AN ESSAY THE MEANS OF LESSENING PAIN, AND FACILITATING CERTAIN CASES OF DIFFICULT PARTURITION. By WILLIAM P. DEWEES, LECTURER o.v MIDWIFERY, ix Philadelphia. ................................ ut si Ccecus iter monstrare velit. Hor. PHILADELPHIA: PRINTED FOR THE AUTHOR, BY JOHN H. OSWALB. 1806. AN INAUGURAL DISSERTATION, FOR THE DEGREE OF DOCTOR OF MEDICINE, SUBMITTED TO THE EXAMINATION OF THE REV. JOHN ANDREWS, D. D. PROVOST, (Pro Tern.) THE TRUSTEES AND MEDICAL PROFESSORS OF THE UNIVERSITY OF PENNSYLVANIA, ON THE 2l6t DAY OF APRIL, j806. TO WILLIAM SHIPPEN, M. D. Professor of Anatomy. BENJAMIN RUSH, M. D. Professor of the Institutes &? Practice of Physic, Z?c, CASPAR WISTAR, M. D. Adjunct-Professor of Anatomy. JAMES WOODHOUSE, M. D. Professor of Chemistry. BENJAMIN SMITH BARTON, M. D. Professor of the Materia Medica. AND PHILIP SYNG PHYSIC, M. D, Professor of Surgery, IN THE UNIVERSITY OF PENNSYLVANIA, THIS ESSAY, IS RESPECTFULLY INSCRIBED, By their obliged Friend, THE AUTHOR. \ AN INAUGURAL DISSERTATION, &c. XT10 WE VER easy the act of Child-bearing may be, among savage tribes and certain individuals in various states of society, we find it among others an operation of great pain and frequent danger. It is not intended here to inquire minutely into the causes of this departure from its original simplicity, but merely to glance at some of the most evident; among which we must regard civilization and re- finement as the most prominent, if not exclusively the only ones. It is not compatible with my pre- sent purpose, to point out in what manner these have operated to effect this change; I shall there- fore only state, a change has been produced in the female human system, which subjects it to pain and difficulty in parturition: to shew in what some of these changes consist, and how to ameliorate them, is more especially the object of the present essay. ( 8 ) The causes of difficult and painful labours are various, and may with great propriety be divided into two general heads, namely, those which arise from some imperfection of the Pelvis, and into those which may tend to interrupt the natural and healthy functions of the soft parts ; the latter however only comes within our present notice. The soft parts concerned in labour, are those which are directly, and those that are indirectly employed;—the form- er are the uterus, vagina, perinoeum ; the latter, the Abdominal Muscles, those of the thorax, dia- phragm, &c. A short anatomical description of the Uterus, with some physiological remarks, is judged neces- sary, that some of the opinions advanced may be the better understood. The Uterus is a hollow viscus, in which the great object of conception is performed. From the Phee. nomena of Labour, and from actual dissection in the gravid state, we do not hesitate to say it is com* posed chiefly of muscular fibres and blood vessels. Although it be admitted on all hands that it pos. sesses muscular fibres, yet anatomists are not so well agreed as to the manner in which they are distributed. Dr. William Hunter, in his plates of the gravid uterus, delineates them as transverse in the body, but, at the fundus, as describing concentric circles round each ( * I orifice of the Fallopian tubes; therefore, according to him, there are two orbicular muscles, and a trans- verse one. Malphigi describes them as forming a net work, while Ruysch contends they appear in con- centric planes at the fundus, forming an Orbicular Muscle. This diversity of description proves, that the dis- tribution of muscular fibres in the uterus has never been satisfactorily traced, and that their accounts have been very much influenced by the individual theory of these great men. Great patience has been exercised, and much labour expended in these re- searches, by very many excellent Anatomists, be- sides those just named, yet they have never been able with their knife to clear up this point; we must therefore have recourse to other means to satisfy ourselves on this head ; the only certain one, it ap- pears to me, is to deduce them from the action of the uterus itself; this at least warrants two distinct sets, the one circular, the other longitudinal. The circular fibres are those which run in the direction of the transverse diameter of the uterus; they most probably commence at the fundus, and terminate at the extremity of the os tinea?. They act somewhat like a sphincter muscle, and are, as we shall prove by and by, inferior in strength to the longitudinal fibres, which are those running in theperpendiculardirection of the uterus; that is, in lines mere or less direct ( io ) from the fundus to the termination of the neck; they serve to diminish the length of the uterus.* The uterus is usually divided into fundus, body, and neck. The fundus is made to comprehend all that portion which is above the insertion of the Fal- lopian tubes ; the body, that portion below the tubes, but superior to the neck ; the neck that part which is pendant Irom the body, and terminated by the os tincae. This viscus is abundantly supplied with blood vessels, which very frequently anasto- mose ; so much so, that when injected in the im- pregnated state, they appear scarcely any thing else* These vessels however are very different in size in different states of the womb ; in the unimpregnated state they are small, though numerous, and are much convoluted ; in the impregnated state they are much enlarged. The veins are much larger than the arteries; they very frequently anastomose, are without valves, and terminate in, or expand into sinuses of sufficient size, in some instances, to admit the extremity of the finger. It has been usual to consider the fun- dus, body, and neck, of the uterus, as a single vis- cus, whose actions were similar and dependent on * The uterus may have fibres running in very many more di- rections than the two just mentioned, but the two noticed, will serve to explain the phenomena of labour sufficiently, without having recourse to them. ( 11 ) each other; I have my doubts of the propriety of this combination, as it does not accord with many circumstances connected with this organ. Hither- to the physiology of the uterus has been but too carelessly considered; regard having chiefly been paid to the consequences of its action, rather than the mode in which these actions were performed. I do not flatter myself I have completely and sa- tisfactorily explained, the various functions of this organ; but I hope to awaken attention to this sub- ject in others, whose talents and leisure, will better fit them for the investigation. What will be ad- vanced on this head, is offered with diffidence, con- scious of the difficulty that attends enquiries of this kind, and the impossibility of reducing speculations, to mathematical demonstration. The office of the body, and fundus, is diametrically opposite to that of the neck, or mouth of the uterus, in time oi la- bour ; while it is the duty of the former to contract, it is that of the latter to relax ; and on the more or less perfect establishment of these different actions, other things being equal, depend the facility, or dif- ficulty of labour. Before we proceed farther, let us inquire into the functions of these parts. From re- viewing the various changes which take place in the uterus from the time of impregnation, to the expul- sion of the mass it has been maturing, we cannot fail being struck with the various resources it seems c ( 12 ) to possess, and the wonderful order it pursues, to give the greatest possible chance of perfection to the ovum ; to secure it against accident ; and finally, to cast it off when it can no longer be useful to it. The various changes which the womb undergoes in these several processes, Jiave been pretty distinct- ly marked, and the various phenomena of labour pretty faithfully recorded ; but we have yet to la- ment, that so little progress has been made in the knowledge of remedies to prevent or overcome the difficulties which but too frequently occur in the different stages of gestation, and parturition : this can only be acquired by a more minute investiga- tion of the laws of nature, and attention to the in- fluence of certain agents acting on the female con- stitution in general, but more particularly on the u- terine system, and especially, on the different parts of the uterus itself. To believe in the influence of certain causes on the different parts of the uterus, may at first sight appear unphilosophical; and to suppose we shall ever have the different parts of it under subjection, will be considered as Utopean; but notwithstanding this, I have no hesitation in believ- ing that the time will arrive, when we shall be able to prescribe internal remedies with as much certain- ty for a preternatural rigidity of the neck of the u- terus, and for a too feeble or too powerful contrac- tion of its fundus and body, as we do now for an in- ( 13 ) termittent. For I cannot help regarding the neck of the uterus as a distinct and independent part from the body and fundus; and as having its own pecu- liar laws and actions ; and that this separation of powers, is absolutely necessary to the explanation of some of the phenomena exhibited by health and dis- ease, and the influence of certain agents on these parts. My reasons for thinking so are, first, that we find the fundus and body may be distended to a great extent without affecting the arrangement of the neck; thus in every uterine pregnancy we see these parts gradually yielding to the influence of the ovum, un- til about the sixth or seventh month; while the neck remains very much the same as before impregnation: Secondly, that after the sixth or seventh month the neck undergoes its changes, while the fundus and body become in a great measure stationary, so that two distinct processes, or rather the same process is performed at two different periods, and in differ- ent parts, in the order we have just mentioned. Thirdly, that the neck may be affected by disease, while the fundus and body may remain free, and the reverse ; and the neck may contract, or relax, while the other parts are in opposite states; thus in women who are in the habit of aborting from some peculiarity of the uterus, we find that the body and fundus may be excited into action while the neck C i* ) for a long time remains passive; and also, the neck may relax, and the body and fundus after some time may be excited to contraction. Also in cases of atony of the uterus after a too sudden delivery, the body and fundus may contract while the neck is the only part in fault, and vice versa. Now were these parts not influenced by different circumstances, these things could not happen : since two distinct actions are going on at one and the same time; or one of these parts may be labouring under disease without involving the other. That a woman may carry her child to the full period allotted for its perfection (and that she may afterwards produce it with the least possible trou- ble) a number of circumstances must concur with the greatest possible regularity. That she may car- ry it to the full period of gestation, she must be ex- empt from all and every cause capable of exciting uterine contraction; or at least that degree of it which would sooner or later, terminate in delivery ; and that delivery maybe the effected with the greatest facility, the following circumstances must obtain ; first, there must be a subsiding of the abdominal tumour, and if at this time a finger be introduced through the os tineas, we shall find the membranes alternate !y tense and relaxed; these circumstances v are owing to the uterus now beginning to contract, ( 15 ) and forcing the presenting part into the pelvis. Se- condly there must be a secretion of mucus from the vagina; in some instances this flows from it, seve- ral days previous to the onset of pains; but for the most part it only happens a few hours before they are felt. This mucus is secreted from the surface of the vagina, and perhaps from a portion of the neck of the uterus. Why these glands are excited to this duty may perhaps be difficult to explain, but their action appears intimately connected with a certain state, or condition of the os tincse; thus we find, caeteris paribus, this secretion to be most abundant, where there is the greatest disposition in the mouth of the uterus to dilate or relax ; and with this, is connected, the same disposition of the perineum. It must be observed, that the secretion here spoken of must not be confounded with Leucorrhoea, as this discharge is by no means so favourable to this effect. Thirdly, The mouth of the uterus must yield easi- ly, that the contractions of the body and fundus may not be exerted for too long a time unavailingly. The dilatation of the mouth of the uterus, when best performed, is either before or very quickly after the painful contractions of the uterus have taken place; this in general is done without the mechani- cal aid of the contents of the uterus. r ^ ) Fourthly, The body and fundus must contract with sufficient force, to make the child pass through the pelvis. Fifthly, The perineum must unfold without much or any mechanical force, that the child may not be detained in passing through the os externum. Sixthly, There must obtain between the foetus and pelvis, a proper proportion, and the former must be well situated, that it may derive every advantage from the circumstances just enumerated. Having thus pointed out what ought to obtain, that labour may be short and easy, we shall proceed to investigate some of these phenomena: and first, that of the Dilatation of the mouth of the Uterus. It is a fact very well known to accoucheurs, that sometime before the period of labour, the mouth of the uterus is a little way opened: this does not uni- versally obtain, but yet sufficiently often to warrant the assertion, that it does for the most part. This first degree of dilatation however, is by no means essential to a speedy delivery, since it is general- ly accompanied with very firm and unyielding edges ; this obliges us to enquire, whether this state be the effect of mechanical, or any other power. In order to which, we shall remark, that there are ( 17 ) two states of the os tineas at this period; the one, as just mentioned, attended by very resisting edges, and the other with soft and yielding ones ; these are essentially different. In the former case, it must be ^regarded as the effect of the mechanical stretching of the uterus, the fibres of the neck of which have been sufficiently unfolded to widen this aperture so as to admit the extremity of the finger, or even a larger bo- dy; the uterus appearing as it were, not to have suffi- cient substance to cover the ovum completely. But this in some other instances, may arise from another cause ; thus, when the uterus is not so fully distend- ed, we may also pass the finger; but in this case it is owing to the neck and mouth, never being so com- pletely shut after the first child, as in the virgin state; therefore this case can only happen where the uterus has been subjected to the influence of labour. In the other case, we have mentioned the mouth of the uterus to be in a very different state; that is, its edges are pliant, and may by a very gentle force be enlarged. This depends on a very different cause, and must be regarded as a salutary step towards la- bour. Baudelocque* appears to look upon both these States as the effect of the same cause; for he ob- * Vol. 1. p. 336 Heath's. Trans. ( 18 ) serves that, " The orifice of the uterus is almost al~ " ways a little open before the epoch of labour. We " see the reason of this, by following, step by step, " the order of the developement of that viscus, and " by attending to all that passes at its orifice in the. " latter periods of gestation." In this paragraph he alludes to an explanation he has previously given, in which he endeavours to ex- plain the successive developement of the uterus, and eventually the opening of its mouth at the time of labour; we shall therefore transcribe it, that our quotation may be the better understood. He ob- serves, page 132, par. 199 and following, that " the " fibres of the fundus and body of this organ, are " more supple, and naturally more disposed to un- " fold, than those of its neck, furnish almost the " whole of the amplification necessary before the " sixth month of pregnancy; so that till that time " the uterus seems to borrow nothing from its neck. " It is at this epoch that the fibres of the latter part " begin to develope, and contribute with the form- " er to the dilatation necessary for the convenient " lodgment of the foetus and its appurtenances. " From this time all the fibres extend and unfold " in the same proportion, and continue to do so for " sometime: but towards the end of pregnancy, " the dilatation of the uterus is made almost en- " tirely at the expence of the fibres of its neck ; be- ( 19 ) " cause those of the fundus make a greater resist- " ance ; and there no longer exists a perfect equi- " librium in the re-action of those two parts, either " on each other, or on the produce of conception. " As soon as that equilibrium is destroyed, the fi- " bres of the body, and especially those of the fun- " dus of the uterus, begin to make efforts to expel " the substances which constitute the pregnancy, " and do it in a manner sensible to the touch. If " we then introduce the finger through the orifice of " the uterus, so as to touch the membranes of the " foetus, we find them flaccid one moment, and tense " the next; which clearly demonstrates this alter- " nate action." " At this time the fibres of the neck of the ute- " rus sustain not only the whole effort of the inter- " nal agents, which they participated before with " those of the fundus, but also the effect of the re- " action of the latter on those same agents; which " constrains them to unfold so rapidly, that in less " than two months the neck is developed, and en- " tirely effaced. " If the cavity of the uterus becomes still larger " after this period, it is all at the expence of these " fibres, now become weaker. At first they dis- " tend and lengthen, then they seem to range them- D ( 20 ) " selves by the side of each other ; which renders " the uterus so thin in this part, that the edges of " its orifice are often no thicker than two or tiiree " folds of common paper. " It is by the same mechanism, that the dilata- " tion of the orifice of the uterus begins to be ef- " fected, and labour pains manifested. If the end " of the ninth month of gestation is almost always " the epoch of those pains, it is because the order " of the successive developement of the different " parts of the uterus, as I have stated it, is almost " immutable. " The cause of this first degree of dilatation be- " ing well known, must throw the greatest light " upon that which takes place in time of labour ; " and shews us it is not immediately and entirely " the effect of that species of wedge Avhich the sub- " stances subjected to the contractions of the ute- " rus present to its orifice."* From this it would appear that the opening of the mouth of the uterus at the commencement of labour, and also that degree of opening which exists long before this period, is the effect of the same cause ; namely, the influence of the body and fun- dus mechanically acting upon the orifice of the womb. But this cannot be the case for the reason just stat- * Ibid Vol. 1. p. 336. ( 21 ) ed ; namely, that the degree of opening may be the same, but the resistance of the edges of the mouth is very different; in the one case the circular fibres of the neck obstinately maintain their contraction ; whereas in the other, they are in a greater or less degree relaxed; and that this relaxation is not the effect of this uterine effort acting mechanically is evi- dent, since we find it existing where there is no por- tion of the ovum made to engage in it, consequent- ly cannot act like a wedge. Besides were it owing to this cause, it would appear like a part that was yielding to a mechanical impulse, and would conse- quently exhibit marks of resistance; that is, it would still maintain the action of contraction, and not that of relaxation. Indeed Baudelocque him- self seems aware of this objection, for he observes page 337, par. 616, " Although in many cases, " where the waters drain off prematurely no part " of the child can engage in the orifice of the " Uterus, yet it does not fail to open, in the same " manner as if the bag formed by the protrusion " of the membranes were entire; from whence we " see that the action of that organ is alone suffici- " ent to effect the dilatation of its neck. But it " will perform it so much the more easily, as the " uterus is more distended, and as the body it " contains is more solid," ( 22 ) Here he appears to abandon, in a great degree, his mechanical doctrine, and confesses the action of the uterus alone to be sufficient to effect the dilata- tion of its neck; but he does not pretend to deter- mine what that action is; he conjectures in the next paragraph, that the soft and gradual pressure of the distended membranes may have an influence On it; for " Independently" says he " of the force " which the membranes distended by the waters " exert in the orifice, when they can engage in it " like a wedge, the soft and gradual pressure which " they continually exert on all the neighbouring " parts, determines a repletion in them, which fa- " vours their developement and renders it less " painful." But unfortunately for this conjecture, should this determination take place, it would have a diametrically opposite effect; for the more turgid or engorged with blood the neck should become, the less disposed would it be to dilate. Of this we have abundant proof, when this part becomes inflamed.* Besides, the uterus in many instances dilates as kindly after the evacuation of the waters as before, of this the following history is a proof: Mrs.----- is always surprized by a discharge of the waters * It must however, be admitted that during labour, or evea before, there is some increase of determination to these parts, as there is an increase of action in their vessels, as we can sometimes determine by the touch. C 23 ) » without any pain; but this so quickly succeeds, and the child so suddenly expelled, that her nearest neighbour cannot get to her before it happens. This has obtained with all but her first labour. Were it necessary, we might multiply authorities to a great extent, to disprove this mechanical doc- trine ; but shall only give one, Dr. Denman, vol. II. page 37. " More than one case," says the Dr. " has occurred in my own practice, to which par- " ticular attention has been paid, for the purpose of " registering the observation, in which the labour " has commenced properly, and proceeded with " much activity till the Os uteri was fully dilated, " and then ceased altogether for several days : at " the end of that time the membranes breaking, the " action of the uterus has returned and the labour " been finished speedily, with perfect safety to mo- " ther and child." Here we see the dilatation effected without the wedge-like influence of the membranes or child. From what has been said, we trust it will appear that, in the most natural and favorable cases of - bour, the mechanical power of the Ovum has no in- fluence in dilating the mouth of the uterus. It must however be admitted there are many instances where the contrary obtains; thus we see cases where the action of the uterus is so rapid and pow- ( 24 ) erful, that the child is forced through the orifice with great violence, and risk of lacerating it; but in these instances the mouth of the uterus exhibits a very different appearance from that where the di- latation is effected by a different agent. When the head, or presenting part, is made to force its way, the mouth of the uterus transmits it with great re- luctance, and evident hazard; for it pertinaciously resists, as is evident to the touch; while on the contrary when it has dilated, agreeably to the laws of nature, it yields most willingly. It has most probably been owing to a proper distinction not being made between these cases, that the mechani- cal account of the dilatation of the mouth of the uterus has so universally prevailed; but there is scarce a writer on this subject who does not furnish facts to disprove his own doctrine on this head. The cases just mentioned are to be looked upon as departures from the healthy and ordinary pro- gress of labour; and are therefore not to be consi- dered as militating against the doctrine we wish to establish. It may be asked, how it comes to pass if the membranes distended with their water are of so little consequence to the opening of the mouth of the uterus, that a painful and tedious labour most frequently follows where they have been prematurely ruptured? The answer we conceive to be easy. In those cases where the membranes are ruptured ( 25 ) some time before the legitimate pains of labour have commenced, the uterus is oftentimes thrown sud- denly into contraction, and this before it is prepared, (if we may so express it) for the regular routine of parturition; consequently the neck is not in a dis- position to dilate; not because it fails in assistance from the membranes, but because all the preparitive conditions are not complied with; therefore not properly prepared to perform all its duties. But is is by no means an invariable thing for a labour to be tedious after this early escape of the waters; unless indeed we date the commencement of the labour from this event; in this case the labour might, with strict propriety, be said to be tedious; as twenty-four, thirty-six, eight and forty hours, nay in some instances, a much longer period has inter- vened before the delivery was effected: we may therefore safely, we believe, lay it down as a rule, that a more tedious and painful labour does not en- sue from the premature rupture of the membranes, unless the uterus is thereby immediately thrown into contractions ; but should no pain succeed for some time, the labour will be, ceteris paribus, as in ordinary. After having endeavoured to shew in what man- ner the mouth of the uterus is not dilated, it may he considered incumbent to point out in what way m ©ur opinion this effect is produced. This is con- ( 26 ) fessedly a difficulty of some moment, but it must be attempted; and should we fail in being satisfactory on this head, we shall experience but the fate of all who have gone before us. We trust however, it will appear subject to certain laws, whose ultimate effect we have in our power to imitate; and this should be regarded as a matter of some consequence. But before we proceed farther with this subject, we must stop to enquire into The different kinds of contractions of the Uterus. First, The longitudinal contraction :—this is per- formed by the fibres of the uterus, so called, or those fibres which run from the fundus to the neck; it serves to shorten the uterus in the direction of these fibres; consequently to expose its contents more and more, by making them aproximate the mouth j and this will be in proportion to the diminution of resistance at this part, and the force with which these fibres may act. The circular contraction:—this action is perform- ed by the fibres so named; they, as it were, run round the uterus, commencing at the fundus, and terminating in the circle forming the neck: they tend to diminish the capacity of the uterus in the direction of its transverse diameter, consequently have little or no immediate agency in expelling its contents. ( 27 ) The simple contraction:—or when either of these sets of fibres act separately, as before labour more especially, when the finger is introduced through the ostincae, we find the membranes alter- nately tense and relaxed: in this case we presume the longitudinal fibres act alone, as there is no stif- fening of the circle forming the mouth; or as when the waters have been evacuated, the uterus is made to embrace its contents, and no pain for a long time is produced; we suppose in this instance, the cir- cular fibres act alone, as there is no effort to expel the contents of the uterus, which would not be the case did the longitudinal fibres co-operate with them. Compound contraction :—or when both sets of fi- bres act; their united action is proved, we conceive, when there is a hardening of the mouth of the ute- rus, and an evident depression of this viscus with its contents. Tonic contraction :—by this we understand that uniform action which the uterus exerts to reduce it- self to its original size ; this appears to be the ef- fect of all the fibres folding themselves up after the distracting cause is removed. The spasmodic, or that contraction of the uterus which is for the most part accompanied with pain. E ( 28 ) It must be remembered however that pain does not necessarily belong to this species of contraction, since some women are delivered without it. We should therefore, agreeably to this fact, rather call this species the alternate contraction of the uterus; as it has a greater or less interval between each con- traction : when this action is best performed it is, we presume, chiefly by the longitudinal fibres. It may here become a question how are the fibres of the uterus enabled to perform this alternate con- traction ? Since we know that a muscle after having contracted, cannot repeat that contraction without being first relaxed and then elongated. Where resides this elongating power in the uterus ? This enquiry, so far as I know, has never been made, but the ne- cessity of determining it will immediately present itcelf, when the question is asked. To solve it, no doubt, is difficult, perhaps impossible, with our pre- sent imperfect knowledge of the anatomy and phy- sic-logy of this important viscus ; but is it not jus- tifiable, under such circumstances, to hazard a con- jecture, however small its approach may be to truth ? If this be the case, and we are allowed to urg- a crude opinion, we would say, we must look for this power in the blood vessels and sinuses of the uterus. The first change the uterus suffers from impreg- nation, is distension ; the next, that of contraction. ( 29 ) The uterus is then put in a state of elongation by the powers within it, which, when it suffers to a certain degree, contracts ; what is the effect of this contrac- tion ? It approximates its fibres ; it expels a consi- derable quantity of blood from its sinuses and largef blood vessels, into the general system of the mo- ther ; it diminishes the size of its blood-vessels ; it makes them become more convoluted ; the uterus becomes paler, a proof of a lessened quantity of blood: the face of the woman becomes suffused, nay sometimes livid. To facilitate the departure of blood from the ute- rus during its contraction, the veins are not furnish- ed with valves, by which means the blood is allow- ed to pass freely in the direction of any given im- pulse. What is the effect of the subsequent relaxa- tion ? The fibres become longer, straighter, and more easily distensible ; the sinuses and large ves- sels are less compressed, and transmit more blood in a given time ; the face of the woman becomes pal- er ; the uterus becomes again pretty suddenly charg- ed with blood, as is evidenced by its deeper colour; its fibres are distracted or elongated by this influx of blood, a;id hence are enabled to contract. It mav be urged against this opinion, that the ute- rus contracts for the most part more frequently, and more powerfully, as its substance becomes increased ( 30 ) in density,—as towards the close of labour; conse- quently the influx of blood must be much retarded, and of course its impetus or quantity insufficient to elongate the fibres sufficiently to allow of a new con- traction. But in answer to this we must observe, that at this period of labour the circulation is very- much encreased, and although the absolute quantity in the uterus may be diminished, the velocity is ve- ry much augmented ; and added to this, its irritabi- lity is much encreased, therefore, less distension will be required. It may also be said, there are in- stances of the uterus ceasing to act for a considera- ble time, and where we must suppose the circula- tion to go on in it. That the uterus in some cases will cease to act, is most true ; but this by no means destroys the supposition we have been making,— as this part, like all others, may have its fibres in a condition in which they will not obey their ordinary stimuli—it may proceed from exhaustion, or from local plethora ; stimuli will cure in the one instance, and blood-letting in the other. The irregular contraction :—or when a part of any set of fibres act; as in cases of what is called spuri- ous pains. f Having thus noticed in a general way the vari- ous actions of which the uterus is capable, we shall proceed to enquire intc— ( 31. ) The Relative strength of the different sets of fibres. We have already observed that the longitudinal fibres were stronger than the circular; our reasons for thinking so, are,—first, that were they of equal strength in all parts of the uterus, delivery could not take place, since the circular fibres would embrace the body of the child, and thus retain it; their ac- tion being as we have already said, to diminish the uterus only in its transverse diameter, consequently is at right angles with the longitudinal. Secondly, that when, from any circumstance, the power of the circular fibres is encreased, either absolutely or re- latively, there the labour does not advance ; there- fore the circular fibres are not to be considered as directly instrumental in expelling the child. Third- ly, as the circular fibres, from the direction of their action, do not immediately contribute to the ad- vancement of the child, they must be considered as the weakest set,—since delivery takes place without their direct aid ; the longitudinal fibres have then not only to move the child, but overcome their re- sistance. Now let us apply these facts to the explanation of the dilatation of the uterus and the progress of la- bour. When the woman has carried her child to the full time of gestation, that process termed labour ( 32 ) must ensue, that she may be enabled to part with it —for this purpose, one part of the uterus must yield or dilate, while another must contract. The uterus is closed at bottom, and maintained in that situa- tion by the contraction of the muscular fibres of its mouth, but these must relax that the child may ef- fect its escape. We must therefore regard the cir- cular, and longitudinal planes of fibres, as a kind of antagonist muscles to each other. The longitudi- nal fibres yield more willingly to impulse from with- in the uterus than the circular, during gestation; owing perhaps chiefly to their greater length, or perhaps greater laxity ;* they continue to yield un- til they are so much upon the stretch as to induce a diposition to contract; this they eventually do. The circular fibres, on the other hand, from their greater rigidity, most probably are put immediately upon the stretch ; they therefore have a constant stimulus to excite their contraction ; hence the mouth of the uterus keeping closed. But so soon as the longitu- dinal fibres becomes uneasy, from distention, they become refractory and will yield no more without re- sistance ; they then contract, and continue to do so until the stimulus of distention becomes still more powerful, which eventually brings on the period of labour. By the contraction of the longitudinal fi- * Hence perhaps the lengthened form of the uterus. ( 33 ) bres, the length of the uterus diminishes ; this puts the circular upon the stretch, since the uterus can- not diminish in one direction, while the mouth of the uterus remains shut, without augmenting in ano* ther, therefore the circular fibres are a little distract- ed, and they immediately co-operate with the longi- tudinal, and force the uterus with its contents lower into the pelvis ; in this instance, what we have term- ed the compound action of the fibres, takes place; this is proved by the edges of the mouth of the ute- rus stiffening during the contraction. This kind of action is reciprocated for some- time ; but the circular fibres eventually yield to the influence of the longitudinal; first, from their having expended a portion of their power in maintaining a state of contraction so long; and secondly, their be- ing absolutely the weakest fibre ; hence the circular fibres which constitute the neck, relax ; and hence the dilatation of the mouth of the uterus. It may be asked if the contraction of the longitu- dinal fibres prove a stimulus to the circular, how does it happen while the membranes remain entire, that they do not continue this contraction until the membranes are ruptured or even longer, since the stimulus of distention must be applied, as often as the longitudinal fibres continue to contract ? To this we would answer, that, when these fibres are acting ( 34 ) properly, the longitudinal are gradually getting the ascendancy of the circular, or in other words, the circular contract less forcibly; in consequence of which, the mouth of the uterus becomes more dilat- ed, which allows the membranes to be pushed down during the contraction, as the Liquor Amnii will na- turally be forced to that part which gives the least resistance to its escape, and of course the uterus will be less distended transversely, and the circular fibres be put less upon the stretch ; or what is the same thing, less stimulated ; then as they are less stimu- lated, by the uterus having more room for the dispo- sition of its contents, they will contract less forcibly ; and this diminution of force, in contraction, enables the membranes to protrude still farther, which again has its effects in lessening their contraction, by offer- ing still more room for the waters to retire in, dur- ing the contraction of the other fibres, and eventual- ly they cease to act. Secretion of Mucus and yielding of the external parts. During labour, and even before, in some in- stances, there is a considerable discharge of mucus from the neck of the uterus, and vagina, which is extremely favorable to the dilatation of the external parts. Previous to labour, and more especially dur- ing it, there is a more than ordinary determination ( 3« ) of blood to these parts, which, when not excessive, stimulate the glands here situated, to an increase of action ; hence the abundant flow of mucus. This mucus is sometimes tinged with blood, which arises from the rupture of some of the small vessels of the chorion, or perhaps placenta. This mucus seems to serve a double purpose;— first, it lubricates the passage, and by that means al- lows the child to pass more easily; and secondly, it facilitates the relaxation of the vagina perineum, by diminishing the quantity of fluids sent to these parts during this period; and thus acts like topical depletion, which we well know, favours relaxation; this we are inclined to believe is the chief use of this discharge. Were it merely to lubricate the pas- sage, we could always obtain the same end by artifi- cial means ; but every body knows this does not an- swer the purpose equally well. This fact is tacitly implied, if not acknowledged, by every writer on the subject of midwifery, when they caution against fre- quent touching, lest you waste the natural mucus of the part; why this caution, if it were merely to moisten, since we have a number of substitutes ? No, the fact is, frequent touching stimulates these glands beyond the secreting degree, therefore the parts become dry, for want of it; and rigid, because the parts have failed in this depletion. This is the F ( ™ ) true principle on which we should caution against indiscriminate touching. Of the Contraction of the Fundus and body of the Uterus. That the uterus may be enabled to expel its con- tents, as we have already said, the fundus and body must contract, while the mouth must relax. We have endeavoured to shew how the latter was effected; let us now for a moment attend to what must be done by the fundus and body, that delivery may take place. When the mouth of the uterus is sufficiently di- lated to allow the child to pass through it, the fun- dus and body must continue to contract; this con- traction is of two kinds, namely the tonic, and the spasmodic or alternate. The tonic contraction is chiefly performed by the circular fibres; by this con- traction, the whole of the internal surface of the ute- rus is applied to the body to be moved, and the lon- gitudinal fibres by this means are brought more closely into contact with it, and of course are ena- bled to act with more effect; this perhaps is the chief use of the circular fibres at this period of la- bour, as they do not, in any instance, directly con- tribute to the advancement of the child, as we have ( 37 ) already observed, and shall now endeavour to prove more fully. We shall relate some circumstances attending the contraction of the uterus which will deserve notice, and to the truth of which every accoucheur will bear testimony : first, that a considerable degree of con- traction may take place in the circular fibres without producing pain; thus, after the evacuation of the waters, and the uterus is closely applied to the body of the child, even to a degree that would render turning impracticable—yet no pain is felt:—Se- condly, when this contraction is violent, it throws the uterus into inequalities, and sometimes divides it like an hour glass ; this obtains in a degree before the birth of the child, but more especially after it, and before the expulsion of the placenta. In these instances, the contraction is obstinately maintained— but no pain is felt;—Thirdly, if the finger be applied to the presenting part, during the continuance of this contraction, it is. not found to advance :—Fourthly, when this constriction is most violent, the longitudi- nal fibres act, for the most part, with more force ; since they are not only obliged to effect the delive- ry, but also to overcome this additional resistance; another proof of their superior strength :---Fifthly, This stricture continues without any intermission, as far as we can determine, for hours ; but this does not suspend the painful and alternate contractions of ( M ) the other fibres; nor does this constriction relax during this alternate contraction, therefore, much time is lost and much pain endured from this cir- cumstance ; it however yields eventually, and from the same cause, and in the same manner as the mouth of the uterus does at the commencement of labour: —Sixthly, when the painful contraction takes place, the presenting part is pushed lower into the pelvis ; but when this ceases, it most frequently recedes a little. From these facts, the following inferences, we think, are deducible. First, That the circular fi- bres may contract to almost any degree, without being attended with pain:—Secondly, That their contraction alone, however violent, does not forward the child:—3dly, That they do not possess the power of alternate contraction in the same degree as the lon- gitudinal fibres; and that they may exert this power, it is necessary at first to have them distracted by some force or other. 4thly, That the pain felt during labour, must in a great measure, if not en- tirely, depend upon the contraction of the longitudi- nal fibres. 5thly, That the changes the uterus has suffered from civilization and refinement must be chiefly confined to its longitudinal fibres. From what has been said, then, the spasmodic or alternate contraction of the uterus, appears to be r 39 ) nothing more than an increased effort it makes, to overcome the obstacles opposed to its progress to a state of vacuity; and that the pain attending their contractions depend upon certain physical changes which the longitudinal fibres have undergone from the causes just mentioned. Why a particular set, or given direction of fibres should have suffered more than another, may be impossible to determine; but that they have, we believe to be most certain. This change, however, is by no means confined to the u- terus, as every strait muscle of the body appears to have participated with it: since it is admitted that the man of the civilized world has lost much of his original strength. On the other hand the circular muscles, as far as we can determine, have lost no- thing of their primitive power; since it is more than probable, that various sphincters* among which we may reckon the circular fibres of the mouth of the uterus, perform their duty as effectually and as pow- erfully, as in the time of our first parents. Do not these facts emphatically account for women who have suffered these changes, having more tedious andpainfullabours,thanthosewho havenot undergone them,-—as the women of savage nations, the women of Calabria, &c. and without the necessity of having * The heart, or intestines may also be included. ( 40 ) recourse to a physical necessity, derived from the erect position of man, or the peculiar construction of the pelvis ?* The different actions we have assigned the ute- rus, must not be considered as exclusively belong- ing to woman;--as the brute, doubtless, has the same. It is indeed true that the labours of the brute are not generally attended with pain or difficulty, and this is urged against the idea of pain being of artificial origin, as they have also undergone great changes; but it must be remembered they have not suffered the same revolutions as man, or at least not in equal extent; but that the same general pheno- mena, progress, and casualties attend them, as oc- cur to the human female, is most certain; and when causeso ccur, capable of diverting their labours from their usual healthy course, the same difficulties take place, and are attended with the same symptoms--- namely pain. The influence of domestication has been per- ceived by those who are in the habit of raising cat- tle, horses, sheep, &c. and we are assured by them, that many lose their lives from the difficulties attend- ing their labours. I have myself more than once * See Osborn's Essays. ( 4! ) seen the mare and cow suffer extreme agony in bringing forth their young; but it must be admit- ted, that this does not occur so frequently as to ena- ble us to establish any proportion between their pain and difficulty, and that of the human female; nor would it be of any use, were it in our power ; all that is contended for, is, that those animals, which man have familiarized by his care, and made sub- servient to his purposes, have suffered, if not in equal degree with himself, yet sufficiently to justify the position....that they, in consequence of the habits imposed upon them, have been rendered less heal- thy, and occasionally subject to difficulty and pain from parturition. ■ What the ultimate effect of this familiarization (if we may so term it) may be, we cannot pretend to determine : not that it will be more extensive than it is at present, is rendered more than probable, from what we have already witnessed. }Tis said their uteri alone, are capable of expel- ling their contents without pain, and without any assistance from the abdominal muscles; this may be true ; as we are told by Van Sweitenf on the authority of Hemsterhuys, " that the womb of a " pregnant bitch, the abdomen being open, by its t Comment. yoI. 14. p. 49. ( 42 ) " own efforts only, forced out the foetus; the dia- " phragm and muscles of the abdomen remaining " quiet and yielding no assistance." But can we determine there was no pain attending the efforts of the uterus in this cruel experiment, since it was placed in a new situation ? If pain attended, it will not be insisted on, as necessary to the delivery, but rather be considered as the consequence of the en- creased action the uterus was obliged to exert, to relieve itself of its load; for although the uterus, unaided by the auxiliary powers, may be capable of expelling its contents, yet it must surely be ad- mitted, it will do it with more facility with them. The same may be insisted on, with the human fe- male, since pain, with them, is nothing but the ef- fect of a certain degree, or kind of contraction; neither is it the cause of the termination of their labours, but the result of that cause....namely, Con- traction. Should an equal degree of contraction take place without pain, as with it, the labour would be terminated with as much speed and certainty. But can this happen with the human female? Certainly it can, and does every day. The human uterus is as capable of expelling its contents, without the aid of the abdominal muscles, as that of the brute, and also without the interposi- tion of pain; of the former ability, many instances are upon record; many women labouring under ( 431 ) ascites, have been delivered; here the auxiliary powers could give no assistance; children have al- so been delivered after visible life has ceased in the mother, by the aid of the uterus alone; here no assist- ance could be derived from the abdominal muscles. And of women being delivered without pain, it would be idle to cite them, as they must occur in every man's practice. Pain then, must be regarded as disease, since it cannot be proved necessary; this disease has its origin in the changes produced by civilization and refinement. In what'do these changes consist? This we do not pretend to answer. We might say it is in a peculiar sensibility or irritability of the sys- tem in general, or in the uterus in particular. But would this explain it ? Would this not only be sub- stituting one inexplicable phenomenon to account for another ? We only know with certainty that these different states exist, but why, or how induced, is impossible to say. We know also, and may advance it without fear of contradiction, that the female system during preg- nancy and labour, is much disposed to that state termed inflammatoiy ; and that slight causes will produce fever, or local inflammation. This is ac- knowledged by all writers on the subject, and has G ( 44 ) led Dr. Rush to consider pregnancy and parturition, as diseases. That they ought to be considered as such, in but too many instances, is certain; for there are but few cases, in which we are not obliged to mitigate their violence, or shorten their duration. It is not within our present view to speak of preg- nancy as a disease ; we shall therefore confine our- selves to labour and its consequences. To relieve pain, has engaged the attention of phy- sicians from the earliest ages; and their endeavours have been rewarded with more success in every other, than that which attends parturition. This has arisen, perhaps, from less attention being paid to this, than to the other states of pain, from an idea of its being inevitable, rather than from the impossibility or difficulty of subduing or alleviating it. " In sorrow shalt thou bring forth children;" was the curse inflicted on our first parents for their disobedience ; and from hence it was inferred, that pain was not only unavoidable, but necessaiy ; I have endeavoured elsewhere* to shew the falsity of * Medical Museum, Vol. 1. No. Ill- ( 45 ) this conclusion ; we shall therefore not dwell upon it here, but proceed to shew, that the condition of woman in this particular can be much ameliorated. The cause of pain and difficulty, for the most part, depends upon a certain condition of the soft parts that are subservient to labour; we shall there- fore consider this subject under the following heads. First, Where rigidity of the mouth of the uterus depends on the circular fibres maintaining their con- traction for too long a time, but where no inflamma- tion attends. Secondly, Where the rigidity is attended with inflammation. Thirdly, Where the rigidity arises from previ- ous local injury ; either from mechanical violence, or from inflammation and its consequences. Fourthly, Relative rigidity, or where it proceeds from disproportionate powers, between the longitu- dinal and circular fibres. Fifthly, Tonic rigidity, or where the circular fi- bres, remote from the mouth, embrace the body of the child too powerfully. r 46 ) Rigidity of the first kind. This particular state of the mouth of the uterus, may be divided into three varieties; first, where the subject is very young ; secondly, where the subject has passed the five and twentieth year; and in la- bour with their first children; and thirdly, where the uterus has been prematurely thrown into action. Var. 1. or where the subject is very young. In this case, where the subject is very young, and has arrived at the full period of gestation, we very frequently find the soft parts concerned, to yield with great reluctance, and the labour become extremely tedious and painful. This unwillingness to yield, may arise from the uterus not having acquired its complete developement before impregnation had taken place, though sufficiently for the purposes of gestation. If this be admitted, and of which we be- lieve there can be no doubt, we shall very readily comprehend why its subsequent actions should be performed with less order, or more reluctance, than if it had received its ultimate finish. It is a fact well known, that the uterus is one of the last organs of the body which is perfected ; and no doubt, con- nected with this perfection, is that of the vagina and perineum. If, then, impregnation should take place ( 47 ) before this period, the actions of these parts will be less perfectly performed—as the actions of parts, must depend upon the condition of the parts them- selves; consequently, an uterus, &c. so situated, cannot act with such order and effect, as when parts are completely formed, and whose actions of course are properly established, or can be properly esta- blished when necessary to be called forth: hence, in very young girls or women, we frequently find the labour very tedious. The mouth of the uterus yields unwillingly; the contractions of the fundus and body are performed in a desultory manner ; the perineum dilates reluctantly, and is in great danger of laceration ; the head or presenting part will often remain stationary at the inferior strait, for hours, owing to the unwillingness of the soft parts to give way ; so that for the most part they are stretched from the mechanical pressure of the child ; the Ha- morrhoidal veins become much distended; the rec- tum is more or less protruded, and inflammation of considerable violence supervenes, through the whole tract of the vagina, which sometimes terminates in- suppuration or gangrene. The circular fibres of the mouth of the uterus ve- ry obstinately maintain their contraction for a long time, either from their not having received their due organization, and therefore not acting exactly as in- tended by nature; or from the longitudinal not hav- ( 48 ) ing, from some cause or other, acquired their de- signed strength, the circular will have a relative in- crease of it. A great deal of time is therefore em- ployed, and much pain endured, before the mouth of the uterus will open; and even when it does, it seems more like being mechanically, than naturally opened. See cases, i, ii, iii. Far. 2*, or where the subject is not very young. The same general phenomena take place in this variety, as in the first. This kind in general howe- ver, is rather more obstinate ; the parts, from not having been employed early according to the design of nature, seem to forget a part of their duty. This kind also is more disposed to take an inflammatory action. Much may be done for this variety, by pro- per regimen, &c. a few weeks before labour is ex- pected. See cases, iv, v, vi, vii, viii, ix, x, xi. Far. 3, or where the action of the uterus is pre- maturely excited. Whatever is capable of exciting the contractions of the uterus, can produce this variety ; it may hap- * Here the subject is also supposed to have completed the term of gestation. ( 49 ) pen at any period of gestation; but it is designed on- ly to speak of it, as it takes place at the latter period of gestation. This may occur in any subject, and in any pregnancy, as the uterus is always liable to be thrown into action. It would be useful could we always with certainty distinguish this variety from the two just mention- ed ; as at its commencement, it would require very different treatment. This is not always very easy, more' especially where there is a compleat oblitera- tion of the neck of the uterus. We can, however, for the most part, do it by the following marks. First, when the uterus is prematurely excited to action, we can sometimes, (as at the eighth month) feel a portion of the os tincse :—Secondly, when we examine the mouth of the uterus, we find it rigid, both in the absence and presence of pain :—Third- ly, when we pass a finger through the mouth of the uterus and touch the membranes, we do not find them so tense, as when the uterus is naturally dis- posed for labour:—Fourthly, the pains are more irregular in their accessions, and continuance; some- times quickly following each other, then more slow- ly—now long and severe, then short and trifling:— Fifthly, there is no secretation of mucus, nor dis- position in the perinceum to relax :—Sixthly, there U no immediate subsiding of the abdominal tumour. ( 50 ) When the uterus is thus thrown into action ; if not quickly prevented, it will continue to contract until labour, strictly so called, takes place. When this happens, it scarcely ever fails being tedious and painful. It behoves us, therefore, to distinguish this state from the other, that we may, if possible, prevent the labour coming on. See cases xii. xiii. Regidity attended with inflamation and fever. The cases of difficult labour, attended with infla- mation and fever, occur more frsquently than with- out them. The three varieties just spoken of, are all liable to these additional symptoms:—First, from local irritation, either of the presenting part acting mechanically on the mouth of the uterus, more es- pecially after the evacuation of the waters; or from the officious and ill-judged interference of the accou- cheur Or midwife, attempting, by force, to open it: —Secondly, from improper diet or drink. When inflammation comes on, the woman becomes ex- tremely restless, and does not enjoy that calm which is common at the cessation of pain: the vagina be- comes hot and dry ; the mouth of the uterus thick- ens and becomes more unyielding ; the secretion of muscus, if it had taken place, ceases ; the pulse be- comes quick, frequent and hard; the respiration hurried ; the head much pained; the face flushed ; ( 51 ) great thirst; the skin hot and dry, or profusely sweating. See cases, vii, viii, ix, x, xi, xii, xiii, xiv, xv. Rigidity from local injuries. The parts concerned in labour, are frequently made to suffer, by injudicious treatment or negli- gence, a degree of inflammation, that very much de- ranges their natural structure. Should this inflam- mation terminate by resolution, it does not do it so completely, as not to leave a thickening of the parts, from which they sometimes never recover; this thickening, which is owing to an unabsorbed quan- tity of coagulating lymph, offers very considerable difficulties to the dilatation of the parts; they cannot assume their healthy or natural action while this is present. At other times, when the inflammation has been considerable, an injury may be done to the neck of the uterus, &c, by the effusion of coagulat- ing lymph, (agglutenating their fibres as it were) that they cannot ever after take on the healthy re- laxation ; and of course will yield with difficulty to the propelling powers of the fundus and body of the uterus. When inflammation has been more violent or unsuc- cessfully treated, it may terminate in suppuration or gangrene. In consequence of these unfortunate H ( 52 ) terminations of inflammation, the parts, if the pati* ent survives, heal up so unfortunately, as to leavq large cicatrices, in the mouth of the uterus, vagina and os externum, which will offer immense difficulty to labour. These parts parts are also subject to laceration, more especially the vagina and perineum. When these wounds heal they present very firm cicatrices through the whole extentjof the injury. These scars are sometimes so firm, and so unfortunately situated for labour, that they completely resist, for a very long time, every effort of the uterus to expel its con- tents. See cases, xvii, xviii, xix, xx. Relative rigidity. The longitudinal fibres of the uterus may be ren- dered so inactive, that they cannot contract with suf- ficient force to overcome the resistance of the circu- lar. This may happen from a variety of causes, but we shall only notice one, namely, a kind of apoplexy of the uterus. This case is known, by labour having come on kindly at first, and gradually diminishing in force ; by the mouth of the uterus having dispo- tion to dilate ; by its thickening,—by the presenting part not protruding during pain; by the pain ex- tending itself all over the abdomen; by the woman's complaining of a sense of suffocation; by a hard and ( 53 ) full, or depressed or labouring pulse ; by the irregu- larity of the pains both in force and frequency. The mouth of the uterus in these cases cannot open, al- though disposed agreeably to the order of nature, as the fibres destined to keep it shut are relatively stronger than those intended to open it. The contractions, therefore, of the longitudinal fi- bres, are feeble and transitory ; the mouth of the uterus does not dilate, though not positively rigid ; the abdominal tumour does not continue to subside; there is a secretion of mucus, and a disposition in the external parts to dilate, which perhaps pretty clearly points out the favourable situation of the mouth of the uterus ; but it cannot dilate until the longitudinal fibres have shaken off their torpor; or in other words, until the cause of this torpor is re- moved ; they then resume their healthy contraction, and the labour is for the most part quickly termi- nated. See cases, xxi, xxii. Tonic rigidity. This only occurs where the waters have been drained off a long time, and the whole of the inter- nal surface of the uterus is closely applied to the body of the child. Such is the nature of the circu- lar fibres, that they always contract in such a man- ner as to come in contact with the substance pre- ( 54 ) sent in the uterus ; they do not however, do this suddenly, it requires some time, and in proportion to that time, other things being equal, will be the intimacy of this contact. While the child is still in the uterus, it must necessarily present to it some inequalities; but such is the arrangement of nature in general to guard against this disposition of the uterus, that the body of the child is so placed as to offer as few as possible. But the care of nature in this particular must be often thwarted, by accidents of various kinds, which are capable of retarding the labour; for instance, suppose the mouth of the uterus well opened, the waters discharged, the head of the child somewhat advanced, when something may happen, no matter what, that will delay the de- livery of the head, or obstruct its progress; what will be the consequence ? the uterus will apply it- self to the body of the child, and be disposed to do it in all possible points; the head being in the pel- vis, the neck of the child is more or less extended ; this will offer a much smaller substance to the parts of the uterus near it, than the rest of the body; the circular fibres will go on contracting at this part un- til they embrace the neck ; this will divide the ute- rus into two chambers as it were, and in conse- quence thereof the labour will be delayed, and turn- ing rendered impracticable—hence the difficulty of this operation after the waters have been long eva- cuated. This peculiar contraction has been men- ( 55 ) tioned by authors, but none, as far as I know, have ever offered a remedy for it. This case occurs sufficiently frequent to make it an object of particular attention; as many infants, I fear, have been sacrificed to the crotchet, from this cause intercepting delivery. See case xxiii. Having spoken as concisely as the nature of the subject would admit, of the various causes of rigi- dity, we shall proceed to say a few words on the principal remedies which have been employed with a view to relieve it: they are opium, warm bath, and blood-letting. OPIUM. This has been, and still continues to be, the favo- rite remedy with most accoucheurs, for the rigidity of the os uteri; but we conceive, nothing but theo- ry has ever given it employment; it was supposed, that when the mouth of the uterus did not open kindly, it was affected with spasm, and on this prin- ciple was opium exhibited; but as far as my ex- perience goes, never with advantage. I have re- peatedly tried it myself, and often seen it employed by others, but without, in a single instance, produ- cing the effect for which it was prescribed; some- times it evidently did mischief. ( 56 > It must be remembered we are speaking of it, as given for the express purpose of dilating the os uteri, or disposing it to dilate. It has undoubtedly been used with advantage, in those cases where it was conceived the uterus was prematurely excited to action—it has suspended the contractions for the proper time, and when they were renewed the ute- rus was healthily disposed, and the labour soon fi- nished—but here it was given, not to dilate the month of the uterus, but to suspend the contrac- tions of the longitudinal fibres. This medicine cannot, we conceive, ever be recommended with any chance of success, where the object is directly to make pains more efficient, by taking off the resist- ance of the mouth of the uterus. Nor can this drug be considered as an innocent