September, contains an ovum as
   large as a chesnut.  This consists of an exterior membrane, which incloses a
   foetus about six inches long, and coiled up.  About an inch from the tail, the
   umbilical cord passes out, which consists of vessels that go to ramify on the
   exterior membrane, which resembles the chorion of the sow.  There is also
   a connection with a vitellus, which is as large as a hazel nut.
     The coluber natrix is said, by Valmont-Bomare, to have a placenta and cord
   within the egg, but  this is  contrary to the general structure of eggs; most
   likely the chorion has been taken for the placenta.  The  eggs  of reptiles
   are often deposited in packets, the eggs being g-lued together.
     The egg of the turtle is as large as a lien's, and is inclosed in a covering
   like parchment It is deposited in the sand, and is hatched in about 24 days.
   The egg of the alligator is similar in structure to that of the turtle ; it is rather
   larger than a goose's egg, and covered with a thin skin, so transparent, how-
   ever, that the foetus may be seen through it.
     Those animals which are called oviparous hatch their eggs out of the body
   either by sitting on them as we see in fowls, or by exposing them to the heat
   of the sun, as the turtle, crocodile, and many serpents.   Oviparous  fishes,
   which comprehend all those called osseous, expel their ova into the water,
   where they are fecundated by the  male, but without copulation.  Many fishes
   leave the sea, and come up the rivers to spawn. Others remain in the ocean;
   and the eggs, specifically lighter than the water, float on the surface.  Many
   fishes attach them to marine plants, and in some cases the ova are fixed to
   the body of the parent.  The ova  are covered with a kind of mucus, which
   has been supposed to defend them  from the water.
     The ova of  frogs, &c. are  likewise fecundated and  hatched out of the
   body.  They are enveloped in a glary matter, which perhaps contributes to
   their increase; for during incubation, the egg both enlarges and changes its
   shape.
      Those animals which hatch their eggs  within the body are  called ovo-
   viviparous, such as cartilaginous fishes, as the shark, skate, and torpedo, &c.
   The scorpion and venomous serpents also belong to this class. Ovo-viviparous
   animals expel  the young fully formed, and therefore have been sometimes
   considered as  having uteri hke quadrupeds, and a cord attached directly to
   it.  SpaUanzani at first supposed  that the foetus of the torpedo was attached
   directly to the uterus, but afterwards found that it was contained in a distinct
   ovum.  Experiences, p. 294.   See also Cuvier Lecons d'Anat. Comparee,
   Tom. V. p. 142. The shark is said to have an uterus like the bitch, and Belon
   says he saw a female dehvered  of eleven young, attached by a cord. Its mode 
325
of gestation most likely is similar to the torpedo. This class expel their young
often very quickly.  A female syngnatus hyppocampus was observed to ex-
pel at least a hundred in a very short time.
  Analogous to ovo-viv iparous animals, are those which receive the ova into
cells on the surface of the body, where they are hatched.   This is well seen
in the pipa, a species of toad.  Even the tadpoles are  said to be  metamor-
phosed in these cells.   The opossum tribe has a modification of this gesta-
tion; for in them the foetus, when very small, is expelled into a bag situated
on the belly, and immediately attaches  itself to a nipple.  The utero-gesta-
tion of the opossum  of North America lasts only from 20 to 26 days, and the
embryo  when expelled does  not exceed a grain. It remains in the sac about
50 days, and acquires the size of a mouse.   In other animals, as for instance
the bat, the young after birth attach themselves to the nipple, partly for the
convenience of being transported or carried about.
  In  plants, we  find likewise a placenta  or structure,  intended for the
nourisliment and respiration  of the foetus.   To take the kidney bean for an
example,  we find within  the membranous covering two parenchymatous
lobes, or cotyledons; and at the margin betwixt these, there is the corculum
or cicatricula.   During incubation, we find that  this sends up a small shoot
called the plumula, and down a radical into  the earth.  But to support the
plant until the  root  and  leaves  are capable of maintaining it we find the
cotyledons rise  up out of the earth, on each side of the plumula, forming
what are  called seed leaves.  These both serve for the respiratory organs,
and also supply pabulum, which is absorbed by proper vessels, and in con-
sequence thereof they presently are destroyed. When there are more lobes
than two in the seed,  there are a corresponding number of seed leaves.  In
many cases these cotyledons do not rise out of the ground, but the plumula
alone appears.  This  is the case with the garden pea, but the  cotyledons
still perform their functions below the ground, and  exist until the foliage of
the plant, or adult organs, be formed.  The  greatest part, then, of a vegeta-
ble seed or ovum, consists, like the eggs of fowls, of an apparatus intended
for the  nutriment and respiration of the foetus, whilst the embryo itself is
very small. The cotyledon consists, in many  eases, of a farinaceous sub-
stance.  In other seeds it is  oily and farinaceous, and in some is almost
all oily.
  Vegetable ova sometimes are contained in a dry pericarpium, and are shed
into the earth when it bursts.  But others have an  apparatus provided, not
only for their present  growth, but also for accelerating their incubation in
the earth.   In stone fruit and nuts, we find that vessels  pierce the shell at
the bottom, and pass on toward the top,  and reach the  kernal or lobes, which
are contained within the shell, enveloped in  a soft membrane. They arc in-
serted very near the embryo.   Now, for the  farther  support of these parts,
we find  that stone fruits are covered with a  quantity  of nutritious  matter.
The almond, for example, has  its  ligneous nut covered with a fleshy sub-
stance about an inch thick, inclosed in a proper  membrane.  The rhamnus
lotus has the  stone surrounded with farinaceous matter, which tastes like 
326
gingerbread.   Other seeds are contained in a parenchymatous or succulent
substance, as the apple or pear, or in a firm white substance like cream or
marrow, or in a mucilaginous matter as the gooseberry, or in an organized
puln. as the orange and garcinia  mangostona.   Some  are  deposited in a
luscious fluid at first, which ultimately becomes farinaceous, as the plantain.

                            chap. xvn.

  NOTE 1, p. 169.—In Dr. Clark's case the morning sickness, and other
signs of pregnancy, appeared very  regularly.   At the end of nine months,
attempts were made to expel the foetus. These were followed by inflamma-
tion and decline of health.   Then  suppuration took place, and  the  patient
sunk.  Transactions of a Society, &c.  Vol.  II. p. 1.  In Mr. Mainwaring's
case, in  the  same work, p. 287,  the  patient suffered much from morning
sickness, and pain at the groins.
  NOTE 2, p. 169.—In the Journal de Scavans for 1756, we are told of a
woman at Louvain, who at first had so dreadful pain when she went to stool,
that she thought her bowels were coming out.—In Pouteau's case, the woman
suffered great pain till after the second month.  Melanges, p. 333.
  NOTE 3, p. 169.—Bianchi mentions a case, in which, in the first months,
the woman complained of  great pain  in the lower belly, with nausea and
fainting fits. The motion  of the  child ceased in the fifth month, and then
milk was secreted.   De Nat. in Hum. Corp.  Vitioso Morbosoque Gener. p.
166.—In  Dr. Mounsey's case, the pain, vomiting, and fainting fits, continued
till the  woman quickened.  Phil. Trans. Vol. XLV.  p.  131.—In Dr. Fern's
case, the person complained of great pain till the third month; and from that
period till the eighth month, was subject to convulsions and syncope.  Phil.
Trans. Vol. XXI. p; 121.
  NOTE 4, p. 169.—In Dr. Perfect's case, no labour  pains came on, but the
motion of tiie child ceased at the end of nine months.   The abdomen neither
increased nor diminished in size for two years and seven weeks ; but she
was afflicted with constant pains in the hypogastric region, attended with
fever, and  finally sunk  under marasmus.   Cases in Midwifery, Vol. 11.
p. 164.
  NOTE 5, p. 170.—Vide cases by  Longius, in his Epistolx,  Tom. II. p.  670.
Tulpius Opera, lib IV. c. 39, p. 358.—Pouteau in his Melanges, p. 373.—Air.
Shiever,in Phil. Trans. No.  303, p.  172.—Winthrop, Phil. Trans. Vol. XLHl.
p. 304, and Simon, p. 529.—Lindestaple, Vol. XLIV. p. 617.  Morley,  Vol.
XIX. p. 486.  Gordon, in Med. Comment. Vol. XVIII. p. 323.  Cammel, in
Lond. Med. Jour. Vol. V.  p. 96.  Case by M. Bergeret, in the Recueil Pe-
riodique.Tom. XIV. p. 289.
  NOTE 6, p. 170.—Vide Marcel. Donatus, De Med.  Hist. Mirab. lib. IV. c.
22.—Horstii Opera, Tom. II. p. 536. In this case, the foetus was discharged
both by the vagina and rectum.—Benevoli, in his  Dissert, p. 104, gives an in-
stance where the greater part of the child was expelled by the vagina, but the
woman died before the process was completed.—Mr. Smith's case, in Med 
327
Comment. Vol. V. p. 314.—In Mr. Colman's case, pains came on, and the head
was felt in the pelvis at the time of her reckoning, and long afterwards, but
the os uteri could not be perceived. In some time, hectic fever, with diarrhoea
and sore mouth, appeared.  Six months after her attempts at labour, an onen-
ing was felt in the vagina, but  very  unlike the os uteri.  The hand was in-
troduced, and a putrid child was extracted.  Some fxces continued to come
by the wound, but at last she got well. Med. and Phys. Jour. Vol. II. p. 262.—
See also Camper's case, in his Demonst. Anat. Path. lib. II. p. 16, and Dr. Fo-
thergiU's case, in Mem. of Med. Society, Vol. VI. p. 107.
  NOTE 7, p. 170.—Vide Stalpart Vander Wiel, Opera, Tom. I. p. 305.  In
this case, bones came away with the urine.—In the case of Ronseus, the
child was discharged parti}  by tiie bladder, but chiefly by the anus.  Epist.
Med.—A similar instance is  related by  Morlanne,  the extraneous matter
forming  a nucleus for a calculus.   Recueil Period. Tom. XHI. p. 70.—In
Prof Josephi's case, the child was found altogether  in  the bladder.  Med.
and Phys. Jour. Vol. XIV. p. 519.
  NOTE 8, p. 170.—Vide case of Mrs. Stag, in Lond. Med. Obs. and Inqui-
ries, Vol. II. p. 369;  and cases by Mr. Jacob,  Dr. Maclarty, and  others.
   NOTE 9, p. 170.—In Mr. Giffard's case, the child was expelled entire by
the anus, and even the cord was found hanging out of the intestine.  Phil.
Trans. Vol. XXXVI. p. 435.—See also Mr. Goodsir's case, in Annals of Me-
dicine, Vol. VII. p. 412.
   NOTE 10, p. 170.—In Dr. M'Knight's case, although the exsarean opera-
tion was performed before any bad effects were produced on tiie health, no
part of the placenta could be found.
   NOTE 11, p. 170.—In Dr.  Clark's case, the tube burst in the second month,
and the woman died from loss of blood.  Transactions of a Society, Vol. I. p.
216.—Vide case by  Duverney, in  his works, Tom. II. p. 353,  and by M.
Littrein the Memoirs of the Acad, of Sciences, for 1702, and by Itiolan, in
his works.  See also Med. Comment. Vol. 1. p. 429.—In Mr.  T.  Blizard's
case, rupture took place at a very early  period, for the woman had miscar-
ried only five weeks previous to this event.   Vide Edin. Phil. Trans. Vol. V.
p. 189.—Mr. Tucker's case, Med. and Phys. Journal, XXIX. 448.
   NOTE 12, p. 170.—I have known .the foetus retained for twenty years;  and
there are some instances, where  it has been retained thirty, forty, or fifty
years.  Mrs. Huff, whose case is related in the Med.  ainl Phys. Jour, for May
1800, carried the child fifty years.  Middlcton's patient carried it sixteen years.
Phil. Trans. Vol. XLIV. p. 617. Mounsay's thirteen years, Vol XLV. p.  121.
Steigertahl's forty-six years, Vol. XXXI. p. 126. Broomfield's nine years,  Vol.
XLI. p.  696.  Sir P.  Skippon's patient discharged  it by suppuration at the
groin, after retaining it twenty years, Vol. XX1V. p.  2070.  See also cases by
M. Grivel, in Edin. Med. Jour. Vol. II. p. 19, and Dr. Caldwell, p. 22.  Some-
times no attempt is  made to expel, but the foetus is converted into a  sub-
stance, which Fourcroy finds to resemble the gras des cimetiercs.  System,
Tom. X. p. 83.  Sandifort relates a case, where, after attempts at labour, no
further inconvenience was  sustained, but the child was found after twenty- 
328
 two years to be indurated.  Observationes, lib. II. p. 36.  He quotes Ncbel
 for a case, where  it was retained fifty-four years.  Chesclden found it con-
 verted into earthy matter.  The late Mr. Hamilton of this place had a pre-
 paration of a foetus, covered with calcareous matter, which was retained 32
 years.  This woman had pains at the end of nine months, after which the
 belly decreased in size.
   NOTE 13, p. 170.—In the 5th Vol. of the Edin. Med. Essays, there is re-
 lated a case, in which  the patient  seemed to have a second extra-uterine
 pregnancy before she  got quit of the  first.—See also Primrose de Morb.
 Mul. p. 326.—Mr. Hope, in the 6th Vol. of the Med. and Phys. Jour. p. 360,
 details  a  case,  where the woman in the seventh month of pregnancy had
 pains, which continued for three weeks, and then went off, leaving a hard
 tumour on the  left side, which was somewhat painful; she then had another
 pregnancy, and a  fortnight after delivery, began, after taking a laxative, to
 vomit, and continued to  do so, ultimately throwing up feculent matter.  The
 case ended fatally.—See also Turk, in Haller, Disp. Chir. IV. 793.
   NOTE  14, p. 170.—In Mr. White's case, related in  Med. Comment. Vol.
 XX. p. 254, the symptoms were very hke those of retroversion, and the case
 was only distinguished by the result. In  Mr. Cammel's case, there was not
 only a  tumour betwixt  the vagina and rectum, but the os uteri was turned
 upward and forward. Lond. Med. Jour. Vol. V. p. 96. Mr. Kelson's case very
 much resembled retroversion, for in the tenth week both the urine and stools
 were obstructed.   In about a fortnight,  the  impediment  was suddenly re-
 moved, and the uterus felt in situ.  She continued well till the ninth month,
 when labour ineffectually came on; but  in  process of time, tiie  child was
 discharged by the anus.   Med. and Phys. Jour. Vol. XL p. 293.
  NOTE 15, p. 171.—Boehmerlongagoobservedthis; and Dr. Baillie, in the
 79th Vol. of the Phil. Trans, mentions, that Dr. Hunter had a preparation of
 tubal pregnancy, in which the uterus was found enlarged to double its na-
 tural size, and containing decidua.   He also  states, that in an ovarian case,
 the uterus was enlarged, thick, and spongy, and  its vessels enlarged.  Dr.
 Clarke found the uterus, in the  second month of an extra-uterine pregnancy,
 exactly of the same size  as if the embryo had been lodged within  it.  The
decidua was formed, and the cervix filled with gelatinous matter.  Trans-
 actions of a Society, Vol. I. p.  216.  See also a case  by  Saviard,  in  Phil.
 Trans. No. 222,  p. 314.   A case, similar to Dr. Clarke's  is related by Mr. T.
 Blizard, in the Edin. Phil. Trans. Vol. V. p. 189.  See also Annals  of Med.
 Vol.111, p. 379.
  NOTE 16, p.  171.—In  Mr. Houston's case, the cervix was so closed up that
it would not admit a probe.  Phil. Trans. Vol. XXXH. p. 387. The decidua
woukl appear sometimes to enlarge, and form a mass like placenta, which in
Mr. Turnbull's  case was expelled with  hemorrhage.   Mem. of  Med. So-
ciety, Vol. m. p. 176.
  NOTE 17, p.  171.—In a case related  by Varocquier, the ovarium did not
acquire a larger size than an egg.  The woman died, after suffering violent
pain in the left side, low  down.   The viscera were slightly inflamed.  Mem. 
329
 de l'Acad. de  Sciences, Tom. CXI1I, p. 76.   In  the case by L'Eveille, the
 foetus was apparently betwixt three and four months  old.  Rapport de  la
 Societe" Philomatique, Tom. I. p. 146.  See also a case  in the  Recueil
 Period. Tom. XIII. p.  63;  and in the  Recueil des Actes  de la Societe de
 Lyon
   NOTE  18, p. 171.—Vide  Chambon,  Malad. de la  Grossesse, Tom II. p.
 ?>73.  Case by St.  Maurice, in Plul. Trans. No. 150, p. 285.  In the case re-
 lated by La Rocque, the ovarium  was found ruptured, and the abdomen full
 of blood.  Journ. de Med 1683.  Boehmer found the ovarium ruptured, and
 the foetus half expelled.  Obs. Anat. fuse.  prim. Dr.  Forrestier's patient,
 after violent colic  pains, voided blood  by the anus. The  hemorrhage and
 fainting fits  proved fatal. The foetus was found in the  ovarium.  Annals  of
 Medicine, Vol. III. p. 379.
   NOTE 19, p. 171.—Vide Roederer, Elemens, c.  15. §. 758.   In Air. Dumas'
 case, a fluid  like chocolate was drawn off by tapping, which was twice per-
 formed.  The ovarium contained hair, bones, &c. La  Med Eclaree, Tom.
 IV. p. 65.  Mr. Bell's tubal case excited ascites.
   NOTE 20, p. 172.—Vide Dr. Kelly's case, in Aled. Obs. and Inquiries, Vol.
 IH. p. 44.  In Mr.  Clarke's  case, the placenta was attached to the kidneys
 and intestines. Mem of Med. Society, Vol. III. p. 197.  In the Mem.  of the
 Acad, of Sciences, there is a  case related, where the placenta adhered to the
lumbar vertebrx.   In  the history  by La Coste,  it was placed under the
 stomach and colon.  Vide CEuvres de  Duvemey, Tom. II.  p S63.  In Mr.
 Turnbull's case, it was very  thin, and adhered to the intestines.   Mem.  of
 Aled. Society, Arol. III. p. 176. A case of ventral pregnancy, complicated with
hernia, is related by M. Martin in the  Recueil des Actes de la Societe de
 Sante de Lyon.  Courtial found it adhering to the stomach and colon.
   NOTE 21, p. 173.—Dr. Maclarty relates the case of a negress, where the
breech of the child protruded through an ulcer,  at the lower part  of the
 abdominal tumour, and the arm at the upper part of the tumour.   The in-
termediate portion of skin was divided,  and the fcetus extracted.  The head
of the child stuck firmly, but was brought out with the forceps.  There was
no placenta, but putrid matter was discharged with the child.  The woman,
 recovered.  Med.  Comment. Vol.  XVII. p. 481.  Another case is related
by Duvemey, where the child was extracted from the groin; and  this  is
one of the rare instances where the placenta was  not destroyed.   It was ex-
tracted with the child.  CEuvres,  Tom  II. p. 357. Cyprianus gives  an inr
stance of the child being removed, after having been retained twenty-one
months.  Histor. Fcetus Hum. Salva Matre, ex Tuba F.\cibi.  Mr Brodie en-
larged the navel with  a lancet.  Phil. Trans. Vol. XIX. p.  580.   See also
 M. Baynham's case, in Med.  Pacts, Vol. I. p. 73.  In Mr. Bell's case an inci-
 sion four inches in length was made, and the bones of two children extracted.
 Med. Comment. Vol.11, p. 72. Dr. Haighton  relates an interesting case,
 where some bones were discharged by the  vagina, but the tumour also
 pointed above the pubis, and through this one of the ribs  appeared.  The
 practitioner made an  incision, but so great hemorrhage came on, that he
   VOL.  I.                            U t 
330
was obliged to apply a bandage till next day, when he extracted the bones
The  woman recovered.  Med. Records, p. 260.  Dr. M'Knight performed
the operation in  the twenty-second month,  although the woman  enjoyed
tolerable health; very dangerous symptoms supervened, but the  woman,
who  certainly was  brought into a very hazardous state by the premature
operation, did recover.  No placenta was found.  Mem. of Med.  Society,
Vol.  IV. p. 342.
  NOTE 22, p. 173.—In Dr. Morley's- case,  this happened two years after
the original abscess had healed.  Phil. Trans. Vol. XIX. p. 486.  Mr. Moylc
details a history, where the abscess first of all burst, in consequence of leap-
ing over a hedge.   Bones continued to be discharged for a  year,  without
much injury to the health.  The abscess then healed, but three years after-
wards a tumour again appeared, and,  in consequence of exertion, burst;
when about a yard of intestine protruded.   Some days elapsed before Mr.
Moyle saw her.   The intestine was then gangrenous, but she lived 12 days
longer, and the portion was thrown off before  death. Med. Jour.  Vol. VI.
p. 52.

                          CHAPTER XIX.
  NOTE 1, p. 207.—Air. Pearson relates a case,  where the uterus was re-
troverted, in consequence  of being  scirrhous.  A ide Pearson on Cancer,
p. 113. Dr. Marcet gives an instance where the  uterus was retroverted, with-
out pregnancy, producing constipation and vomituig.  Vide Cooper on her-
nia, part II. p. 60.
  NOTE 2, p. 207.—AI. Baudelocque relates a case, where the fundus uteri
protruded at the os externum, the patient at the same time  having violent
inchnation to expel something.  He was, however, able speedily to reduce
the womb to the^proper state.  Vide l'Art,  &c. §. 125.  In Dr. Bell's case,
a portion of the rectum was  protruded by the  uterus.   Med. Facts, Vol.
VJH. p. 32.
  NOTE 3, p. 208.—AI. Baudelocque gives a case of this kind, §. 253.   In
Dr. Bell's case, as the  woman complained for five weeks of dysuria only, it
is likely, that for that period the retroversion  was not complete.  Med.
Facts, Vol. VIII, p. 32. Dr.  Hunter supposed that it might take place  in
various degrees; it might  be complete, or semi-complete, or even the  os
uteri might remain in  its natural situation.   He  says, that Dr. Combe and
he saw a case, where the os  uteri was pushing out as in  a procidentia; but
this, perhaps, will not be admitted to have  been retroversion.  Med. Obs.
and  Inq. Vol. V. p. 388.  In the same volume, p. 382, Dr. Garthshore relates
an instance of semi-retroversion.
   NOTE 4, p. 208.—In the case described  by Dr. Hunter, Med.  Obs. and
Inq. Vol. IV. p. 400, the bladder after death was found to be amazingly dis-
tended, but not ruptured.
   NOTE 5, p. 208.—In Mr. Lynn's case, the bladder burst, and immediately
afterwards the woman miscarried, but the uterus after death was found to  be
still displaced.  Med. Obs. and Inq. Vol. V. p. 388.  Dr. Squire relates  an
instance in which the bladder also gave way.  Med.  Review for 1801. 
331
  NOTE 6, p. 208.—In Mr. Wilmer's case, the belly was greatly distended;
six pints of urine were drawn off, but the woman soon died.  On inspecting
the body, the bladder, from the disease of its surface, was found to contain a
quantity of coagulated blood, and the inflammation had spread to the colon.
In this case, the umbilicus was protruded hke half a melon, and the disease
was at one time taken for hernia.  The  uterus  was found  to be so firmly
wedged in the pelvis, that it could not be raised up till the symphysis pubis
was sawed away. "Wilmer's Cases, p. 284.
  NOTE 7, p. 208.—In Dr. Ross's patient, after the uterus was reduced, abor-
tion took place; and the woman dying, the bladder was found tobe thickened,
and adhering to the navel.   Annals of Medicine, Vol. IV. p. 284.
  NOTE 8, p.  209.—This is illustrated by Dr. Garthshore's patient who,
notwithstanding these symptoms, ultimately did well.  After the reduction
of the womb she miscarried, and foetid lumps were for some  time discharged
from the bladder.  Med. Obs. and Inq. Vol. V. p. 382.
  NOTE 9, p. 209.—In Mr. Croft's case, the disease was of  a month's stand-
ing, the woman was oedematous, and she was supposed' to have dropsy ;  but
by introducing the catheter, seven quarts of urine were drawn off.  The in-
troduction  was daily repeated for some  time, and then occasionally, as  cir-
cumstances required, for three weeks.  The swelling of the legs went off,
and the uterus  gradually  rose. Med. Jour. Vol. XI. p. 381.
  NOTE 10, p. 209.—A  case is related by Air. Ford, in which the catheter
being allowed to slip into the bladder, produced a sinuous ulcer.  Med. Facts,
Vol. I  p. 96.
  NOTE 11, p.  209.—In Air. Cooper's case, whenever the  tumour  was
pressed back, the woman called out that she could now make water.  Med.
Obs. and Inq. Vol.  V. p.  104.
  NOTE 12. p. 209.—This was done by Dr. Cheston.  The woman remained
long very ill, but she carried her child to the full time, and recovered.  Aled.
Commun. Vol. II. p. 96.  In one instance, by using a long trocar, the uterus
was wounded, and  the woman died.
  NOTE 13, p. 210.—Dr. Hunter mentions a case, in which the uterus re-
covered itself  immediately  after the bladder was emptied.   Med. Obs.  Vol.
IV. p. 408.   And in Mr. Croft's  second case, the water having  been drawn
off for six days, the uterus suddenly rose.  Lond. Med. Jour. Vol. XI. p.  384.
  NOTE 14, p. 211.—Both  Dr. Ross's patient and Dr. Cheston's patient, the
latter of whom recovered,  complained  of uneasiness  in the throat which
Dr. C. considers as  a mark of slow peritoneal inflammation.
  NOTE 15, p. 211.—This  circumstance has  been mentioned by different
writers, and a distinct  case is related by Mr. Merriman, in the Med.  and
Phys. Jour. Vol. XVI. p. 388. Mrs. F. being about five months pregnant,
was suddenly terrified, and felt as if her inside were turned upside down.
The symptoms, however,  were not very acute, for she voided the urine in
the last month of gestation, though with pain and some difficulty.  On the
16th of June, she had some  pains, and a discharge of serous fluid; no os
uteri could be felt, but a large semi-globular tumour at the back part of the
vagina, bearing down toward the  perinxum.  The pains brought on fever, 
                                    332

     and at last delirium and convulsions.  She was bled, and had a clyster, after
     which 3he got some sleep, and the pains continued moderate, though regu-
     lar, for (wo or three days, and she passed both urine and stools. On the 20th,
     nothing like os uteri could be felt; but on the 21st, there was perceived a
     thick  ffattened fleshy substance descending into the vagina, and very soon the
     uterus was restored to its natural situation  The substance was found to be
     the scalp of the child, containing loose bones.   The child and placenta were
     dehvered, and the mother recovered.
       NOTE  16, p. J13.—In  Mr. Bird's case, the accident succeeded to stooping,
     in washing clothes.  Med. Obs. and Inq. Vol. V. p. 1U0.  In Mr. Hooper's
     case, the  woman was frightened by  an ox, and in attempting to escape, fell
     down, after which the svmptoms appeared.   Mr. Evan's patient ascribed it
     to lifting  a burden.   Aled. Comment. Vol. VI  p. 215; and Air. Swan's patient
     to a fall, p. 217.  Air. Alerriman's patient first complained after being sud-
     denly terrified; and Mr Wilmer's patient had the uterus retroverted, after
     being fatigued with weeding.
       NOTE  17, p. 214.—Vide  Chambon, Malad. de  la Grossesse, p. 16.  M.
     "Bn.cdelocque relates a case from the practice of Choppart, where it was pro-
     duced in  the second month of pregnancy, by the action of an emetic. L'Art,
     &c. § 255.
       NOTE  18, p. 214.—Sometimes the  hemorrhage proves fatal.  A singular
     case is to be met with in the Medical Pacts, Vol. 111. p. 171, by Canestrini,
     where the woman had a  double uterus.  One of the uteri, after some pains,
'Xit v*burst in the fourth month.  The ovum was found entire in the abdomen, and
     much btood was effused.
       NOTE 19, p. 214.—A twin case is related by Dr. J.  Hamilton, where the
     uterus was so thin, that even the sutures of the head  could be felt through
     the abdominal  parietes.  Violent pains were produced by the motion of the
     child, the uterus felt very light,  and the woman had been exposed to a de-
     gree of violence.  This case had a  very considerable resemblance, in some
     respects,  to a ruptured uterus, but she was delivered safely of two children.
H^Cases, p.  124.
*?**. ! NOTE 2 J, p. 214.—Sometimes the tumour rather increases.  In Dr. Per-
     cival's cas; , the belly becanu much larger after the accident, and continued
     so for about a year.  Then it subsided all m once, when the woman was in a
     recumbent posture.  Med. Comment. Vol. II. p. 77.
        NOTE 21, p. 214.—Dr. Drake's case, where the uterus seemed to burst in
'■V   /the fourth month,- terminated by suppuration at the navel. Excrement  was
EfiF for some time  discharged at the  opening.  Phil. Trans. Vol. XLV. p. 121.—
     A washerwoman at Brest had the uterus ruptured by a fail in the seventh
     month, and ultimately expelled the foetus at the navel  Mem. of Acad, of
     Sciences for 1709.—Guillerm, in tiie same work for 1746, mentions a woman
     who had the womb ruptured by a fall in the sixth month.  She immediately
;.■' ,  fainted, and a discharge  took place from the vagina. The child was expelled
     by the anus.—See also the cases by Dr. Percival, Mr. Wilson, &c.
        NOTE 22, p. 215.—In the Journ. de Aled. for 1780, there is a case  of a
     woman, who had tiie uterus ruptured in the fourth month of pregnancy. The 
ooo
accident was followed by uterine  hemorrhage, which continued for some
time.   The menses returned, but  the  belly did not subside.  In the ninth
month she died.   The uterus was found of the natural size, but the rent was
still perceptible.
  The uterus for some time does not return to its  unimpregnated state, as
is evident from the following case, which 1 lately saw.   Anne Neilson, aged
24 years, fell on the  ground about  a  month  ago,  being then in the ninth
month of her first pregnancy.  She felt at the time as if something had burst
near the navel, and perceived more fluttering of the child than usual.  This
continued in a certain  degree for  two days, after which, she felt no more
motion. In the course of two or three days after the accident, she was seized
with irregular pains, chiefly about the belly, and these are rather increasing
than diminishing  in  severity.  The belly has  subsided considerably in size,______
is hard, particularly above the  navel, toward  the stomach.  The umbilicj^^H
itself, is soft and prominent.  The bowels are regular, urine proper, tongue
clean, heat natural, pulse 84, has occasional shivering.   On examining,  per
vaginam, the lower part of the uterus is felt soft and tubulated, very unlike
either the gravid  or unimpregnated  womb.  It hangs into the vagina, like a
fleshy inverted cone.  By some degree of attention the os uteri is discover-
ed at the lower part, or rather a little backward.  It has no distinct project-
ing lips as in the  unimpregnated state, but by pressure with the finger, the
aperture is felt  with thin  margins, and the  point of the finger may be in-
troduced a very little way within  it.  The head  of the child is discovered
between the uterus and pubis.  No  distinct member can be felt through the
abdominal parietes.
  Dr. Jeff'ray possesses a preparation of a foetus contained in a kind of cyst
taken from a woman who had carried the child above 20 years : the rupture
was occasioned by a fall.
  NOTE 23, p. 215.—In the Journal de Aled.  for 1780, a case is detailed of
a woman, who, in the month of January, being then seven months pregnant,
was squeezed betwixt the wall and  a carriage, and  had the uterus ruptured.
She instantly felt violent pain in the belly, and a discharge took place, from
the vagina, which continued in variable quantity for. six weeks. The strength
gradually sunk, and in June she began to vomit,  and continued to do so for
several days, when she died.  The  abdomen  was found inflamed, and con-
tained the remains of a putrid child.  The rent was visible in the womb.
  NOTE 24, p. 215.—In Air. Wilson's patient, the accident was produced by
being kicked.   She complained of pains all night after the injury, and next
day had a sanguineous discharge  from the vagina,  and soon afterwards was
attacked with violent griping pain.  The foetus was ultimately discharged
by an abscess,  bursting externally.  Annals of Med. Vol. II. p. 317, and Vol.
IV. p. 401.—Dr. Garthshore's patient ascribed it  to violent exercise.  Med.   4 *;
Journal,  Vol.  VIII.  p. 334—Air. Goodsir's patient to  exertion.  Annals of
Med. Vol.  VII. p. 412.—In the 5th  and  6th volume of the Journal de Med.
are two cases, the first produced by  a fall from a tree, the second by a brui«e
from a waggon.   Other  instances, if necessary, might be added. 
 
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